You could have blown me over with a feather. Osteoporosis and fibromyalgia? What in the world could a chronic pain condition have in common with a low bone density condition? Quite a bit, it turns out.

Osteoporosis refers to reduced bone density, which can translate to weakened and brittle bones, an increased risk of fractures (including the dreaded hip fracture), and a stooped posture. It’s not an uncommon condition at all. According to the CDC, almost 20% of women and 4% of men over the age of 50 have osteoporosis. It’s particularly prevalent in women after menopause as their estrogen levels drop.

Menopause and osteoporosis

The risk of osteoporosis increases greatly after menopause. (From Laboratoires Servier – Wikimedia Commons).

According to the American Family Physician website, one-half of women will experience an osteoporotic fracture in their lifetime. Its risk also increases in men when they age as their testosterone levels drop. At least 40% of women and 15-30% of men will sustain one or more fragility fractures as they age.

Because a fracture is typically the first sign that osteoporosis is present, it’s important to be tested for it as we get older. The American College of Obstetricians and Gynecologists (ACOG) recommends bone density screening for all postmenopausal women 65 years and older. Younger people with an estimated increased fracture risk (https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9) should also get screened.

The Fibromyalgia Connection

Osteoporosis -- Smart-Servier

In osteoporosis the bone becomes less dense…and more brittle.

How osteoporosis became a thing in fibromyalgia (and why it’s never been assessed in its sister disease, ME/CFS) isn’t clear, but what is clear is that researchers started looking into it early on. The first FM osteoporosis study showed up in 1990, and over time was followed by 20 related studies.

The early results were mixed with some studies finding no evidence of low bone density. A 2016 and two 2017 metanalyses concluded, however, that bone density was decreased in FM.

A 2019 study linked low bone density with increased pain sensitivity in FM. That study was followed by an interesting Spanish study which found that following a Mediterranean diet and having a “lean mass” might help improve bone health.

The fact that handgrip strength was positively correlated with bone density in another study suggested that strengthening exercises might help. Just last year, a large case-control study (n=85,000!) found a significant correlation between FM and osteoporosis (p<.001).

Osteoporosis in Fibromyalgia – Possible Causes

A lack of exercise, reduced exposure to sunlight, reduced vitamin D levels, reduced growth hormone levels, the use of steroids, antidepressants, bisphonates, and hormone replacement therapy have all been suggested to contribute to the increased risk of osteoporosis.

Because sex hormone (estrogen, testosterone) levels may impact the risk of osteoporosis and can play a role in chronic pain (and may be altered in FM and ME/CFS), one wonders if they could play a role as well. On that note, one study found that postmenopausal hormone replacement therapy (1,2mg/g transdermal estradiol, 100 mg micronized natural progesterone oral/daily) improved sleep and quality of life in FM.

One research group proposed that FM could be a form of climacteric syndrome that is caused by a general diminishment of ovarian sex hormones over time. They proposed using hormone replacement therapies to reduce inflammation and increase estrogen in FM.

Given the findings that gut dysbiosis may contribute to osteoporosis, gut flora enhancement must be considered as well.

Enhancing Butyrate and Gut Health in ME/CFS, Fibromyalgia, Long COVID and Allied Disorders

Chronic Fatigue Syndrome (ME/CFS) and Long COVID

One has to wonder, given the increased problems with exercise in ME/CFS, what is going on with bone health there. Another potential connection concerns ACE-2 dysregulation – something that has been linked to osteoporosis before.

Eight years ago, in her 20-part series on her journey with ME/CFS, Carol Lefelt described her struggle with the decision to take powerful drugs to treat her severe osteoporosis.

Getting Older: A Chronic Fatigue Syndrome Patient Faces a Difficult Decision

The SARS-CoV-2 virus that triggers long COVID is apparently able to affect bone health and “cause substantial bone loss”. One review recommended that “robust studies” be done to understand the long-term effects of the virus on bone health. Another asserted that the studies thus far indicated that a “strong disruption of bone health in post-COVID-19 patients” may be occurring.

Most interestingly, the review proposed that gut dysbiosis and leaky gut in long COVID may be impairing bone health (!). The same bacterial species that have popped up in ME/CFS studies (Faecalibacterium prausnitzii and butyrate producers) appear to be relevant to bone health in long COVID. In fact, the authors stated that “emerging evidence suggests that dysbiosis of GM is one of the major causative factors for the onset and progression of osteoporosis.


Many factors can contribute to osteoporosis (anorexia nervosa, diabetes mellitus types 1 and 2, diminished ovarian reserve or primary ovarian insufficiency, gastric bypass, HIV, hyperparathyroidism, hypocalcemia, premature menopause, renal impairment, rheumatoid arthritis, Turner syndrome, vitamin D deficiency), most of which aren’t typically associated with FM. Ditto with medications (i.e., antiepileptics, antiretrovirals, aromatase inhibitors, chemotherapy, depot medroxyprogesterone acetate, glucocorticoids, gonadotropin-releasing hormone agonists or antagonists, heparin).

One risk factor, in particular, though, stands out in FM, ME/CFS, and long COVID – lack of exercise. A recent study found that high-intensity, high-impact exercise was the most effective in osteoporosis. While studies typically employ much higher levels of exercise (30-60 minutes several times a week) than people with ME/CFS can tolerate, some people with FM should be able to tolerate them.

Plus, Harvard Health recommends that people diagnosed with osteoporosis start very slowly – just two or three bicep curls – plus some gentle weight-bearing exercises a week and work up to a couple of repetitions a week.

While “high-intensity, high-impact” exercise might sound daunting, it might be the kind of short but intense exertion that some people with ME/CFS/FM can tolerate. Short periods of exercise that don’t stress the aerobic energy production system are probably best for ME/CFS in particular.

Resistance training using elastic bands is an easily controlled type of exercise that might be slowly increased over time in those who can tolerate it. I’ve recently found them an easy way to gently work out a variety of muscles and get a little muscle tone back.

Resistance training causes the muscles to pull on the bones, thus stimulating bone growth. Small weights are another possibility. Cardiovascular exercises such as walking are helpful but are too much for many people with ME/CFS and some with FM. Note that Peter Rowe has found that a stretching regimen that elongates the tendons can be helpful in removing the restrictions that inhibit exercise in these diseases.

Enhancing Butyrate and Gut Health in ME/CFS, Fibromyalgia, Long COVID and Allied Disorders

The Bone Coach

Episode #3: Osteoporosis Causes - Bone CoachI had forgotten about the osteoporosis connection in FM until I saw that Kevin Ellis, aka the “Bone Coach”, was giving a presentation in Dr. Murphree’s “Freedom from Fibromyalgia” Online Summit.

Diagnosed with osteoporosis at the tender age of 31, and suffering from malabsorption and weight loss, Kevin Ellis researched and researched, and eventually developed a program to support better bone health.

I haven’t taken it, but Ellis produced a free “masterclass” program to help people build stronger bones.

You can also watch Kevin interact with Dr. Murphree on the free online Freedom from Fibromyalgia Summit by registering here. I believe his talk is on the 25th

Fibromyalgia, ME/CFS and Long COVID Osteoporosis Poll


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