Prolia vs estrogen

Prolia and Estrogen: Updated Guidance for Bone Health

Prolia (Denosumab)

Prolia is a medication used to treat osteoporosis in postmenopausal women and in men at high risk for fractures. It is a monoclonal antibody that targets RANK ligand (RANKL), a protein that drives bone breakdown.

How Prolia Works

• Inhibiting RANKL: RANKL activates osteoclasts, the cells that break down bone. Prolia binds to RANKL and prevents this activation, reducing bone resorption.

• Slowing bone turnover: When osteoclasts are suppressed, bone turnover slows and the body has more opportunity to build new bone.

• Increasing bone strength: This leads to improved bone mineral density and reduces fracture risk in people at high risk.

  
  

Important Safety Note

Prolia must be given every 6 months without delay. Missing or stopping injections can trigger rapid bone loss and multiple vertebral fractures within months. If Prolia is discontinued, a follow-on medication, usually a bisphosphonate, is necessary to prevent rebound fractures.

Estrogen and Bone Health

Estrogen is a key regulator of bone turnover. After menopause, estrogen levels fall sharply and bone breakdown accelerates, leading to a rapid decline in bone density and an increased risk of fracture.

Hormone Therapy (MHT or HRT)

HRT uses estrogen, with or without progesterone, to reduce bone loss. It lowers bone turnover, preserves bone density and reduces fracture risk. It is particularly effective for younger postmenopausal women, especially those under 60 or within 10 years of their last natural period. It also improves menopausal symptoms such as hot flushes, insomnia, mood changes and vaginal dryness.

Important Clinical Distinction

Once true osteoporosis is established, especially with T-scores below minus 2.5 or with fragility fractures, estrogen alone is usually not strong enough to rebuild bone or prevent further fractures. In these situations, women generally require a dedicated osteoporosis medication such as Prolia or a bisphosphonate, and estrogen may be added only if needed for symptom control.

For women with osteopenia, a combination of estrogen, resistance exercise, vitamin D, calcium and vitamin K2 is often sufficient to stabilise or improve bone density.

ONERO: Australia’s Evidence-Based Bone Strength Programme

The ONERO programme is an Australian, research-based strength programme specifically designed to improve bone mineral density and reduce fracture risk. It is delivered by Accredited Exercise Physiologists trained in the ONERO protocol.

Benefits of ONERO

• increases bone mineral density

• improves balance and functional strength

• reduces falls risk

• suitable for osteopenia and osteoporosis when supervised properly

Learn more or find a trained ONERO provider:https://www.onero.academy

Women with osteopenia often do very well with ONERO combined with good nutrition, vitamin D, calcium and K2. Women with established osteoporosis benefit from ONERO but usually require medication in addition.

Vitamin K2: A Key Nutrient for Bone Strength

Vitamin K2 is essential for proper calcium utilisation.

How K2 Supports Bone

• activates osteocalcin, the protein responsible for binding calcium into bone

• assists vitamin D by directing calcium into the skeleton

• helps prevent calcium from depositing in arteries

• supports bone density, especially when combined with weight-bearing exercise and vitamin D

The MK-7 form of K2 is commonly used because it has a longer half life and provides more stable blood levels.

Calcium: Individualised, Not Universal

Calcium is essential for bone structure but more is not always better. Modern guidelines focus on dietary calcium first.

Recommended Daily Intake for Women

Women aged 19 to 501000 mg per day

Women aged 51 and over (postmenopausal)1300 mg per dayBone resorption accelerates after menopause, which increases calcium requirements.

Therapeutic Range for Osteoporosis

Most major bone societies accept 1000 to 1300 mg of total calcium per day (from food plus supplements combined) as an appropriate target for:

• postmenopausal women

• women with osteopenia

• women at high fracture risk

• women on osteoporosis medications such as Prolia, oral bisphosphonates, intravenous bisphosphonates or anabolic therapy

  
  

Practical Notes

• Aim to meet calcium targets from food first.

• Supplement only if dietary intake is insufficient.

• Excessive calcium from tablets can cause kidney stones and may contribute to vascular calcification.

• Vitamin K2 helps direct calcium into bone and away from arteries.

Food sources include leafy greens, fortified plant milks, tofu set with calcium, nuts, seeds and dairy products.

World Osteoporosis Calcium Calculator

This tool helps determine your true daily calcium intake from food and whether supplementation is necessary.

International Osteoporosis Foundation Calcium Calculator:https://www.osteoporosis.foundation/educational-hub/topic/calcium-calculator

Vitamin D

Vitamin D enables calcium absorption and supports bone, muscle and immune function.

Requirements

• The standard maintenance dose for most adults is 1000 IU per day.

• People with low sun exposure, darker skin, malabsorption, or osteoporosis may require higher doses based on blood results.

• Vitamin D levels should be checked periodically to ensure adequacy.

Oral Bisphosphonates

Oral bisphosphonates are a commonly used first-line therapy for osteoporosis.

Common Options

• Alendronate weekly

• Risedronate weekly or monthly

• Ibandronate monthly (less common)

  
  

How They Work

• bind to bone surfaces

• inhibit osteoclast activity

• reduce bone resorption

• lead to gradual gains in bone density

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Bisphosphonates are suitable for people who:

• prefer oral treatment

• can follow strict dosing instructions

• do not want or cannot take Prolia

• need an option after finishing a course of Prolia

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They may be insufficient alone when T-scores are very low or fractures have already occurred, in which case injectable therapy may be required.

Putting It All Together

For Osteopenia

Women with osteopenia often achieve excellent results with:

• estrogen or perimenopausal HRT

• ONERO supervised resistance training

• adequate dietary calcium

• vitamin D 1000 IU daily

• vitamin K2

• whole-food nutrition and lifestyle changes

This combination is often enough to stabilise or improve bone density and prevent progression to osteoporosis.

For Established Osteoporosis

When osteoporosis is present, especially with fragility fractures or very low T-scores, estrogen alone is usually not enough.Most women require a dedicated medication such as:

• Prolia

• oral bisphosphonate

• intravenous bisphosphonate

• or anabolic therapy where availablealongside supportive measures including exercise, calcium, vitamin D 1000 IU and K2.

Estrogen can still be used for symptom management if indicated but is not relied upon as the primary osteoporosis treatment.

Summary

• Estrogen protects bone but works best in early postmenopause or in women with osteopenia.

• Once osteoporosis is established, stronger medications such as Prolia or bisphosphonates are usually required.

• ONERO is a proven Australian programme to improve bone density and reduce fracture risk.

• Vitamin K2, vitamin D 1000 IU and adequate calcium form the nutritional foundation for bone health.

• The World Osteoporosis Calcium Calculator helps determine true dietary calcium intake.

• Treatment should be personalised based on age, symptoms, severity, fracture risk and medical history.

Appendix: Jaw Osteonecrosis Risk and Long Bone Loading

Osteonecrosis of the Jaw (ONJ)

ONJ is a rare but recognised complication of medications that strongly suppress bone turnover, including:

• Prolia (denosumab)

• oral bisphosphonates

• intravenous bisphosphonates

  
  

What ONJ Actually Is

ONJ refers to an area of exposed bone in the jaw that does not heal within 8 weeks.It is usually triggered by:

• dental extractions

• poorly fitting dentures

• gum infections

• invasive dental surgery

• uncontrolled diabetes or smoking can increase risk

  
  

Actual Risk

• The risk is very low in otherwise healthy women using Prolia or oral bisphosphonates.

• It is highest in cancer patients receiving high-dose intravenous bisphosphonates, not in standard osteoporosis doses.

  
  

Prevention

• Have a dental checkup before starting therapy.

• Maintain excellent oral hygiene.

• Avoid elective tooth extractions during treatment if possible.

• If dental surgery is needed, your dentist and doctor will coordinate timing.

In osteoporosis treatment, the benefits far outweigh the risk.

Importance of Weight-Bearing and Impact Exercise

Medication alone cannot provide optimal bone strength. Bones require mechanical loading to grow and remodel.

Exercises That Strengthen the Long Bones

To stimulate the femur, pelvis, tibia and spine, exercises must include:

• impact or near-impact loading

• heavy resistance training

• movements that stress the long bones vertically

  
  

Effective choices include:

• squats

• deadlifts

• lunges

• step-ups

• weighted carries

• stomping exercises

• progressive jump training (where safe)

• ONERO exercises

• machine-based leg press or hack squat

• overhead pressing for spine loading

  
  

Why This Matters

Bone responds to stress by increasing density. Without load:

• medications work less effectively

• bone formation is limited

• the risk of falls and fracture remains high

  
  

Daily movement is good for health.

But only heavy, targeted, bone-loading exercise improves bone mineral density.

By Dr Purity Carr

Gp & Menopause Doctor

Harvey, WA