Testing without action is information without value. The goal of DEXA scanning, bone turnover markers, and nutritional bloodwork is not to produce numbers to worry about — it is to give you a precise picture of where you are, which allows you to intervene with precision rather than guessing. A woman who knows her DEXA T-score, her vitamin D level, her CTx-to-P1NP ratio, and her dietary calcium intake has a fundamentally different ability to make targeted, evidence-based decisions about her bone health than one who is simply following generic advice.
For most perimenopausal women, the bone health action plan looks like this: establish a DEXA baseline if you have not already, particularly if you have risk factors for accelerated loss. Get vitamin D tested and supplemented to the optimal range, not just the sufficiency threshold. Audit your total calcium intake across food and supplements. Begin or continue resistance exercise as a non-negotiable bone stimulus. And if you have not already, address protein intake — research consistently shows that protein adequacy is a meaningful independent predictor of bone density maintenance in postmenopausal women, and many women are not consuming enough.
Bone health in perimenopause is not passive. It is something you actively build and protect during the window when the stakes are highest. The testing framework described here gives you the tools to know where you stand and whether what you are doing is working. That information is worth having.
📞 If you are unsure what your bone health status actually is or how to interpret your DEXA results in the context of your nutrition, we can help. At The Menopause Dietitians, we review bone health markers alongside your dietary intake and build a targeted nutritional plan. Click the button below to book your free 20-minute Menopause Strategy Call.
For most perimenopausal women, the bone health action plan looks like this: establish a DEXA baseline if you have not already, particularly if you have risk factors for accelerated loss. Get vitamin D tested and supplemented to the optimal range, not just the sufficiency threshold. Audit your total calcium intake across food and supplements. Begin or continue resistance exercise as a non-negotiable bone stimulus. And if you have not already, address protein intake — research consistently shows that protein adequacy is a meaningful independent predictor of bone density maintenance in postmenopausal women, and many women are not consuming enough.
Bone health in perimenopause is not passive. It is something you actively build and protect during the window when the stakes are highest. The testing framework described here gives you the tools to know where you stand and whether what you are doing is working. That information is worth having.
📞 If you are unsure what your bone health status actually is or how to interpret your DEXA results in the context of your nutrition, we can help. At The Menopause Dietitians, we review bone health markers alongside your dietary intake and build a targeted nutritional plan. Click the button below to book your free 20-minute Menopause Strategy Call.
Putting It Together: Your Bone Health Action Plan
Testing is only the beginning. Understanding what your markers show allows you to build a targeted nutritional response. For most perimenopausal women, this includes ensuring adequate calcium from dietary sources first (dairy, fortified plant milks, canned fish with bones, tofu made with calcium sulphate, dark leafy greens) and supplementing only the gap, optimising vitamin D to the 100 to 150 nmol/L range, ensuring adequate protein to support osteoblast function and muscle mass, and addressing any magnesium or B vitamin gaps that affect bone metabolism.
Resistance training — the mechanical loading of the skeleton — is the most powerful non-nutritional stimulus for bone formation, and it works synergistically with the nutritional interventions. Bone responds to mechanical stress by increasing density. This is why weight-bearing and resistance exercise are recommended alongside calcium and vitamin D, not as a supplement to them.
For detailed guidance on the nutritional approach to bone health in menopause, including specific food and supplementation strategies, see the companion post Bone Health After 45 on this blog.
Resistance training — the mechanical loading of the skeleton — is the most powerful non-nutritional stimulus for bone formation, and it works synergistically with the nutritional interventions. Bone responds to mechanical stress by increasing density. This is why weight-bearing and resistance exercise are recommended alongside calcium and vitamin D, not as a supplement to them.
For detailed guidance on the nutritional approach to bone health in menopause, including specific food and supplementation strategies, see the companion post Bone Health After 45 on this blog.
The Nutritional Foundation for Bone Health in Perimenopause
DEXA shows the result of bone remodelling over time — a snapshot of current density. But bone turnover markers are blood and urine tests that show the rate at which bone is currently being broken down and rebuilt. They provide dynamic information that DEXA cannot, and they respond to nutritional and lifestyle interventions within weeks, making them useful tools for monitoring whether your approach is working without waiting years for a follow-up DEXA.
The two most clinically relevant bone turnover markers are CTx (C-terminal telopeptide of type I collagen, sometimes called beta-CTx), a marker of bone resorption that measures how actively osteoclasts are breaking down bone, and P1NP (procollagen type I N-terminal propeptide), a marker of bone formation that measures how actively osteoblasts are building new bone. In a perimenopausal woman with accelerating bone loss, CTx is typically elevated relative to P1NP — meaning breakdown is outpacing formation. Nutritional interventions that support bone formation and dampen excessive resorption should, over time, shift this ratio in a more favourable direction.
Bone turnover markers worth requesting:
Note that these markers are sensitive to recent food intake — CTx in particular should be tested fasting in the morning for the most reliable result. They are also affected by recent fracture, which temporarily elevates both markers.
The two most clinically relevant bone turnover markers are CTx (C-terminal telopeptide of type I collagen, sometimes called beta-CTx), a marker of bone resorption that measures how actively osteoclasts are breaking down bone, and P1NP (procollagen type I N-terminal propeptide), a marker of bone formation that measures how actively osteoblasts are building new bone. In a perimenopausal woman with accelerating bone loss, CTx is typically elevated relative to P1NP — meaning breakdown is outpacing formation. Nutritional interventions that support bone formation and dampen excessive resorption should, over time, shift this ratio in a more favourable direction.
Bone turnover markers worth requesting:
- CTx (beta-CTx) — bone resorption marker; elevated in accelerated bone loss
- P1NP — bone formation marker; low relative to CTx indicates resorption outpacing formation
- Both markers together provide a picture of bone remodelling balance that neither gives alone
Note that these markers are sensitive to recent food intake — CTx in particular should be tested fasting in the morning for the most reliable result. They are also affected by recent fracture, which temporarily elevates both markers.
Bone Turnover Markers: The Tests That Show What Is Happening Right Now
Several bloodwork markers are not bone-specific but have direct relevance to bone health and are worth monitoring in the context of perimenopause.
Vitamin D (25-OH D):
As discussed in this series, vitamin D is essential for calcium absorption in the gut. Without adequate vitamin D, dietary calcium cannot be effectively absorbed regardless of how much is consumed. Aim for a serum level of 100 to 150 nmol/L for optimal bone protection. Many Canadian women supplement at doses that are insufficient to reach this range — testing is the only way to know whether your current dose is working.
Calcium:
Serum calcium is tightly regulated by the parathyroid glands and does not reliably reflect calcium sufficiency — the body will draw calcium from bone to keep serum levels normal. This is exactly the problem. A normal serum calcium result tells you nothing about whether your dietary calcium intake is adequate to prevent bone resorption. Total dietary calcium intake (from food and supplementation combined) needs to be assessed through dietary history, not bloodwork alone. The recommended total intake for perimenopausal women is 1,000 to 1,200 mg per day.
Magnesium:
Magnesium is required for vitamin D conversion, calcium metabolism, and osteoblast activity. It is depleted by stress, alcohol, certain medications, and a highly processed diet. Serum magnesium can be normal even when intracellular magnesium is low — a limitation of standard testing — but it is still worth including in a bone health panel. Dietary sources include dark leafy greens, pumpkin seeds, almonds, legumes, and dark chocolate.
Parathyroid hormone (PTH):
PTH rises when calcium or vitamin D is insufficient, stimulating bone resorption to raise serum calcium. Elevated PTH in the context of low vitamin D or low dietary calcium is a direct driver of bone loss. Testing PTH alongside vitamin D provides a more complete picture of the calcium-vitamin D-bone axis than either marker alone.
Vitamin D (25-OH D):
As discussed in this series, vitamin D is essential for calcium absorption in the gut. Without adequate vitamin D, dietary calcium cannot be effectively absorbed regardless of how much is consumed. Aim for a serum level of 100 to 150 nmol/L for optimal bone protection. Many Canadian women supplement at doses that are insufficient to reach this range — testing is the only way to know whether your current dose is working.
Calcium:
Serum calcium is tightly regulated by the parathyroid glands and does not reliably reflect calcium sufficiency — the body will draw calcium from bone to keep serum levels normal. This is exactly the problem. A normal serum calcium result tells you nothing about whether your dietary calcium intake is adequate to prevent bone resorption. Total dietary calcium intake (from food and supplementation combined) needs to be assessed through dietary history, not bloodwork alone. The recommended total intake for perimenopausal women is 1,000 to 1,200 mg per day.
Magnesium:
Magnesium is required for vitamin D conversion, calcium metabolism, and osteoblast activity. It is depleted by stress, alcohol, certain medications, and a highly processed diet. Serum magnesium can be normal even when intracellular magnesium is low — a limitation of standard testing — but it is still worth including in a bone health panel. Dietary sources include dark leafy greens, pumpkin seeds, almonds, legumes, and dark chocolate.
Parathyroid hormone (PTH):
PTH rises when calcium or vitamin D is insufficient, stimulating bone resorption to raise serum calcium. Elevated PTH in the context of low vitamin D or low dietary calcium is a direct driver of bone loss. Testing PTH alongside vitamin D provides a more complete picture of the calcium-vitamin D-bone axis than either marker alone.
Nutritional Bloodwork Directly Relevant to Bone Health
The DEXA scan (dual-energy X-ray absorptiometry — a low-radiation imaging test that measures bone mineral density at the hip and spine) is the gold-standard tool for assessing bone density. It takes approximately 10 to 20 minutes, involves no injections, and uses a very low level of radiation. Results are reported as T-scores, which compare your bone density to the peak bone density of a healthy young adult, and Z-scores, which compare your density to the average for your age group.
Current Canadian and American guidelines recommend DEXA screening beginning at age 65 for most women, or earlier for women with specific risk factors including early menopause (before age 45), surgical menopause, low body weight, history of fragility fractures, family history of osteoporosis, smoking, long-term corticosteroid use, or inflammatory conditions. If you are in perimenopause or early postmenopause and have one or more of these risk factors, a baseline DEXA is worth requesting from your physician regardless of your age.
A baseline scan in the early perimenopausal years gives you something invaluable: a reference point. Serial DEXA scans over time — typically repeated every one to two years if treatment or significant intervention is underway, or every two to three years for monitoring — show the rate of change, which is often more clinically useful than any single result.
Understanding your DEXA T-score:
Current Canadian and American guidelines recommend DEXA screening beginning at age 65 for most women, or earlier for women with specific risk factors including early menopause (before age 45), surgical menopause, low body weight, history of fragility fractures, family history of osteoporosis, smoking, long-term corticosteroid use, or inflammatory conditions. If you are in perimenopause or early postmenopause and have one or more of these risk factors, a baseline DEXA is worth requesting from your physician regardless of your age.
A baseline scan in the early perimenopausal years gives you something invaluable: a reference point. Serial DEXA scans over time — typically repeated every one to two years if treatment or significant intervention is underway, or every two to three years for monitoring — show the rate of change, which is often more clinically useful than any single result.
Understanding your DEXA T-score:
- Above -1.0: normal bone density
- -1.0 to -2.5: osteopenia — reduced bone density that warrants intervention and monitoring
- Below -2.5: osteoporosis — requires medical management alongside nutritional support
The DEXA Scan: Your Bone Density Baseline
Bone is living tissue in a constant state of renewal. Specialised cells called osteoclasts break down old bone, and osteoblasts build new bone to replace it. In a healthy premenopausal state, these two processes are roughly in balance. Estrogen plays a critical regulatory role in this system: it slows osteoclast activity, keeping bone resorption in check and maintaining the balance. When estrogen declines in menopause, the brakes on osteoclast activity are released. Bone resorption accelerates while bone formation cannot keep pace — and bone density falls.
The rate of loss is not uniform. It is fastest in the first years after the final period, then slows to a more gradual pace in later postmenopause. This means that the perimenopausal window — when many women are not yet thinking seriously about bone health because they do not feel any different — is precisely when the most significant loss is occurring and when early nutritional and lifestyle investment has the greatest potential impact.
Key takeaways:
The rate of loss is not uniform. It is fastest in the first years after the final period, then slows to a more gradual pace in later postmenopause. This means that the perimenopausal window — when many women are not yet thinking seriously about bone health because they do not feel any different — is precisely when the most significant loss is occurring and when early nutritional and lifestyle investment has the greatest potential impact.
Key takeaways:
- Estrogen directly regulates the balance between bone breakdown and bone building.
- Bone loss accelerates sharply in the 3 to 5 years surrounding the final menstrual period.
- The perimenopausal window is the highest-leverage time to intervene — before significant loss has occurred.
Understanding Bone Remodelling — and Why Menopause Disrupts It
Osteoporosis — a condition in which bones become porous and fragile, significantly increasing fracture risk — does not arrive suddenly. It is the end stage of a process that begins years, sometimes decades, earlier. Bone loss accelerates dramatically in the years surrounding menopause: in the first three to five years after the final menstrual period, a woman can lose 10 to 20 percent of her bone density. The majority of that loss happens silently, with no symptoms, no pain, and no warning until a fracture occurs.
This is why the window before osteoporosis is established — the perimenopausal and early postmenopausal years — is the most strategically important time to be paying attention to bone health. And paying attention means more than taking a calcium supplement. It means knowing your baseline, understanding the tools available for tracking bone density and bone turnover, and building the nutritional and lifestyle foundation that gives your bones the best possible conditions to maintain density through the transition and beyond.