I’ve been watching women shrink in multiple ways over my career. There’s the shrinking of women, under pressure to be thinner, maybe on a GLP-1. I was one of them.
Then there’s the shrinking of the spine of older women that leads to height loss that comes after 50. Nobody chooses it. A woman loses a quarter inch, then another. Her spine may settle, sometimes over silent fractures. The story often ends in tragedy: a missed step, a broken hip, a daughter rearranging her life to drive to the hospital and her mother’s many new medical appointments.
I want a different ending for us.
So I read my own recent bone density report the way I’d want you to read yours by paying attention to detail. I told you in my last post that my DEXA came back normal at my hip and spine (L1-L4). Page one of my report says so. Page three, the page most women never see, tells a more complicated story about the same spine.
My L1 vertebra scored −0.8, edging toward osteopenia. My L4, three levels down, scored +2.1, presumable like a 25-year-old’s. It’s the same scan from October 28, 2026. The summary score averaged them into a reassuring +0.6, and if I’d read only that line, I’d have walked out believing my spine was younger than it is.
A gap that wide between neighboring vertebrae usually means something besides bone is being counted. Arthritis, bone spurs, and calcium in the aorta all register on a DEXA as density. The official positions for reading DEXA allow a vertebra to be set aside when it differs from its neighbors by more than 1.0 [1]. My spine is less impressive than its summary, and I’d rather know. I want you to pay attention to your result in this way.
Don’t be falsely reassured when vertebral bone density differs by 1.0. Differences that large usually point to degenerative changes or compression fractures, both of which push BMD up falsely.
We’ve accepted shrinking as the natural shape of an old woman. I don’t. Medicine checks a woman’s bones once, at 65, years after the fastest losses of her life, and offers her a pill if the number is low. The culture spends her teens and twenties asking her to shrink, her forties and fifties asking her to hold everyone else up, and her seventies calling her fragility inevitable. At no point does anyone ask her to be strong.
Here’s the ending I want. Women at 80 carrying their own groceries up the stairs, getting down on the floor with a grandchild and standing back up without a hand, traveling alone, lifting a suitcase into the overhead bin without scanning the aisle for help. I want strength in a woman’s later decades to be expected, trained for, and admired the way my generation once admired thinness. Bone builds where it’s asked to bear weight. A skeleton that carries nothing slowly gives itself away, and so does the independence it was holding up.
Strong bones at 85 are built on purpose, decades ahead of when we need them. So I wrote the protocol I use in my practice and on my own spine. By the end, you’ll be able to:
• read every line of your DEXA and know when a vertebra should be set aside
• order the three lab markers that show how fast you’re losing bone, years before a scan can
• decide whether hormone therapy belongs in your bone plan
• protect muscle and bone on a GLP-1
• choose loading and impact you’ll do, and judge the vibrating belt trial before you spend $1,000
• cut your supplement list to what has evidence
• talk to the young woman in your life about bone
• understand every FDA-approved bone drug, including the one you must never stop abruptly
My last essay was about what our bones remember. This one is about what we do with that memory. Everyone can read the first section, on reading and interpreting your DEXA. The rest, from the lab markers through the medications, is for paid subscribers, and it’s the most complete thing I’ve written on bone. If you’ve been deciding whether to upgrade, this is the post to do it for. I want you lifting your own suitcase at 85, and standing tall in your power.
My Recommended Lab Tests in Women 35+started it all.You Reached Peak Bone Mass at 20. Nobody Will Check Until You’re 65.Incluces the bone turnover markers NTX, CTX, and P1NP, estradiol and testosterone, and GLP-1s.Why our skeletons keep the record, and why I’m worried about our daughters.Your Bones Remember Everything.
This post is the protocol that ties them all together.
We were taught that bone density is a number you get once, at 65, and file away. A DEXA is more useful than that, if you know which numbers to read.
The T-score compares you with a healthy young adult at peak bone mass. It’s the number used to diagnose osteopenia and osteoporosis in postmenopausal women. The Z-score compares you with people your own age, and it’s the one to use if you’re still premenopausal. A Z-score of −2.0 or lower means your bones are below the expected range for your age [1].
Diagnosis rests on the lowest score among the lumbar spine, total hip, and femoral neck [1]. Ask for the printout that shows each vertebra, L1 through L4, along with the summary. If two neighbors differ by more than 1.0, ask whether one should be excluded.
The US Preventive Services Task Force recommends screening for all women 65 and older, and for younger postmenopausal women at increased risk [2]. Risk includes low body weight, a history of missed periods or disordered eating, early menopause, a parent with a hip fracture, steroid use, and significant weight loss. If you have any of these, ask for coverage. If you’re turned down, many imaging centers offer a cash-pay scan.
Small changes on DEXA can be machine noise. Repeat your scan on the same machine, at the same center, so a real change can be told apart from a calibration difference [1].
**Bottom line: **The number on page one may be falsely reassuring. Ask for every vertebra, both hip sites, and your Z-score, and over time, repeat your DEXA on the same machine.
The three blood and urine markers that show how fast you’re losing bone, two years before a DEXA can; the evidence on estradiol and testosterone; my GLP-1 bone protocol; how I think about impact, lifting, and vibration, including what the Osteoboost trial showed and what it didn’t; the supplements I recommend and the ones I skip, including what to know about AlgaeCal; the conversation I’d have with a 19-year-old; and every FDA-approved bone drug, sorted into brakes and builders, with the one rule about stopping denosumab.
I spent 25 years restricting through my peak bone years, and I still read my own spine number with suspicion.
Bone breakdown starts climbing about two years before your final period, often before you know you’re in perimenopause [3].
