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Introduction   

Menopause marks the end of a woman’s reproductive cycle with roughly 1.3 million women becoming menopausal in the United States each year (9). Women are typically familiar with the common symptoms associated with menopause, such as hot flashes, weight gain, vaginal dryness, night sweats, mood dysregulation, and decreased libido, but many women may not be aware that significant bone loss—as much as 20%—occurs during the first five years of menopause (1).

Osteoporosis is the most prevalent bone disorder in humans and affects one in 10 women over the age of 60 globally, yet it is termed a “silent disease” because the patient may not be aware of the symptoms (7). Osteoporosis is more common in Asian and non-Hispanic white women than African American, Hispanic, and other women of color; however, women of all backgrounds are at risk of developing the condition and therefore should prevent against it (1, 4, 7). One in two postmenopausal women has osteoporosis that leads to bone fracture, particularly of the spine, hip, and wrist (1, 6, 7). Fractures are associated with increased morbidity and mortality, and menopause is the most common cause of osteoporosis that leads to these fractures (1, 4, 6).

In the United States, more than two million fractures related to osteoporosis occur each year, with 700,000 of these occurring in the vertebrae, 400,000 in the wrist, and 300,000 in the hip; two-thirds of these fractures occur after age 75 (3, 6, 11). Vertebral fractures are associated with severe pain, loss of height, kyphosis (extreme curvature of the thoracic spine), restricted mobility, and impaired lung function (due to kyphosis) (6). These women can experience impaired body image, loss of independence, increased isolation, decreased self-esteem and self-worth, and anxiety and depression (6).

Hip fractures, which typically occur at age 82 on average, result in greater disability and higher cost than all other fracture types combined (6). Within one year of the hip fracture, women’s mortality rate increases 25% (6). Up to 25% of women with hip fracture require long-term rehabilitation care and 50% will experience prolonged loss of mobility (6). A second hip fracture occurs roughly two years after the first in up to 10% of women (6). Young postmenopausal women are prone to less serious fractures, particularly of the wrist, which can be an indicator of future osteoporosis (6).

Estrogen deficiency that causes postmenopausal bone loss is the main contributor to osteoporosis, but newer research is finding a link between the immune system and the skeletal system (6, 12). Additionally, gut microbiome is now believed to play a role in osteoporosis (12). Regardless of the cause, bone fractures cause increased disability, reduced physical function, poor quality of life, and financial burden (4).

Since osteoporosis is very common and costs the U.S. close to $15 billion, it is imperative that nurses incorporate a skeletal health assessment and review of potential risk factors for osteoporosis into the routine care of postmenopausal female patients (1, 6).

Pathophysiology

Menopause is the complete absence of menstrual periods for 12 consecutive months, which marks the end of a woman’s reproductive years (4, 8, 9, 13). Years prior to this, the menstrual cycle becomes irregular, and women may begin to experience symptoms due to hormonal changes. Menopause can also be triggered by hysterectomy, chemotherapy, or radiation therapy (13). Women ages 45 to 55 experience the transition to menopause, with the median age being 51, although some women may experience menopausal symptoms earlier (8, 9). An earlier transition to menopause may be due to chromosomal abnormalities, autoimmune disorders, certain medications, or other undetermined etiology (11, 13).

During menopause, the ovarian follicles diminish in number and the ovaries stop releasing eggs for fertilization. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) production increases while estrogen levels decrease, which lead to the cessation of endometrial development, causing irregular menstrual cycles until they cease altogether. Additional changes during menopause include vaginal atrophy and fragility due to decreased estrogen levels. Estrogen deficiency also leads to vasoconstriction of arterial walls and an increase of low-density lipoprotein (LDL). Because of this, menopause is linked to the increased risk of cardiovascular disease. Lower levels of estrogen also cause bone reabsorption and overall bone loss (9).

Osteoporosis is a progressive, chronic skeletal disorder where the bones become more porous, and thus less dense, which weakens them and makes them more likely to fracture (1, 4). Although osteoporosis affects both genders and can occur at any age, hormonal changes during menopause lead to osteoporosis, increasing women’s risk of bone fractures (1, 2, 7). Menopause causes estrogen levels to fall dramatically, leading to increased bone resorption, which disrupts bone homeostasis (4).

Osteopenia is a loss of bone mineral density that weakens bones (1). Having a diagnosis of osteopenia does not guarantee a diagnosis of osteoporosis, but there is a strong correlation since osteopenia can be a precursor to osteoporosis (1).

Bone is composed of several elements, including collagen, matrix proteins, calcium crystals, and cellular components. The cellular components of bone are osteoblasts, osteoclasts, osteocytes, stromal cells, mesenchymal stem cells, and hematopoietic stem cells. Osteoblasts produce collagen and other proteins to enhance calcium deposits in the bones. Osteoclasts release hydrochloric acid proteolytic enzymes that demineralize bones, which keep the osteoblasts in check. The osteoblasts and osteoclasts work against each other in an effort to keep each other in check, which in turn results in the continuous formation and resorption of bone, referred to as bone remodeling. This helps maintain calcium levels in the blood. Bone homeostasis is regulated by the interaction of three components: receptor activator of nuclear factor-κB (RANK), ligand for a RANK receptor (RANKL), and osteoprotegerin (OPG). Any imbalance in the relationship among these components can lead to osteopenia and osteoporosis (2, 6, 12).

Bone goes through a continuous cycle of modeling and remodeling where the balance between the bone resorbing cells (osteoclasts) and bone-forming cells (osteoblasts) maintains bone mass (2, 6, 12). During modeling, bone formation or bone resorption occurs, which lends to the shape and dimension of the bones. During remodeling, old and damaged bones are renewed and maintained. Osteoporosis occurs by an imbalance of bone resorption and bone remodeling when bone resorption exceeds bone formation at an accelerated rate (10, 12).

Several health conditions, such as diabetes, hyperparathyroidism, lupus, multiple sclerosis, cancer, organ transplant, and rheumatoid arthritis can lead to osteoporosis. Also, the natural inflammatory state of the aging adult can lead to osteoporosis because immune cells can affect bone remodeling (12).

Risk Factors 

There are no designated risk factors for menopause except for age because it is a natural biological occurrence in women that is not associated with a pathology (9). On the other hand, risk factors for osteoporosis include age, sex, genetics, menopausal status, education level, caffeine intake, tobacco use, alcohol use, diet, decreased physical activity, and body mass index (BMI) and body weight (4, 6).  

Low bone mineral density (BMD) is the best tool for osteoporotic fracture prediction, and there are risk factors associated with BMD (4). Low bone mineral density risk factors are (4, 6, 7): 

• Gender: Osteoporosis occurs more in women than men due to women’s lower peak bone mass and smaller bones. 

• Advanced age: With aging, bone loss happens more quickly, and new bone growth slows, which increases the risk of osteoporosis. 

• Ethnicity: Asian and non-Hispanic white women are at highest risk for osteoporosis, but the condition does affect women of all ethnic backgrounds. 

• Body mass and weight: Bone density is strongly correlated with body weight. Older women with a body mass index (BMI) less than 21 kg/m2 and body weight less than 127 pounds are at greater risk of osteoporosis. Even though overweight and obesity lead to lower risk of osteoporosis, maintaining a healthy weight is encouraged in all patients. 

• Tobacco use: Women who smoke have lower BMD than nonsmokers. Smokers are generally thinner, have lower estradiol levels, and experience menopause earlier than their nonsmoking counterparts. 

• Genetics: Disorders with a genetic component, such as hemochromatosis and thalassemia can affect BMD. 

• Diseases: Disordered eating (anorexia nervosa), chronic inflammatory diseases (rheumatoid arthritis), digestive malabsorption conditions (celiac disease), and endocrine disorders (Cushing syndrome) contribute to low BMD.  HIV/AIDS also puts patients at risk for osteoporosis. 

• Medications: Certain medications can increase bone resorption that leads to bone loss, such as aromatase inhibitors, cytotoxic agents, proton pump inhibitors, selective serotonin reuptake inhibitors, glucocorticoids, antiepileptics, and thiazolidinediones. 

• Surgeries: Procedures like gastric bypass can lead to BMD. 

There are several lifestyle risk factors that are associated with low BMD and osteoporosis. These are (6, 7): 

• Tobacco use 

• Chronic and heavy alcohol use 

• High to excessive caffeine intake 

• Vitamin deficiency, particularly in calcium and vitamin D  

• Low levels of physical activity and prolonged periods of inactivity

Signs and Symptoms 

The major symptom of menopause is change in the regularity and flow of the menstrual cycle, which culminates in the cessation of menstruation. Additional symptoms of menopause are typically viewed as undesirable by women and include (9, 13): 

• Hot flashes: Sudden onset of feelings of heat in the face, neck, and chest accompanied by flushing of the skin characterize hot flashes. This flushing causes intense diaphoresis, and the combination of symptoms can last for three to four minutes at unpredictable intervals. Alcohol, food, physical exertion, and emotional stress can increase the intensity of hot flashes.  

• Heart palpitations and increased blood pressure: Arterial vasoconstriction can lead to increased blood pressure, and heart palpitations can be experienced during menopause. 

• Headaches: Migraine headaches without an aura are more common than migraines with an aura during menopause. Cluster and tension headaches can also increase due to hormonal changes. 

• Night sweats and insomnia: Vasomotor changes can cause night sweats, which can lead to insomnia. 

• Urogenital changes: Vaginal atrophy during menopause can result in dryness, pruritus, and dyspareunia (painful intercourse), while urethral atrophy can cause stress incontinence, and urinary frequency, urgency, and dysuria.  

• Breast changes: Breast size and shape can decrease during menopause, but breast size can also increase if the woman experiences excessive weight gain. 

• Height and weight changes: Women can gain an average of five pounds during menopause, as well as lose height due to osteoporosis. 

• Mood changes: Anger, irritability, anxiety, tension, depression, loss of concentration, and loss of self-esteem and impaired self-confidence can be present in menopausal women. 

If left untreated, the vasomotor symptoms of menopause will eventually dissipate after roughly seven years (9). However, post-menopausal women should be aware that they are at an increased risk for cardiovascular disease. Coronary heart disease rates are as much as three times higher in women who have reached menopause versus those of the same age who have not, which is why women in this age group are encouraged to maintain a healthy lifestyle (9). 

Since osteoporosis silently weakens the bones, the signs and symptoms of the disorder can be difficult to pinpoint prior to the patient sustaining an unexpected fracture. Minor falls that result in a fracture that would not normally cause a broken bone is the main symptom of osteoporosis (7). Also, fracture after normal stresses, such as bending, lifting, or even coughing can indicate osteoporosis (7). 

Other possible warning signs of osteoporosis are losing an inch or more of vertical height, a more stooped or bending posture, dyspnea (when spinal compression impairs lung function), and pain in the lumbar spine (7).

Prevention  

Menopause is not a physiological change that can be prevented; however, the uncomfortable symptoms and risk for serious conditions associated with menopause can be managed.  

Tips to reduce menopause symptoms and serious health complications include (8, 9, 13):  

• Tobacco cessation: Smoking can intensify menopause symptoms, as well as contribute to chronic conditions, such as heart disease. 

• Rest and sleep: Getting enough rest is important during menopause. If insomnia is an issue, women can drink warm milk or chamomile tea at bedtime to help increase drowsiness.  

• Caffeine reduction: Reducing caffeine intake can improve sleep and also decrease bladder irritability.  

• Physical activity: Exercise can strengthen bones, improve flexibility and posture, and improve mood. 

• Cold drinks and temperature control: Drinks that are cold can help decrease the intensity of hot flashes. Ice packs placed on trigger points (inner elbows, behind the knees) and the use of air conditioning and fans can also help cool the body. 

• Healthy diet: Women should eat a diet rich in vitamins and minerals and avoid trigger foods, such as spicy and acidic foods, that can increase the intensity of hot flashes and urinary incontinence. Phytoestrogens are plant-based compounds that can balance hormone loss and the symptoms associated with menopause. Foods rich in phytoestrogens are fruits, vegetables, and legumes.  

• Supplements: Calcium, vitamin D, and magnesium supplements can help increase energy levels. Some herbs like black cohosh have been shown to reduce menopause symptoms. 

• Outdoor recreation: Getting outside in the sunshine can boost vitamin D levels, improve mood, and strengthen bones. 

The primary goal of osteoporosis prevention is to minimize bone loss that can lead to fractures (6). Nurses should assess the patient’s risk factors for fracture (including fall risks), lifestyle practices, and medications to gain a holistic view of the patient (6). Good nutrition (protein, calcium, vitamin D), regular physical activity and outdoor recreation, avoiding tobacco and alcohol use, and regular healthcare screenings are imperative for maintaining healthy bones (6, 11). 

Avoiding falls includes removing loose rugs, electrical cords, and unsteady or unsupportive furniture; providing adequate lighting inside and outside of the home; avoiding walking on slippery surfaces, including those that are wet or icy; maintaining eye care health by visiting an ophthalmologist or optometrist; and wearing appropriate non-slip footwear (11).

Diagnostics and Treatment 

Menopause diagnosis typically does not require laboratory testing, but rather is based on the woman’s age and self-report of symptoms (9). If laboratory testing is performed, a follicle-stimulating hormone (FSH) greater than 40 mlU/mL can indicate menopause due to ovarian failure (9). The nurse should be mindful that medications like estrogens, androgens, and hormonal contraceptives can alter lab results (9).  

Osteoporosis screening should begin at age 65 if the patient does not have significant risk factors. If osteoporosis is a concern due to patient history of falls, fractures, and certain medications, a dual-energy x-ray absorptiometry (DEXA) scan can be done. Most physicians recommend DEXA of the hip and spine to adequately predict osteoporotic fracture. If the patient has hyperparathyroidism, the forearm may be measured in addition to the spine and hip since the bone density at the forearm may be lower than in other bones (11).  

If possible, DEXA follow-up screenings should be performed in the same facility as the original screening to ensure that testing is performed on the same model of machine since results can vary among machines (11).  A T-score on DEXA of -1.1 to -2.4 is indicative of osteopenia, while a T-score greater than -2.5 is indicative of osteoporosis (7). Patients who have a history of low trauma bone fracture are classified as having osteoporosis regardless of T-score (11). 

When patients should have a bone density exam is determined by (11): 

• If the initial T-score is -2.00 to -2.49 at any site, or if the patient has a history of bone conditions or takes medications that decrease bone density, the test should be repeated every two years. 

• For females 65 years and older with no risk factors for accelerated bone loss and an initial T-score of -1.50 to -1.99, screening should be conducted every three to five years. 

• In females 65 years and older with a T-score of -1.01 to -1.49 and no risk factors for accelerated bone loss, DEXA should be performed every 10 to 15 years. 

Ultrasound of the heel is also used to determine future risk of fracture. There are no guidelines for this type of diagnostic, so it is only recommended if access to a DEXA machine is not possible (11).  

The Fracture Risk Assessment Tool (FRAX) is an online tool where patients and healthcare providers can input patient information to estimate the patient’s risk of a 10-year likelihood of having a minimal trauma fracture. FRAX can be used to determine if it is an optimal time for the patient to receive a DEXA test (11). 

Treatment of menopause and osteoporosis symptoms focuses on medications and complementary therapies. Treatment options include (9, 11, 13): 

• Hormonal therapies: These therapies can be in the form of tablets, creams, and patches and can be administered orally, topically, and vaginally. Hormonal therapies include estrogen, estrogen-progestin, estrogen-bazedoxifene, progestin alone, or combined oral contraceptives. Hormone therapy should be used for the shortest duration and the lowest effective dose since the risk of breast and ovarian cancers, thromboembolisms and strokes, and coronary heart disease are prevalent with long-term use.  

• Selective estrogen receptor modulators (SERMs): These medications (raloxifene, bazedoxifene, ospemifene) modulate estrogen action without increasing the risk of cancer. They also prevent bone loss, improve lipoprotein levels, decrease urogenital symptoms (urinary incontinence and vaginal dryness), and decrease vasomotor symptoms, such as hot flashes. 

• Non-hormonal therapies: Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, and clonidine are used for the short-term to treat vasomotor symptoms of menopause.  

• Complementary therapies: Phytoestrogens (soy, red clover, black cohosh), vitamin E, and omega fatty acids treat the vasomotor symptoms of menopause, osteoporosis, and high cholesterol.  

• Osteoporosis-specific therapies: Menopausal women who experience osteoporosis alone, not including menopause symptoms, can use bisphosphonates, such as alendronate, risedronate, ibandronate, and zoledronic acid to slow bone resorption. Oral bisphosphonates need to be taken first thing in the morning on an empty stomach with a full eight ounces of still (not sparkling) water. The patient should remain sitting up after administration to decrease gastric upset and wait for one hour before eating or taking additional medication.  

Denosumab, a human monoclonal antibody, increases bone density in osteoporosis patients. Calcium and vitamin D prevent bone weakness and fractures. Anabolic agents, such as parathyroid hormone and parathyroid hormone-related protein, reduce the risk of vertebral fractures. These are typically administered subcutaneously and are marketed under the brand names of Forteo, Tymols, and Evenity.

Patient Education 

Menopause carries significant morbidity due to its correlation with serious illnesses, such as heart disease and osteoporosis. It is imperative that nurses educate patients about the physiology of menopause and osteoporosis, symptom control, and risk of more serious complications (9). 

Perimenopausal and postmenopausal women should be taught to (9, 10): 

• Stop smoking, especially if starting hormone therapy. 

• Decrease alcohol consumption, especially if excessive since high levels of cortisol seen in people with alcoholism increases bone mineral loss. 

• Engage in 150 minutes of cardiovascular exercise per week and weight-bearing exercise two to three days a week. 

• Eat a healthy diet to maintain healthy weight, including foods rich in calcium and vitamin D. Colas and sodas should be avoided since they are high in phosphorous.  

• Report painful intercourse and urogenital symptoms (urinary incontinence) to the healthcare provider. 

• Use contraception for one full calendar year after the last period and while experiencing irregular menses to prevent pregnancy. 

• Undergo regular healthcare visits to monitor risk for heart disease and osteoporosis. 

The main goal of osteoporosis patient education focuses on prevention of the disease and reducing the woman’s risk for falls. The nurse should also teach about the importance of regular bone density screenings (10).

Research Findings 

Osteoimmunology is a newer field of research that focuses on the physiological interactions between bone and the immune system. The main focal point at this time is the link between bone destruction in conjunction with rheumatoid arthritis, and even though osteoporosis is less understood than rheumatoid arthritis, the latter can help us understand the former (2, 12). 

Estrogen loss increases the number of osteoclasts and decreases the number of osteoblasts, which lead to bone resorption. Today, it is understood that estrogen’s effect on bone resorption occurs indirectly via the release of bone-active cytokines. Among these bone-active cytokines are inflammatory cytokines, which now indicates an immune component of osteoporosis. Proinflammatory cytokines in the presence of osteoporosis is found in many women during the first ten years of menopause. The elderly are prone to increased levels of proinflammatory markers, which in several studies has been linked to bone loss and fracture (2, 12). 

Prior to the 1970s, osteoporosis was thought to be caused solely by hormonal imbalances, but research in the past two decades, in particular, has indicated the firm involvement of immune cells in bone remodeling (12).  The term “immunoporosis” is being used in the field of osteoimmunology to signify the role of innate and adaptive immune cells in osteoporosis (12). The immune system is now thought to be highly linked to the skeletal system, with neutrophils, eosinophils, and mast cells showing direct involvement in osteoporosis (12). Additionally, innate immune cells produce proinflammatory mediators that lead to osteoporosis (12). 

The relationship between gut microbiome and the homeostasis of bone metabolism is also studied closely today. Autoimmune disorders such as diabetes (types 1 and 2) and rheumatoid arthritis change the microbiome in the gut. Additionally, the use of probiotics and antibiotics affect bone health. The gut microbiome influences the absorption of minerals (such as calcium) required for skeletal development and bone density. More specifically, intestinal pH values and microbial fermentation of dietary fibers to short chain fatty acids have a significant impact on the body’s inflammatory process (2). 

Osteoporosis has also been shown to be affected by senescence-associated secretory phenotype (SASP) where the number of senescent cells increases during the process of aging, which can lead to osteoporosis, atherosclerosis, hypertension, and diabetes. Cellular senescence is an arrest of the cell cycle that serves as a defense mechanism in response to stress. Cellular senescence has positive attributes in terms of tumor suppression, wound healing, and protection against tissue fibrosis, but it can be harmful in older individuals when it leads to bone remodeling that can disrupt homeostasis and increase risk of osteoporosis (2).

Resources for Women 

Osteoporosis screening is covered by most insurance plans, including Medicare Part B and most states’ Medicaid programs for women with lower incomes. The Health and Human Services Data Warehouse website includes a map where visitors can enter their location to determine free health clinics near them: https://findahealthcenter.hrsa.gov/.  

Other organizations that provide resources for women who are experiencing menopause and osteoporosis include:  

• North American Menopause Society: https://www.menopause.org/for-women 

• The Bone Health and Osteoporosis Foundation: https://www.bonehealthandosteoporosis.org/ 

• International Osteoporosis Foundation: https://www.osteoporosis.foundation/ 

• The National Institute on Aging: https://www.nia.nih.gov/health/osteoporosis 

• Office on Women’s Health: https://www.womenshealth.gov/a-z-topics/osteoporosis 

• Grassroots Health (Vitamin D Program): https://www.grassrootshealth.net/project/daction/ 

Additionally, The Capture the Fracture® program from the International Osteoporosis Foundation (IOS) and the Own the Bone® program from the American Orthopedic Association provide training and tools to healthcare systems to support post-fracture care and osteoporosis coordination programs worldwide that can improve women’s health (5).

Case Study 

M.J. is a 53-year-old white female who presents to the outpatient clinic with left wrist pain and swelling following a fall onto the left outstretched hand on carpeted flooring when getting out of bed. M.J. is married with two adult children who live outside of the home. However, she states that even though her sons do not live at home, they still contribute significantly to her daily level of stress since they both have substance abuse issues that lend to frequent run-ins with law enforcement. M.J. states that her marriage is solid and that her husband is “good about stepping up when he needs to.”  

M.J.’s current social history is that she smokes one pack of cigarettes a day, drinks 2-3 mixed alcoholic drinks containing vodka each evening (“to calm me down and help me sleep”), drinks 4-6 diet sodas daily while at work, and does not exercise, although her job as a customer service associate at a national department store requires her to stand, bend, lift, and carry up to 10 pounds during her five eight-hour shifts per week. Regarding not having a regular exercise routine, M.J. states, “My job is very physically demanding, and I am constantly moving and lifting things. There’s no need for me to pay the money to go to a gym.” M.J. plays in a bowling league once a week with her husband and several other couples. She does not enjoy the outdoors and prefers to unwind in front of the television or by playing solitary card games. 

M.J.’s pertinent past medical history includes: one pack of cigarettes per day smoker since age 23, general anxiety disorder diagnosed at age 42, heavy drinker since age 35, and underweight for current height and age (height 5’6”, weight 122 pounds). The patient does not take any medications except over-the-counter headache and stomach indigestion remedies. M.J. reports that her diet “could be better” since she does not enjoy vegetables, and she reports receiving adequate rest despite the alcohol and tobacco usage each night before bed. 

M.J.’s family history includes mother deceased at age 78 from cardiac arrest after myocardial infarction 30 days post hip replacement; father deceased at age 63 from lung cancer following four decades of one pack per day smoking; sister alive at age 48 with history of hypothyroidism and major depressive disorder; and brother alive at age 45 with no health history except seasonal allergies. 

M.J.’s physical assessment results include blood pressure 158/87, pulse 88, oxygen saturation level of 93%. Lungs are clear on auscultation bilaterally, and cardiovascular exam reveals a regular rate and rhythm without murmurs. Radial, pedal, and dorsal pedal pulses are normal bilaterally. The patient’s left wrist is swollen with limited range of motion, and the patient reports a pain level of 10 out of 10. X-ray revealed Colles fracture (distal radius) to the left hand, which was casted. All lab blood results are normal except for a vitamin D level of 10 ng/mL (normal is 20 ng/mL). The patient’s DEXA scan results revealed a T-score of -2.2.  

M.J.’s treatment plan includes:  

• Referral to a smoking cessation program 

• Referral to a 12-step alcohol treatment program 

• Referral to a dietician for healthy diet and weight gain guidance 

• Referral to physical therapy for left wrist care post cast removal 

• DEXA scan re-test in two years (at the same facility, if possible) 

• Vitamin D (1,000 IUs) and calcium (1,200 mg) supplementation 

• Alendronate (Fosamax) 70 mg once a week.  

• M.J. is also encouraged to follow the American Heart Association’s guideline for aerobic physical activity.

Conclusion

Due to the aging of society, it is probable that the cases of osteoporosis will only continue to increase dramatically in the future, thus necessitating the need for additional research and more effective therapies (2, 5). Bone health depends on multiple factors, such as age, hormones, diet, and the inflammatory status of the body. Women’s awareness of their risk factors for osteoporosis, specific symptoms, and preventative measures can decrease the incidence of the disease. Additionally, nurses’ understanding that osteoporosis is a “silent” condition can lead nurses to act more proactively in their assessment of women who are at risk for osteoporosis, especially those women who are postmenopausal.

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