Stress fractures—minute cracks in bone resulting from repetitive stress or overuse—are significantly more prevalent in women than in men. Studies indicate that women are over twice as likely to experience these injuries, especially in sports involving high-impact activities like running, hockey, or soccer.
In my practice as an endocrinologist, I frequently encounter women facing bone-related injuries that seemingly develop without warning. These are seldom coincidental and are typically linked to a mix of mechanical load, hormonal shifts, and nutritional gaps. This trend is particularly evident among beginners in running, who may be following generic programs that don’t take into account women’s unique risk factors.
Why Women Are at Increased Risk
Several biological and behavioral elements contribute to the higher incidence of stress fractures among women:
- Lower Bone Mineral Density Women generally have lower BMD than men, which makes their bones more susceptible to cumulative microtrauma under physical stress.
- Hormonal Variability Estrogen plays a vital role in bone preservation. In women, natural hormone fluctuations during the menstrual cycle—and especially the decline seen in perimenopause and menopause—can weaken bone remodeling, heightening fracture risk.
- RED-S (Relative Energy Deficiency in Sport) Inadequate energy intake, whether intentional or unintentional, is common among female athletes. This underfueling can disrupt hormones, suppress bone formation, and increase systemic inflammation, all of which predispose to bone injuries like stress fractures.
Perimenopause: A Critical Window for Injury Risk
The perimenopausal transition, often beginning in a woman’s 40s, is characterized by erratic hormonal shifts—particularly declining estrogen—which significantly impact musculoskeletal health.
Here’s how perimenopause elevates fracture risk:
- Rapid Bone Loss: Estrogen dips can trigger accelerated bone density decline—up to 2% annually—compromising skeletal strength.
- Impaired Recovery: Reduced estrogen slows bone repair, making microdamage more likely to evolve into stress fractures, even with moderate physical activity.
- Muscle Wasting & Joint Instability: Loss of estrogen also affects muscle mass and joint support, altering gait mechanics and increasing stress on bones.
- Vitamin D and Calcium Challenges: Age-related reductions in vitamin D levels and calcium absorption further hinder healthy bone metabolism.
How Women Can Protect Bone Health
Awareness and proactive strategies go a long way in reducing the chance of injury:
- Bone Density Screening: A baseline DEXA scan is advisable for women over 40, especially if there’s a history of menstrual irregularities or previous fractures.
- Hormonal Assessment: Testing for hormonal imbalances allows early detection and may prompt consideration of HRT when clinically appropriate.
- Optimized Nutrition: Ensuring adequate calcium, protein, and vitamin D intake is vital. Avoid overly restrictive diets, particularly for active women.
- Smart Training: Low-impact strength training and cross-training are ideal ways to support bone integrity while minimizing overuse injuries.
- Menstrual Tracking: Disruptions in menstrual patterns can be an early marker of low estrogen or energy imbalance and warrant clinical follow-up.
Final Thoughts
Stress fractures shouldn’t be dismissed as minor sports injuries. They’re often early warnings of deeper issues in skeletal and hormonal health, especially in women. The perimenopausal years represent a particularly vulnerable time due to shifting hormone levels and declining bone integrity.
By encouraging early screening, delivering personalized treatment, and supporting women with targeted hormonal and nutritional guidance, we can help them maintain strength, agility, and confidence throughout every phase of life.