CRITICAL IMPLICATIONS OF FEMALE BONE METABOLISM IN ORTHOPEDICS: STATE OF THE ART.

Abstract

Female bone metabolism is a dynamic and tightly regulated process that plays a pivotal role in musculoskeletal health and orthopedic outcomes across the lifespan. Bone remodeling depends on the balance between osteoblastic bone formation and osteoclastic bone resorption and is strongly influenced by hormonal status, nutrition, genetics, physical activity, and systemic disease. In women, this balance is profoundly affected by reproductive and aging-related transitions, including adolescence, pregnancy and lactation, perimenopause, menopause, and postmenopause. Maximal peak bone mass is typically achieved by late adolescence or early adulthood and is a major determinant of future fracture risk. Inadequate nutrition, low energy availability, and insufficient weight-bearing activity during this critical period can compromise bone strength. In female athletes, Relative Energy Deficiency in Sport (REDs), formerly described as the Female Athlete Triad, is characterized by low energy availability (LEA), reproductive hormone suppression, and impaired bone health, substantially increasing the risk of bone stress injuries (BSI) and potentially leading to long-term deficits in bone mineral density (BMD). Hormones, particularly estrogen and progesterone, are central regulators of female bone metabolism. Estrogen deficiency-most notably during the menopausal transition-leads to accelerated bone loss, deterioration of bone microarchitecture, and a marked increase in osteoporotic fracture risk. Early or surgical menopause, aromatase inhibitor therapy, and chemotherapy-induced ovarian insufficiency further heighten this risk. Menopausal hormone therapy has demonstrated efficacy in preventing bone loss and reducing fracture incidence when appropriately prescribed. Adequate intake of key nutrients, including calcium, vitamin D, magnesium, and vitamin K, along with anti-inflammatory dietary patterns, is essential for maintaining bone integrity, optimizing fracture healing, and supporting surgical outcomes. Bone health is a critical determinant of success in orthopedic procedures such as fracture fixation, joint arthroplasty, and rotator cuff repair, as low bone mineral density (LMD) is associated with implant failure, delayed union, and revision surgery. This state-of-the-art review integrates current evidence on female bone metabolism, highlighting its relevance to sports injuries and orthopedic practice. It underscores the importance of early identification of at-risk patients, comprehensive bone health assessment, and individualized preventive and therapeutic strategies to improve musculoskeletal outcomes in women.