Would you take HRT mainly for osteopenia before menopause symptoms start?

[EngineerMumOf2]

Looking for some shared experiences or sensible advice from anyone who’s navigated this.
I’m in my mid-40s with two kids, fit, healthy BMI (around 50kg), active, non-smoker, non-drinker, eat well, and have never broken a bone. My periods are still regular (missed just one about a year ago), and thankfully I don’t have the classic perimenopause symptoms like hot flushes or brain fog. No family history of breast cancer or other cancers either. My mum had back and knee surgery in her 60s, but she's doing grand now.
A recent DXA scan showed slightly low bone density (osteopenia) in my lumbar spine. I asked about bioidentical/body-identical HRT to protect my bone mineral density, and a couple of months ago my GP agreed to prescribe cyclical HRT: Evorel 50 patches alongside Utrogestan 200mg (micronised progesterone, taken two weeks on, two weeks off).
Now that I’m taking it, I’m second-guessing myself. Given that I have virtually no vasomotor/perimeno symptoms and feel completely well, is it sensible to stay on HRT solely as a preventative measure for bone health at my age? Or would you hold off and rely on diet, weights, and lifestyle until actual perimenopausal symptoms kick in?
Would love to hear what your GPs or menopause specialists advised if you were found to have low spine density early on. What would you do?

What height are you? Have you always been petite/ low weight? There is an association between being of low body weight and increased risk of osteoporosis ( and especially for those below 56kg) because those women tend to have a smaller frame and hence reach a lower peak bone mass. Hence why when menopause hits, they tend to lose bone density at a faster rate - going into older age, women who are overweight actually tend to have better bone health. Conversely, being underweight in older age can mean increased risk of fractures and general fraility . I would agree that starting on HRT now is a good option, as well as carrying on with your healthy lifestyle and appropriate exercise, particularly weight bearing and using weights. Worth seeking advice on an exercise programme in your area from any health/ exercise professionals who specialise in women’s health/ joint care..

I'm also in my mid-40s, active, healthy and a lower body weight similar to yours. I have osteopenia in my spine and I'm on the cusp of osteoporosis in my femoral neck. I have unfortunately had a couple of fractures in recent years. I have absolutely no perimenopause symptoms at all but a recent blood test showed that my estrogen levels were very low despite having a regular cycle. My rheumatologist advised HRT with a high dose of estrogen to support my osteoporosis treatment and the GP has just prescribed it today funnily enough. I've been told you can be asymptomatic in perimenopause and still have declining estrogen levels that affect your bone density. I'd be interested to hear what others have to say.

And what @ForNavyPoster said about bodyweight as well. A little extra fluff is protective. I'm trying to put weight on but I don't find it easy.

I am on it for this reason although I'm older than you. I have osteophenia and have broken 8 bones during the past few years. I'm approaching three months on HRT and feeling better. I also take omega three and vitamin d everyday. I think I need all the help I can get. I had anorexia when younger.

Thanks for these replies.
I’m 5ft 2in and always around 50kg as baseline rather than sudden weight loss.

Seeing how quickly bone density can silently drop before fractures happen has really reframed this for me.
My recent bloods showed both my calcium and Vitamin D were technically "in-range", but sitting right at the lower end. I actually had a diagnosed episode of Vitamin D deficiency in my 30s, so that’s definitely another thing I need to stay on top of alongside diet and lifting weights.

I’d also ask this thread to know about the longer-term side of things especially Cancer risk: For those who started bioidentical/body-identical HRT primarily for bone mineral density, what has your medical team said about breast cancer risk over time? Has anyone had discussions about how micronised progesterone (Utrogestan) compares over a few years of preventative use?Is there an optimal window, or an age/duration after which it shouldn't be continued to stay on the safe side?

The Britiish menopause society has these that may help you. https://thebms.org.uk/wp-content/uploads/2025/12/01-NEW-INFOGRAPHICS-NOV2025-C.pdf. And https://thebms.org.uk/wp-content/uploads/2025/09/12-NEW-BMS-ToolsforClinicians-Fast-Facts-HRT-and-Beast-Cancer-Risk-SEPT2025-B.pdf My clinical background has been in palliative care and older adults and I personally am going to stay on HRT until 60-65 , and then review it then, as I am likewise on it for bone health and many women in my family struggle in older age with pain and loss of mobility. Historically there hasn’t been the good quality research to swing me either way into definitely stopping at a particular age ( and rather too much publicity given to outdated research around non bio identical HRT) …... and I would get people to think about the contrast between what we hear about the negative aspects of HRT but meanwhile nothing ,if ever, said about the fact that women get put on the pill sometimes as teenagers and may be on it for decades. At the end of the day it’s about your personal circumstances and family history…..if HRT will help you stay active and exercising as long as possible, this will help many aspects of ageing….but equally I understand for some women they will want to minimise their cancer risk .

I think if you are naturally slim and petite that is just the way it goes sadly but you make a really good point that often people don’t realise that this level of bone loss starts silently, if they don’t have other menopause symptoms. I think if you have children yourself with a similar body type it’s explaining how important weight bearing exercise and doing weights is, alongside eating well and not smoking ( and being a restrained drinker, there are a lot of women who were teens in the 80’s and 90’s who manage to put away a lot of alcohol on a regular basis now in middle age!). Young women perhaps don’t realise that we build up all our healthy bone mass in our teens and 20’s, it peaks by the late 20’s but then it starts to decline around 35… so it’s trying to get the message out that osteoporosis prevention starts when you are young .

@EngineerMumOf2 Would you like to share your actual results from the DEXA scan? You can do it by PM if you prefer.

I've had DEXA scans for 20 years (once every 2 years privately.) Osteopenia diagnosed with no risk factors.

I've had excellent advice from my consultant gynaecologist and input from a rheumatolgist (who is on the advisory board for the Royal Osteoporosis Society.)

I'd not factor in your height and weight too much - mine is the same and has been stable my entire life - I am not 'thin' by any means.

I can chat to you in detail if you want to.
Basically, my bone density has improved hugely with HRT. I've had many conversations about the risks and benefits with my dr.

It all depends on what your T -score is and how low it is now.

I’d also ask this thread to know about the longer-term side of things especially Cancer risk: For those who started bioidentical/body-identical HRT primarily for bone mineral density, what has your medical team said about breast cancer risk over time?

Currently, HRT is not prescribed as a prevention for osteoporosis with minor bone loss.

I started HRT for menopausal symptoms and continue to do so (having stopped a couple of times.) It was never prescribed solely for my bones.

The cancer risk using the older types of progesterone /HRT is 4 extra cases per 1000 women over a 5 year period.

There is very little data on using body identical HRT as there are no trials and the drugs are not included in the data available on HRT. In the latest meta analysis of thousands of women only 30 on micronised progesterone were included.

There are a couple of European studies which show less BC using body identical progesterone (it's the progesterone not estrogen that is the factor in BC.)

Go for it. Osteoporosis is horrific. I started HRT too late and the loss of bone density in the first few years of menopause is huge. The other drugs to improve bones can have some horrific side effects.

Please also start lifting weights and stomping round. Even hopping for thirty times on each leg every day has been proven to help. Star jumps etc. US orthopaedic surgeon Vonda Wright is brilliant on this.

Solgar calcium magnesium and zinc tablets are good combined with vitaminD3&K2 spray daily. The K2 sends the calcium to the bones.

Good bone foods apart from dairy are sardines and bony fish, bone broth, almonds, kale and prunes.

Sorry - I wish I’d known all this when younger.

When assessing risks v benefits it’s worth bearing in mind that more women die of heart disease than breast cancer - and HRT started early enough protects the heart.

That's great advice @EvelynBeatrice but many GPs will not prescribe HRT for osteopenia if it's relatively slight. It's not licensed for that.

On a DEXA scan, a normal T-score is above 1.
Between -1 and -2.4 is osteopenia.

Osteoporosis is -2.5 and below.

I thought the advice had recently changed and that HRT (when not contraindicated) was indeed a frontline treatment for osteopenia?

I'd be interested to see that.

It is licensed for osteoporosis but I've not seen anything about osteopenia .many many woman have a T-score below 1 but nowhere near -2.5

I am not saying OP shouldn't have it- but she needs to say what her bone density is and or if she also has other symptoms.

Most women I know have had to pay privately for advice and prescriptions as NHS rheumatology where I am will not see you or make any treatment recommendations if you have osteopenia until the first fracture….unsurprisingly most of us would rather prevent that happening

thebms.org.uk/publications/consensus-statements/prevention-and-treatment-of-osteoporosis-in-women/

Exactly.

Yup. I’m constantly nagging my girls to eat a slab of cheddar every day to build up their bone bank!!

Happy to share my numbers from my recent scan:

• Lumbar spine (AP): BMD 0.935 g/cm², T-score: -2.1
• Femoral neck (L): BMD 0.825 g/cm², T-score: -1.5
• Femoral neck (R): BMD 0.776 g/cm², T-score: -1.9
• (Total hips and forearm were normal, around -0.3 to -0.4) So the spine is sitting in osteopenia at -2.1, with the femoral necks not too far behind.

Cancer is scary but, for me, the loss of personal agency through possible immobility and disability and the excruciating pain of broken bones is a worse prospect. As you age sadly, it’s a case of ‘ choose your poison’!! 😬

Did you get a Z score too- which is age-measured?
You are only mid 40s so that score is quite low.

I think for you, with your spine at -2.1 you should definitely use HRT. You don't have far to go to -2.5.

My consultant has always said there are some small risks with HRT but there are also risks NOT using HRT. And for the individual, it means taking their personal circumstances into account.

If you are only mid 40s, the risks of HRT don't apply anyway.
They only start once you get to the average age of menopause - 51.

The BMS also says that as far as they know, the risks of body identical HRT don't start till at least 5 years on it. So that means your risk is zero for a long time at your age.

I do. I have never broken a bone, but neither to my knowledge had my mum and aunts, all who took no HRT and are now having serious bone health issues (and UTI issues too). Id like to be a fit and health as possible 80yo, like my HRT taking step mother.

As your GP has already prescribed hrt you should carry on.

A broken vertebra is not fun. It's agony and there are no quick fixes for it.

You can have at least 5 years of HRT risk-free, have a scan in 2 years and see how that is, and reassess at 50 with another scan.

Reading this thread as a 41 year old woman has scared me. I am SO unprepared and have so little knowledge on any of this. Not to derail the thread but any suggestions for reading so i can educate myself? I assume I would have to pay for a private DEXA scan?

Yes. Unless there is a history of osteo in your family or you have other risk factors (look them up.)

Costs vary but I pay around £200 for a scan, done every 2 years (or 3 if no issues.)

Your scores are pretty similar to mine but the other way around. -1.8 in the spine overall, -2.5 in the femoral neck. This was at age 43. They put me on osteoporosis treatment straight away because I'd had what was a deemed a fragility fracture in light of my BMD scores. As mention above, -2.1 is not far off -2.5 so I would definitely stick with the HRT in your position.