Emerging evidence is reshaping how clinicians understand women’s bone health after menopause. A new wave of observational data suggests that women with a history of infertility, recurrent miscarriages, stillbirth, or low parity face a significantly higher risk of osteoporosis once they reach natural menopause. Surprisingly, age at menopause, which was long considered a primary determinant of bone loss, appears to have little influence on these associations. In fact, the studies are highlighting that reproductive history itself may be a powerful predictor of long-term skeletal health.
Dr Sandhya Mishra, Consultant – Reproductive Medicine – Obstetrics and Gynaecology, Milann Fertility Hospital, Bengaluru, says, “For decades, menopause was seen
as the turning point for bone density decline due to reduced oestrogen levels. However, fertility patterns across a woman’s life may offer even deeper insights. Conditions such as repeated pregnancy loss, difficulty conceiving, or having fewer children than biologically attempted are often rooted in underlying hormonal, metabolic, or autoimmune factors. These same factors may also compromise bone strength over time.”
Importance of reproductive history for bone health
Women who face infertility often have hormonal irregularities, which include low oestrogen, thyroid disorders, polycystic ovarian syndrome (PCOS), or diminished ovarian reserve, each of which plays a crucial role in regulating bone turnover. When oestrogen levels remain suboptimal for years, bones tend to become porous long before menopause begins, explains Dr Sandhya Mishra.
Similarly, recurrent miscarriages and stillbirths, although caused by diverse factors, are frequently linked to chronic inflammation, autoimmune disorders, and coagulation abnormalities. Many of these conditions subtly alter calcium metabolism or increase bone resorption, contributing to reduced bone density later in life.
Low parity, which is defined as having fewer pregnancies carried to a viable gestational age, has also been identified as a risk marker. Each full-term pregnancy creates a surge of oestrogen that temporarily protects bone mass. Dr Sandhya Mishra says, “Women who do not experience these protective phases may have comparatively lower cumulative oestrogen exposure across their lifetime.”
Age at menopause is not the full story
Traditionally, early menopause is considered a strong predictor of osteoporosis. While this remains true, recent insights reveal that irrespective of when menopause occurs, a woman’s reproductive journey, fertility challenges, pregnancy outcomes, breastfeeding patterns, and parity, may independently shape her bone health trajectory.
Dr Sandhya Mishra says, “This is particularly important for Indian women, who often delay fertility for education and career or face silent reproductive disorders that go undiagnosed for years. By the time they reach menopause, many of these women have never been evaluated for underlying endocrine or metabolic issues that could have been managed early.”
Also, most women always put family responsibilities first over their personal health, making conditions like low bone density go unnoticed until a fracture occurs.
Why fertility–bone health integration should be prioritised
Reproductive health is not confined to the years of attempting conception. Instead, it forms the foundation for lifelong metabolic and skeletal well-being. Dr Sandhya Mishra says, “Women with infertility or recurrent pregnancy loss frequently undergo hormonal assessments, but these evaluations rarely extend to bone markers, vitamin D levels, or long-term osteoporosis risk screening.”
Integrating bone health into fertility care can help clinicians identify at-risk women decades earlier, enabling timely intervention through lifestyle modification, nutritional counselling, and medical therapy when required.
Remember, reproductive challenges are often windows into deeper hormonal imbalances. When a woman experiences infertility, repeated miscarriages, or low parity, it is not just about fertility; it is about her long-term health. Screening these women for bone health early can prevent major complications after menopause. A woman may reach menopause at a normal age but still be at high risk of osteoporosis if she has had unresolved fertility or pregnancy-related issues.
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