Healthcare provider sitting next to patient and explaining the link between estrogen and osteoporosis

Estrogen And Osteoporosis: What's the Link?

Written on December 22, 2023 by Jillian Foglesong Stabile, MD, FAAFP. To give you technically accurate, evidence-based information, content published on the Everlywell blog is reviewed by credentialed professionals with expertise in medical and bioscience fields.

Table of contents

Osteoporosis is a common condition that affects more than 10 million men and women in the United States.[1] Osteoporosis-related fractures are associated with pain, disability, increased healthcare costs, loss of independence, and even death. The rate of death in the first year after an osteoporotic hip fracture is more than 20%, and the annual cost of hip fractures is around $13 billion.[2] Read on to learn more about the relationship between estrogen and osteoporosis.

What Exactly Is Osteoporosis?

The process by which your body builds and remodels bones is complicated, but to put it in simple terms, osteoporosis is a weakening of the bone due to decreased bone density. Different types of cells in the bone are responsible for breaking down and building up the bone on an ongoing basis: osteoclasts and osteoblasts. Over time, and under certain circumstances, the interaction between these types of cells can lead to an imbalance and more bone can be resorbed than built. This leads to low bone density and means that bones may break more easily. A mild decrease in bone density is known as osteopenia and a more severe decrease is osteoporosis.

How Is Osteoporosis Diagnosed?

Osteoporosis is diagnosed using a test called dual-energy x-ray absorption or DEXA. DEXA is an x-ray scan that requires you to lay on a table while a scanner is used to measure the density of your bones, usually the humerus or upper arm bone, the vertebrae or backbone, and the femur or upper leg bone.

Complicated measurements are used to calculate scores that are reported as part of the bone density results. T scores are based on average bone density readings of people of all ages. They are reported as negative or positive numbers, assuming that the bone density of a healthy young person is zero. The lower your bone density, the more likely you are to be at risk for fractures. A T score of -1.5 to -2.4 is considered osteopenia, which is low bone density but not low enough to be associated with a significantly increased risk of fractures. A bone density of -2.5 or lower is osteoporosis and is associated with a significant increase in fracture risk. Z scores are specific comparisons to other people in your age group. This score is used more frequently in people who are under age 50, including children. A Z score of -2.0 is concerning.[3]

A bone density showing a T score in the osteopenia range of -1.5 to -2.4 in a patient with a current or past fracture commonly associated with osteoporosis is also considered to be osteoporosis.

The United States Preventative Services Task Force recommends screening women aged 65 and older and postmenopausal women less than 65 who are at increased risk for osteoporosis.[4] Although osteoporosis can also occur in men, the data are inconclusive, and routine screening for osteoporosis is not recommended in men. If the initial screening DEXA is normal, then repeat screening every four to eight years is reasonable. If osteopenia or osteoporosis are present, then screening is recommended at a more frequent interval.

What Is Estrogen?

Estrogens are a class of steroid hormones.[6] There are three main types of estrogen in the body: estrone, estradiol, and estriol.[7]

Everlywell Womens Health Test CTA graphic

Estrogen has many roles in the body [8]:

  • In the breast, estrogen helps with the development of the tissues of the mammary glands and other tissues. It also helps with the development of mammary ducts.
  • In the uterus, estrogen helps with the thickening of the endometrial cells which prepare the uterus for the implantation of a fertilized egg.
  • In the vagina, estrogen supports the growth of the mucosal cells that line the vagina and surrounding tissues. Estrogen thins the mucus before ovulation which allows the sperm to get into the uterus.
  • In the bones, estrogen plays a role in the development of long bones and the fusion of growth plates in children and young adults. In older adults, it slows the cells that reabsorb bone and aids in bone strength.
  • In the heart and blood vessels, estrogen plays a role in cholesterol metabolism.

Estrogen also plays a role in brain function, blood sugar levels, muscle mass, circulation, collagen production, and moisture in the skin in both men and women. In men and people assigned male at birth, estrogen affects the sex drive and the ability to produce sperm and maintain an erection.

What Is The Role Of Estrogen In Osteoporosis?

Estrogen receptors are present in many types of cells in the bones. When estrogen binds to these receptors, it increases bone growth and decreases bone reabsorption, which leads to higher bone density.[5] As people age, estrogen levels drop. This leads to an increased risk of osteoporosis in both men and women.

Studies have shown that postmenopausal women on estrogen therapy have a decreased risk of osteoporosis-related fractures compared to women who have not been on estrogen therapy.[9] That said, estrogen therapy is not the only treatment to prevent osteoporosis. Estrogen therapy may not be an option for many women, including some with migraines or a family history of estrogen-sensitive cancers such as breast or ovarian cancer. Estrogen therapy may also not be an option for people with a history of blood clots or an increased risk of blood clots. Smoking is one risk factor for blood clots. Before considering any kind of hormone therapy or other medication for osteoporosis, it is important to discuss your risk factors with your healthcare provider.

Know And Manage Your Hormone Levels With Everlywell

If you have questions or are concerned about your hormone levels, the first step is to discuss your concerns with your healthcare provider. You may want to consider lab testing to get more information on your hormone levels, which you can do with the Everlywell Women's Hormone Test.

If your at-home test reflects a need for further care, Everlywell helps connect you with a vetted health professional who can provide a virtual consultation. Find out more about how Everlywell can help make treatment more convenient and accessible by checking out the complete range of at-home tests online today.

How Does Hormone Replacement Therapy Work?

What Is Bioidentical Hormone Therapy?

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  1. Tu KN, Lie JD, Victoria Wan CK, et al. Osteoporosis: A Review of Treatment Options. P.T. February 2018; 43(2]: 92-104.
  2. Burden of Osteoporosis. International Osteoporosis Foundation. Accessed December 19, 2023.
  3. Bone Mineral Density Tests: What the Numbers Mean. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Published May 2023. Accessed December 19, 2023.
  4. Osteoporosis to Prevent Fractures: Screening. U.S. Preventive Services Task Force. Published June 26, 2018. Accessed December 19, 2023.
  5. Cheng CH, Chen LR, and Chen KH. Osteoporosis Due to Hormone Imbalance: An Overview of the Effects of Estrogen Deficiency and Glucocorticoid Overuse on Bone Turnover. Int J Mol Sci. Feb 2022; 23(3]:1376.,resorption%2C%20which%20result%20in%20osteoporosis.
  6. Lee HR, Kim TH, Choi KC. Functions and physiological roles of two types of estrogen receptors, ERα and Erβ, identified by estrogen receptor knockout mouse. Lab Anim Res. 2012; 28(2]:71-76.,%2C%20adipogenesis%2C%20and%20cardiovascular%20systems.
  7. Low estrogen levels in menopause. University of Rochester Medical Center. Accessed November 24, 2023.
  8. Delgado BJ, Lopez-Ojeda W. Estrogen. Stat Pearls. Updated June 26, 2023. Accessed December 19, 2023.
  9. Nelson HD. Postmenopausal Osteoporosis and Estrogen. American Family Physician. 2003;68(4]: 606-612.
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