Stronger Bones, Stronger Women: Dr Kenna’s Guide to Fracture-Proofing Your Future

In this blog, Dr Kenna Stephenson, (left) a family physician and Associate Professor at The University of Arizona College of Medicine, shares her practical advice on how women can prevent fractures now, and falls tomorrow. 

Why bone health matters early

Bone health often only becomes a priority after someone suffers a fracture; however, ideally it should be a focus from childhood, because bone mass peaks in our 20s. Building higher peak bone mass can delay the onset of osteopenia and osteoporosis later in life.

The advantage of youth does not guarantee good bone density though, as I discovered by chance as a 26‑year‑old medical intern.

A surprising DEXA scan result

I was fortunate that a radiologist offered me a complimentary screening with his new DEXA machine – the gold‑standard test for diagnosing osteoporosis. It directly measures bone mineral density (BMD) at key fracture‑risk sites such as the hip and spine, using very low‑dose X‑rays.

Being a non‑smoker, non‑drinker, physically active, with plenty of outdoor sunlight exposure and no chronic disease, I anticipated good results.

My history suggested this as well. The only time I had suffered a fracture was when I was ten years old and collided with a large woman at a roller‑skating rink. She lost her balance and fell on me, resulting in a broken wrist.

Shockingly, the DEXA scan revealed that my bone density was that of a senior woman. On reflection, I realised I had risk factors in childhood and adolescence that contributed to this outcome, particularly gymnastics, cheerleading and poor nutrition.

Understanding the Female Athlete Triad

This pattern is part of a medical condition known as the “Female Athlete Triad”, which typically affects physically active girls and women, especially in sports that emphasise low body weight. Long‑distance runners, gymnasts and dancers show higher rates of this condition.

The Female Athlete Triad is defined by three components: 

•       Low energy availability with or without disordered eating 
•       Menstrual dysfunction 
•       Low bone mineral density

Girls and women in sports that emphasise leanness have higher risk, including gymnastics, cheerleading, dance, figure skating, middle‑ and long‑distance running, pole vaulting, lightweight rowing and wrestling. This condition was formally recognised by the American College of Sports Medicine in 1997 – seven years after my alarming DEXA result.

Athletes can present with a single component or any combination, and recognition by coaches, parents, trainers and physicians is essential for early intervention.

How bone loss develops

Bone loss can range from mild thinning (osteopenia) to severe weakness (osteoporosis) when young people do not build enough bone. This can happen because of hormone problems, not eating enough and/or doing too much intense exercise. 

Research shows that Triad‑associated problems in female long‑distance runners may be present even when BMI is in the normal range. Low bone mass increases the risk of stress fractures and raises the likelihood of osteoporosis and fractures with aging.

Other risk factors for women

More generally, for women, other risk factors to be aware of include early menopause, a sedentary lifestyle, family history, certain athletic pursuits (such as dance, figure skating and long‑distance running), chronic diseases and some medications.

Since that revealing scan in my 20s, I have ordered thousands of DEXA scans, guided patients with osteopenia and osteoporosis through treatment, and conducted clinical research in osteoporosis.

Screening, FRAX scores and insurance

Some insurances and health plans do not cover DEXA scans for women younger than 65, so calculating your FRAX score – an estimate of a person’s 10‑year risk of breaking a major bone (hip, spine, forearm or shoulder) due to osteoporosis – can be very helpful. You can do this at: www.knowyourbones.org.au 

Medications and supplements that improve bone metabolism are often warranted; however, relying on infusions or tablets alone is not enough.

Why muscle mass matters for fractures

A recent study of over 20,000 patients (95% female) aged 40 and older found that a decrease in muscle mass increased fracture risk over 7 years, highlighting the importance of maintaining good muscle mass as we age.

For the 37% who were already on osteoporosis medications, their fracture risk rose significantly as their muscle mass decreased, with a 26% increase in hip fracture risk and a 10% increase in other fractures.

These results support my approach to bone health: combining strategies to build muscle mass and improve balance with medications and supplements that increase bone density.

Building muscle: my top recommendations

In terms of building muscle, my top recommendations include progressive strength training and using a weighted vest. These approaches are especially valuable for women in and after menopause, when bone and muscle loss tend to accelerate.

One of my post‑menopausal patients in her 50s/60s refused medication and instead embarked on weightlifting to build bone. She went on to become a world champion weightlifter for her age group.

A simple weighted‑vest routine

For patients who have limited time or finances, I have designed a Weighted Vest Workout routine, using movements based on research showing they can increase bone and muscle mass and improve balance: https://youtu.be/_UiobO7UJrM?si=Or_l27lOnAcYvcHu

I recommend the Elite or Pro Hyperwear vests, which are washable, durable and make a perfect Mother’s Day or birthday gift. Based in Austin, Texas, Hyperwear ships internationally and has kindly offered a 5% discount code – DRKENNA – redeemable at www.hyperwear.com. 

For patients with a sedentary lifestyle, I encourage building a regular routine of using a weighted vest several times a week to improve strength and balance as a preventative measure against osteoporosis and falls.

Begin by holding onto a chair back or countertop during movements, then, as confidence increases, perform the routine unaided.

• Start with 2 or 3 pocket weights in the vest, positioned evenly front and back.
• Do three sets of toe/calf raises, lunges, squats and jumps. (Exercises may be omitted or modified for health conditions.) 
• Begin with hands on hips; over time, extend arms outward and upward as balance and strength improve.
• Rest for 15 seconds between each set. This brief rest enhances the bone‑building effect.
• Add 3–4 pocket weights per week to the vest (as tolerated), aiming to gradually reach a total weight of about 10% of your body weight.

After use, I spray my vest with a fabric spray and air it out, then machine‑wash it about once a month.

Confidence and independence in everyday life

The habit of including forward lunges, as described in my routine above, paid off at a parade recently. Wanting a closer look, I stepped up to the viewing line and knelt on one knee. Even without anything to hold onto, I was able to move forward and backward in that tight space, arms extended, while holding my bag and phone. 

Incorporating these exercises brings greater confidence of movement and more enjoyment in everyday activities – something I have just experienced firsthand.

Learn more about Dr Kenna and listen to her podcast interviews at https://doctorkenna.com

References

1.     Hamaguchi K, Kurihara K, Fujimoto M, et al. The effect of low-repetition and light-load power training on bone mineral density in postmenopausal women with sarcopenia. BMC Geriatr. 2017:17

2.     Roghani T, Torkaman G, Movasseghe S, et al Effect of short-tem aerobic exercise with and without external loading on bone metabolism and balance in postmenopausal women with osteoporosis. Rheumatol Int 2013:33(2):291-8

3.     Jessup JV, Horone C, Vishen RK, Wheeler D, effects of exercise on bone density, balance and self-efficacy in older women. Biol Res Nurs. 2003;3:171-80.

4.     Snow CM, Shaw Jm, Winters DM, Witzke KA. Long-term exercise using weighted vests prevents hip bone loss in postmenopausal women. J Gerontol & Biol Scie Med Sci ,2000;55(9): M489-91.

5.     Klentrou P, Slack J, Roby B, Ladouceur M. Effects of exercise training with weighted vests on bone turnover and isokinetic strength in postmenopausal women. J Aging Phys Act. 2007:15(3):287-99.

6.     Black DM, et al, Stephenson K (site PI) Once-yearly Zoledronic acid for treatment of postmenopausal osteoporosis, The New England Journal of Medicine. 2007:356(18):1809-1823

7.     Stephenson, K, The Gospel of Women’s Health: Awakening Athena Again, Spotlight publishing 2023. Available in audio, print and digital versions www.doctorkenna.com

8.     Giangregorio LM, Alexiuk MR, Tangri N, Bohm C, Leslie WD. Among people on osteoporosis medication, loss of appendicular or total body lean mass is an independent risk factor for hip and major osteoporotic fractures. Osteoporos Int. 2024 Nov;35(11):2025-2035.

9.     Lu M, Li M, Yi L, Li F, Feng L, Ji T, Zang Y, Qiu J. Effects of 8-week High-Intensity Interval Training and Moderate-Intensity Continuous Training on Bone Metabolism in Sedentary Young Females. J Exerc Sci Fit. 2022 Apr;20(2):77-83.

10. MacKnight JM. Osteopenia and Osteoporosis in Female Athletes. Clin Sports Med. 2017 Oct;36(4):687-702.