24: The Thing Killing as Many Women as Breast Cancer That Nobody Is Talking About. Part 3

Hey, it’s Megan. Grab your coffee and let’s have a convo.

INTRO

Welcome back. I’m Megan Pfiffner and this is Mornings with Megan. We are wrapping up our three part move pillar series today and I have to tell you I saved one of my favorites for last. We have talked about cardio, we have talked about resistance training and today we are actually going to talk about bones and jump training and DEXA scans and lean mass and why all of this is actually just one conversation. I know on the surface bones don’t sound like the sexiest topic.

But I promise you, by the end of this episode, you’re going to see your skeleton in a completely different way. Because your bones are not just a frame that holds you up. They are a living, metabolically active organ system that is doing things your doctor probably has never told you about. And what happens to them in perimenopause matters enormously. And here’s the part that genuinely excites me. I think this will excite you too.

Almost everything that we can do for our bones is something that we’re already doing or something that we should be doing anyway. This is not another thing to add to your list. This is understanding why the list you already have is working on more levels than you realize. So let’s get into it.

WHAT BONE ACTUALLY IS

I want to start with some basics because I think most of us have a very flat image of what a bone is. We think of it as a structure, hard, static, calcium, like scaffolding, the thing that breaks when you fall.

But bone is a living tissue. It is constantly being broken down and rebuilt in a process called remodeling. Two types of cells run in this process, osteoclasts, which break down old bone tissue and osteoblasts, which build new bone. They are working all the time, every day, your entire life. Bone is in a constant state of renovation. And bone does a lot more than hold you up.

It’s a mineral reservoir storing and releasing calcium and phosphorus to keep your blood chemistry balanced. It protects your organs. But here is the piece that I think most people have never heard. Bone is an endocrine tissue. It produces hormones. Specifically, it produces a hormone called osteocalcin, which plays a role in insulin sensitivity and glucose metabolism. Your skeleton is participating in your metabolic health in a direct and active way. There is also emerging research

on bone’s role in immune function with bone marrow producing the immune cells that run your body’s defense system. So when we talk about bone health and perimenopause, we are not just talking about fracture prevention. We’re talking about a system that is deeply integrated with your hormones, with your metabolism, and with your immune function. The stakes are bigger than most people realize.

WHAT HAPPENS IN PERIMENOPAUSE

Now, here is where it gets very relevant for where you are right now.

Bone remodeling is regulated in part by your sex hormones. Estrogen acts as a brake on the breakdown side. It suppresses osteoclast activity, which means it keeps the demolition crew in check. When estrogen starts to fluctuate and decline in perimenopause, that brake releases. The osteoclasts become more active, breakdown accelerates. Progesterone plays the other side of this equation. Progesterone stimulates osteoblast activity, the building side.

In the years before your periods stop, when you’re cycling irregularly, when your cycles are short or anovulatory, your progesterone output drops. You lose the builder. And when you hit menopause and stop cycling entirely, you lose both signals in a meaningful way. The result is that remodeling process tips towards breakdown. You are losing more bone than you are building. And this happens fast in the first few years after menopause.

We are talking about 1 to 3% of bone mineral density per year in early menopause. That adds up. The reason this matters so much right now in perimenopause before you have crossed that threshold is that you are still in a window where you can do something about it. You can build bone. You can strengthen the structure before the remodeling balance tips. Perimenopause is not the beginning of the end of your bones. It is an alert that it is time to take this seriously.

OSTEOPOROSIS IS NOT INEVITABLE: BECK AND WRIGHT

I want to say something clearly here because I think a lot of women hear bone loss and menopause in the same sentence and they assume that osteoporosis is just part of the deal, that it’s coming for you no matter what. That is not the full picture. And I want to bring two voices up here who I find incredibly motivating on this. The first is Dr. Belinda Beck, one of the leading researchers in the world on exercise and bone health.

Beck calls osteoporosis and osteopenia diseases of childhood. What she means by that is that bone density you build in your teens and twenties is the bank account you draw from for the rest of your life. Peak bone mass is largely established by your mid-twenties. After that, you are managing what you have. But the key word there is managing. You are not just watching it decline. Her research, which we will get into,

shows that the right exercise can not only slow bone loss, but can actually reverse it in postmenopausal women. Not just slow it down, reverse it. The second voice is Dr. Vonda Wright, a double board certified orthopedic surgeon and author of the New York Times bestseller Unbreakable. Wright has spent 30 years operating on women who fracture. And what she says clearly is this, most of the fractures she sees were preventable. Women come to her after a break and it is often

when they find out for the very first time that they had osteoporosis. Nobody told them. Nobody screened them. The insurance system in the United States does not cover DEXA scans until the age of 65, which as Wright points out, years after the window when you could have actually done something about it. She calls this the critical decade between the years of 35 and 45 where most women still have estrogen on board and have every opportunity to build the habits that will determine what their skeleton looks like at 70 and at 80.

Her message is urgent and it is also hopeful. Frailty is not inevitable, but you do have to step in front of it. Together, Beck and Wright are pointing at the same thing from different angles. The research shows we can change this, but we have to act in this window, which is now. And here is the mortality framing I want you to hold on to. Approximately 40,000 women per year in the United States die from hip fractures.

That is roughly the same number of women who die from breast cancer annually. We are rightly terrified of breast cancer, but this particular consequence of poor bone health is killing women at the same rate with almost none of the cultural fear and awareness around it. A hip fracture in a postmenopausal woman is not just a broken bone. It is a clinical event with serious mortality implications. The data on this is stark and it should change how seriously we take this conversation.

BONE, LEAN MASS, AND THE METABOLIC CONNECTION

I want to come back to something I mentioned earlier because it connects this episode directly to everything that we talked about in episode 23 on resistance training. Bone is endocrine tissue and muscle is endocrine tissue. They talk to each other.

When we talk about lean mass, the muscle that you are carrying on your body, we talk about it as a glucose sink, an insulin sensitivity tool, a metabolic organ. We talked about it in episode 23 about the relationship between lean mass and cardiovascular disease, type 2 diabetes, metabolic syndrome, and insulin resistance. We talked about how being under-muscled is one of the most under-diagnosed metabolic problems that I see in my practice, especially in women who look healthy on the outside but whose glucose and hA1c

are quietly creeping up because there is simply not enough muscle to handle the glucose load. Lean mass and bone mass are not separate conversations. They are one conversation. Muscle pulls on bone. Mechanical load from muscle contraction is one of the primary signals that tells bone to remodel and strengthen. More muscle means more load on bone, which means stronger bones. When women lose muscle in perimenopause, and they do, they are also reducing the mechanical stimulus that keeps their bones building.

And here’s where the perimenopause piece comes layered in a way that I want you to really sit with. Declining estrogen affects both muscle and bone simultaneously. The same hormonal shift that accelerates bone remodeling towards breakdown also accelerates sarcopenia, the loss of muscle with aging. You are fighting on two fronts at the same time, which is exactly why a resistance training and movement strategy in perimenopause has to be proactive and intentional,

not the casual walk a few times a week that most of us were told was enough. The lean mass and bone health connection also ties directly into cancer risk, which I want to flag briefly because it is real and underappreciated. Adequate muscle mass is associated with lower risk of several cancers, particularly breast cancer and colorectal cancer, through multiple pathways, including insulin regulation, inflammation, and immune function. When we talk about building muscle in perimenopause,

we are not just talking about metabolism and bone. We are talking about building a body that is physiologically more resilient across the board.

ENTER DEXA

So how do we actually know what is going on with your bones and your lean mass? This is where the DEXA comes in. And I want to spend some time here because I think it’s one of the most underutilized tools in women’s health. DEXA stands for Dual Energy X-Ray Absorptiometry. It is a low

radiation scan that measures bone mineral density and body composition. It is considered the gold standard for both, with what we have access to as consumers. And it does two things that matter enormously in perimenopause.

First, it measures bone density. The output you care about is your T score and your Z score. Your T score compares your bone density to a healthy young adult at peak bone mass. A T score between negative one and negative 2.5 indicates osteopenia. Below negative 2.5 is osteoporosis. Your Z score compares you to age-matched peers, which is useful for context and understanding where you land relative to other women at the same stage of life. Second,

and this part I find just as valuable, your DEXA measures lean mass and fat mass, with regional breakdowns. You can see exactly how much muscle you were carrying in your arms, legs, and trunk. There is a metric called an ALMI, Appendicular Lean Mass Index, which measures the muscle in your limbs relative to your height. This is how we assess for sarcopenia before the clinical consequences show up. You can be a woman of normal weight, eating a healthy diet, and have

quietly inadequate muscle mass that is already affecting your glucose, your bone, and your long-term health trajectory. DEXA scans show you that before the scale does, which is basically never. How to use it. Get a baseline scan. One time per year is a standard recommendation. Same location, same time of day before eating.

Consistency matters because you’re going to be tracking trends and the meaningful comparison is your first scan to your fifth scan, not the numbers against some population average.

GLP-1 CALLOUT

A note specifically for anyone on GLP-1 medication. If you are taking semaglutide, tirzepatide, or any of the GLP-1 receptor agonists for weight loss, please get a DEXA scan before you start. This is not optional in my view. The research is clear that without intentional resistance training and adequate protein,

somewhere between 26 and 40% of the weight loss on those medications comes from lean mass, not fat. And bone density can drop with rapid weight loss as well. The scale will not tell you this is happening. A DEXA scan will. Most practitioners working seriously with GLP-1 patients recommend a baseline scan and follow-up at three to four months in, specifically to catch lean mass and bone changes early before you lose something that is really hard to rebuild. If your prescribing provider has not mentioned a DEXA, ask about it.

This is your health and you deserve the data.

MHT AND BONE HEALTH

Let’s talk about menopausal hormone therapy and bone health. The research here is actually quite strong and I think it’s underused in the bone health conversation. Estrogen containing MHT consistently shows meaningful protection against bone loss and fracture. One of the most compelling data points comes from the work covered in the book Estrogen Matters, which synthesizes the long-term fracture data. Estrogen therapy can reduce fracture risk by up to 50%.

That is comparable to bisphosphonates, which are the drugs most commonly prescribed for osteoporosis, and the benefits of MHT persist as long as you are taking them. Bisphosphonates can only be taken for five years because after that five-year period, there’s an increased risk for fracture. Here is a significant development in that conversation. In November 2025, the FDA removed the long-standing black box warnings for menopausal hormone therapy,

following a comprehensive review of the scientific literature showing that the risks are markedly lower for women who initiate MHT within 10 years of menopause or before the age of 60. Randomized studies show that women who initiate MHT within that window have a reduction in all-cause mortality and in fractures. More women now have access to MHT, and more providers feel confident prescribing it because the outdated warnings that drove two decades of fear have been removed. If you have been hesitant to have this conversation with your doctor,

now is the time. A few important caveats. Not all forms of MHT are created equal when it comes to bone protection. Systemic estrogen, meaning oral or transdermal estrogen that circulates throughout your body, is what the bone research is largely based on. Local or vaginal estrogen, which is wonderful and I recommend it for any kind of genitourinary symptoms, likely does not move the needle when it comes to bone density in a meaningful way because the systemic absorption is minimal.

If bone protection is part of your MHT conversation, systemic estrogen is the relevant form and that conversation belongs with your physician or menopause literate provider. The type of progestogen also matters in ways that are not fully settled in the literature. The WHI data that caused so much fear around MHT used synthetic progestins. Micronized progesterone, the bioidentical form, is considered metabolically neutral and the progesterone and bone research of Jerilynn Prior and colleagues may actually support bone formation through the effects on osteoblasts. This is one of the places where the nuances of MHT gets lost in the headline conversation.

And I want to be direct, calcium and vitamin D alone without systemic estrogen or exercise do not protect against hip fractures in postmenopausal women not on estrogen. That is not a knock on calcium and vitamin D, which are important for many reasons. But the just take your calcium recommendation is not a bone protection strategy on its own. It’s part of a foundational piece, but it is not the sole solution.

USING DEXA WELL

A few practical notes on getting the most out of your DEXA scan. Same machine, same location, every time you scan.

The DEXA calibration varies between machines, so comparing a scan from one facility to a scan from a different facility is not reliable. You want your own longitudinal data, which means that you need consistency. Morning, fasted, no exercise beforehand. Hydration affects soft tissue measurements, and recent exercise can temporarily alter some of the readings. Nine to 12 months is the standard interval between scans for otherwise healthy people. You are looking for trends over time, not month-to-month changes. One scan tells you where you are

right now, four scans tells you where you’re going. Ask for the full report, including your ALMI or FFMI if they are not automatically included, and ask for the visceral adipose tissue. A lot of facilities will give you the basic printout. Ask for the full report. This is your data. You deserve access to it. And finally, use your scan as a conversation opener with your provider, not as a verdict. A low T score is not a reason to panic.

It’s information and it tells you what to prioritize. It tells you where to direct your resistance training. It tells you whether the conversation about MHT needs to be more urgent. Data is not scary. Ignorance is scary.

RESISTANCE TRAINING AND BONE: THE REFRESHER

We covered resistance training in depth last week. So I will not relitigate the full argument here, but I want to make sure that you understand why resistance training is for bones and not just muscle. When you load your skeleton, you create mechanical strain on bone tissue.

That strain is sensed by cells called osteocytes, which are embedded in the bone itself. They signal to osteoblasts to ramp up bone formation. The process is adaptive. Bone builds where load is applied.

This is why resistance training builds bone at the hip and spine, which are the clinically important fracture sites, in a way that walking does not. Walking is load-bearing and it does help, but the magnitude of the load matters and targeted sites matter.

For bone health specifically, the research hierarchy is: heavy resistance training, then high impact loading, then general weight bearing activity. You want to be in that top tier of that hierarchy if bone density is a priority, which for perimenopausal women, it should be. How heavy? Heavy enough to meaningfully load the skeleton. This is one of the reasons that Dr. Stacy Sims pushes back on the light weights, high reps model that has dominated women’s fitness conversation. Her point is not that you need to be a power lifter. Her point is that load is the signal.

If the load is not sufficient to challenge the bone, the remodeling response is muted. This is also the premise behind Dr. Belinda Beck’s research team’s LIFTMOR work, which is why I want to spend time on that next.

THE LIFTMOR STUDY

Dr. Belinda Beck is a bone researcher at Griffith University in Australia, and her research team’s LIFTMOR trial, which stands for Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation, is one of the most important studies in the space. I want to walk you through it because the results are genuinely remarkable.

The LIFTMOR trial took postmenopausal women with low to very low bone mass, osteopenia and osteoporosis, and put them through a high intensity resistance and impact training program. We are talking about deadlifts, overhead press, back squats and jump chin-ups. This is not yoga or light resistance bands. Heavy supervised progressive lifting with impact.

The sessions were twice a week, 30 minutes each, supervised by Dr. Beck’s research team.

After eight months, the women in the high intensity group had significant improvements in bone mineral density at the lumbar spine and the femoral neck, which is the hip. These are the sites where osteoporotic fractures are the most devastating. The control group doing low intensity exercise did not see those improvements. The high intensity group also improved functional performance

and no serious adverse events occurred during the supervised sessions. Here is the thing that I find especially exciting about this data. These women were not on MHT. They were postmenopausal. They had already lost estrogen’s protective brake on bone breakdown, and they still reversed the bone loss through exercise alone. That is an extraordinary finding on its own. Now, layer in what we know today. In November 2025, the FDA removed the long-standing black box warning on menopausal hormone therapy. More women have access to MHT, and more providers feel comfortable

prescribing it. What does that mean for this episode? The LIFTMOR women reversed bone loss without MHT. If you add systemic estrogen into that picture, the bone protection potential compounds. Exercise builds bone. MHT protects the bones that you have. Together, they are a more powerful combination than either alone.

Beck’s research team’s work was also important because of the safety signal. There has been real hesitation in the medical community about putting women with osteoporosis through heavy lifting out of fear that they would break something. LIFTMOR showed that under proper supervision with progression, this population could lift heavy, get stronger, and see meaningful bone benefits without injury.

The bones most at risk from osteoporosis are the ones most responsive to load. Heavy resistance training is not contraindicated for women with low bone mass. For many women, it is the most powerful non-pharmacological intervention available.

JUMP TRAINING: THE SECOND BONE BUILDER

Now let’s talk about jump training. This is the piece that connects everything. Episode 22 on interval training, episode 23 on resistance training, and the bone conversation that we’re having today. The research on jumping and bone is solid, and it runs across multiple well-designed studies.

When you jump and land, the force traveling through your skeleton is a multiple of your body weight. That spike of load is the signal that your bones are waiting for. In premenopausal women, the evidence is particularly strong. One randomized controlled trial found that after 16 weeks of high impact jump training, hip bone mineral density improved in premenopausal women performing 10 to 20 jumps twice daily with 30 seconds of rest between each jump. A separate study of

postmenopausal women showed that over an 18-month period of progressive jumping, 50 to 100 two-footed hops three times a week, participants saw significant gains in hip bone mineral density, suggesting that the benefit is not limited to younger women. I want to be honest with you that the postmenopausal jumping data has more variability in it than the premenopausal data, and outcomes depend significantly on how the program is designed and progressed. The principle is sound. The details of the dose and type of impact matter.

This is an area of active research and the LIFTMOR program itself included jump chin-ups and drop jumps alongside heavy resistance training, which is how Beck’s research team combined both stimuli. The through line across these studies is this. Load has to be sufficient. Short bouts with real recovery periods between repetitions appear to work. The rest between jumps is not laziness, it’s part of the protocol because bone responds better to intermittent loading than continuous loading without recovery.

Now here is the efficiency piece that I am genuinely excited about and it connects directly back to Dr. Stacy Sims. Sims frames jump training as one of the most time efficient tools in the perimenopausal toolkit, specifically because it serves double duty. Jump training at intensity is a HIIT session. You are getting your cardiovascular and metabolic stimulus at the same time as your osteogenic stimulus. One workout,

two major physiological benefits. Think about a jump rope session structured as intervals. Think about squat jumps with work rest periods. Think about plyometric circuits in 10 to 15 minutes. This is not about adding bone work on top of your cardio. This is about doing your interval training in a way that also sends a bone building signal. Sims also talks about the neuromuscular benefits of jumping. When you jump and land, you are training reactive strength and proprioception, the physical skills that prevent falls.

Fall prevention is ultimately the proximal goal of bone health. Strong bones are wonderful. Not falling in the first place is also part of the strategy. I want to be direct with you about something before we talk about how to start because jump training asks something specific of your body that resistance training does not. The tissues that will feel this first are your feet, your ankles, and your calves.

The tendons and connective tissue of the lower leg are load-bearing in a very concentrated way when you jump and land. And they need to be ready before you add volume or intensity. This is not a reason to avoid jump training. This is a reason to prepare smarter. If you have any concerns about ankle stability, foot mechanics, or lower leg tightness, this is a genuine case

where seeing a physical therapist before you start is not a detour. It’s getting started the right way. A PT can assess your landing mechanics, your ankle mobility, and your calf strength and flexibility and give you a progression that’s specific to your body. This is not extra, this is being smart. If you’re starting from scratch, begin with controlled, soft, two-footed landings. Can you hop in place and absorb the landing quietly? That is your starting point. Build volume before intensity.

Add height and complexity gradually. Your tendons adapt more slowly than your muscles and giving them the time that they need protects you from injuries that would sideline the whole program.

PELVIC FLOOR CALLOUT

And one more thing before we move on. If you’re experiencing any leaking when you jump, I want you to hear this clearly. That does not mean that jumping is not for you. It means that your pelvic floor is asking for some attention. And this is not something that you need to tolerate or just manage around.

This is addressable at multiple levels and through multiple types of support. Start with a pelvic floor physical therapist. A pelvic floor PT can assess what is actually happening, whether it is a strength issue, a coordination issue, or something structural, and build a program specifically for you. Low dose vaginal estrogen is also highly effective for urinary symptoms in perimenopausal and postmenopausal women working on the urinary tract tissue at the root cause level. That is a conversation worth having with a urologist,

a urogynecologist, or a menopause literate provider. Leaking with impact is extremely common in perimenopausal women. It is not a verdict. It is a symptom and it is treatable. We’re going to do a full episode on the pelvic floor because it connects to everything that we’ve been talking about across this whole move series. But I didn’t want to leave you with don’t let the leaking stop you from jumping without also telling you that help exists and you deserve access to it.

THE WRAP

Let me bring this all together. Your bones are a living organ system that is deeply woven into your metabolic health, your hormone signaling, and your immune function. The same hormonal shifts in perimenopause that affect your mood, your sleep, and your body composition are also shifting the balance of your bone remodeling. This is not a distant concern for your future self. This is a present active process that you have meaningful influence over

right now. Osteoporosis is not inevitable. Dr. Belinda Beck’s research team’s work shows we can reverse bone loss in postmenopausal women with the right training. Dr. Vonda Wright has spent 30 years watching women fracture from a disease that was preventable, and she is clear:

frailty is a choice that we make by not acting. It is not an inevitability of aging. The window is not closed. It is open right now. Heavy resistance training, which we covered in episode 23, is the most powerful bone building exercise intervention available. It builds lean mass, which drives metabolic health, insulin sensitivity, cardiovascular protection, and cancer risk reduction, and loads the skeleton at the hips and spine where it matters the most.

If you are doing your two to three resistance training sessions per week, you are already doing your single most important bone health intervention.

Interval training using jumping, your jump rope, jump squats, plyometric intervals, are also serving as your HIIT or SIT sessions from episode 22. You are not adding a bone workout to your week. You are doing your interval training in a way that sends an osteogenic signal at the same time. Get your DEXA scan. Know your T score and your Z score. Know your ALMI. Get a baseline so that in two years and in five years you have data to work with. If you are on a GLP-1, this is especially urgent.

Baseline before you start, follow up at three to four months. Have the MHT conversation with your menopause-literate provider if you have not already. The black box warning has been removed. Systemic estrogen is one of the most effective bone-protective interventions that we have, and it is also managing your symptoms, your cardiovascular risk, and your cognitive risk at the same time. Bone protection is another reason it belongs in that conversation. And take this with you. The decisions that you make right now

in this window are among the most powerful in your life. This is why we move, not to be smaller, to be structurally resilient for the long game. That wraps up our Move Pillar of the Perimenopause Matrix three-part series: cardio and intervals, resistance training, bones and jumping. If you’ve not listened to episodes 22 and 23, go back. They are a trilogy and they build on each other.

If this episode was useful, share it with someone you love. Leave a review. It is genuinely the thing that helps other perimenopausal women find the show. I’ll see you next week.