October 22, 2025 • 66 mins
Your bones are silently changing beneath the surface, and for women entering menopause, that change accelerates at an alarming rate. Did you know you could lose up to 30% of your bone mass in the first 5-7 years after menopause? This silent thief works without symptoms until a fracture occurs, often when it's too late for prevention.
In this episode, Speaking of Women's Health Podcast Host Dr. Holly Thacker reads Chapter 12 of her book, "The Cleveland Clinic Guide to Menopause," and offers additional insights and tips you won't find in the book.
This isn't just about preventing fractures – it's about maintaining independence and quality of life as you age. Breaking a hip after 65 carries a 40% one-year mortality rate, yet this risk is preventable with proper screening and treatment. Whether you're approaching menopause, recently diagnosed with bone loss, or simply planning for healthy aging, this episode provides crucial knowledge to keep your skeleton strong for decades to come.
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Episode Transcript
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Holly L. Thacker, MD (00:05):
Welcome to the Speaking of Women's Health
podcast.
I'm your host and author of theCleveland Clinic Guide to
Menopause and I am back in theSunflower House with you going
over chapter 12.
This is March 2023, and this isabout boosting bone health, and
(00:31):
I'll certainly encourage you totune in to an April Speaking of
Women's Health CME podcast withone of our Specialized Women's
Health fellow graduates, a verysuccessful osteoporosis expert
physician, dr ChristyTuff-DeSapri.
So on to boosting bone health.
(00:54):
Midlife is a critical turningpoint for a woman's bone health.
There's a direct relationshipbetween menopause and the
development of bone thinningdisorder, termed osteoporosis.
In the five to seven yearsfollowing menopause, which is
the final menstrual period, orloss of making eggs and ovarian
(01:20):
function, a woman can lose up to20 to 30 percent of her bone
mass, and when a womanexperiences early menopause, she
is especially at risk for rapidbone loss.
So this makes midlife a primetime to both prevent and treat
low bone mass, so that we canstay strong, healthy and in
(01:43):
charge in our later years.
And yet so many women don'trealize, or they're just not
advised by their health carefolks, to begin testing for bone
loss early.
Alyssa's experience is far toocommon.
This is Alyssa's story.
I'm 52 years old and I haveofficially entered menopause, so
(02:06):
I thought it would be a goodidea to see a physician who
specializes in women's health.
But when my new doctorsuggested that I get a bone
mineral density, a BMD, alsocalled DXA, I was skeptical.
My former doctor always told methat getting a bone density
test before age 65 was just awaste.
(02:27):
He said no risk factors, noreason to get the test.
Well, my new doctor explainedthat this was kind of
old-fashioned thinking.
She said that even without riskfactors, every woman should
have a bone mineral densityassessment within two years of
menopause.
She told me that being femaleis a risk factor for bone loss
(02:48):
because of the metabolic changesand the marked estrogen
deficiency that we experienceafter midlife.
So I got the test my newphysician ordered, and the
results really surprised me.
I was diagnosed with osteopenia.
The doctor explained, though,that this didn't necessarily
mean I had a quote disease.
(03:09):
It just meant that I have lowerbone density than other women
my age, and it also meant that Icould be losing bone and that
I'm potentially at higher riskthan an average woman for bone
breakage, also known as fracture, as I get older, if this new
doc hadn't tested my bonemineral density, I would just
(03:31):
continue to assume that my boneswere strong, because you can't
see or feel a loss in bonedensity.
So it turns out that the pastdoctor's claim that I didn't
display risk was just dead wrong.
This brush off game that hegave me about not needing a bone
mineral density at my age waskind of scary, and I wonder how
many other women simply trustwhat they're told without
(03:54):
getting another opinion.
So what is osteopenia?
Osteopenia is a conditioncharacterized by decreased
calcifications or deposits ofcalcium salts which are needed
to form bone.
And when you lose the calciumor you lose the architecture of
the bone, you have reduced bonedensity and this may warrant not
(04:19):
just preventive but alsotherapeutic pharmacologic
treatment.
So being told that you haveosteopenia simply means that you
have less bone mass than theaverage woman, and having less
bone mass than average isn'tnecessarily a problem.
But it is important toestablish your baseline bone
(04:39):
density because if you lose bonedensity rapidly, it's a problem
and needs to be addressed.
The less dense your bones are,the more likely you are to break
a bone.
So half of all women haveosteoporosis by age 55.
And I describe how much calciumyou have in your bones is kind
(05:00):
of like how much money you havein the bank.
So if you have a lot of moneyin the bank, you can make
withdrawals at a much fasterrate than putting deposits in
before you go bankrupt.
So if, genetically or becauseof other medical conditions or
past hormonal or vitamindeficiencies or other conditions
(05:21):
like celiac there's so manydifferent things that can
negatively affect your bone Ifyou tend to have less bone
density than average, you justcan't make as many withdrawals
as deposits, or you're going toreach a critical bankruptcy
phase, which is bone breakage.
(05:42):
And so many women think thatbreaking a bone is just part of
aging, or because they fell offtheir bike or because they were
running on black ice.
But that's not so.
If the bones break after age 40, it's different than childhood,
when the bones are growing andsoft and haven't fully
mineralized and reached theirpeak bone density.
But in any person over 40, maleor female, if you break a bone
(06:05):
it needs to raise a red flag.
So what exactly is osteoporosis?
Well, it is the loss of thebone density, mass and strength,
leading to both increasedporosity and vulnerability to
bone breakage.
So type 1 osteoporosis isrelated to menopause and is
generally almost alwayspreventable with hormone therapy
(06:27):
or other non-hormonal agentsthat affect the bone breakdown
rate, whereas type 2osteoporosis is related to aging
and it affects older women overthe age of 65 as well as men,
but it's still modifiable andmanageable as well.
So our focus today is mainly ontype 1, and it's important to
(06:48):
note that osteoporosis is not anormal part of aging.
It can be prevented and treated, though there is no specific
cure.
The key is to identify rapidloss in bone density during the
peri and postmenopausal years,especially those first five to
seven years, so that you cantake action to slow the process
(07:09):
and, in some cases, stop it andeven rebuild bone.
This is very important, as it'sgoing to protect you from
debilitating bone fractures.
There's a number of approvedoptions to both prevent and
manage osteoporosis, one ofwhich is menopausal hormone
therapy.
If you've recently started intomenopause, knowing your bone
(07:33):
status may affect your decisionabout whether to use hormone
therapy or use additionaltreatments or other treatments,
and whether to continue hormonetherapy treatments or other
treatments and whether tocontinue hormone therapy.
So who gets osteoporosis?
Well, 80% of people withosteoporosis are women, but
(08:01):
osteoporosis is mistakenlythought of a disease of only
older white women or a problemof skinny, frail women.
But neither of theseassumptions is completely true.
In fact, in the United States,osteoporosis and low bone
density affect millions of womenand men over age 50.
So according to the NationalOsteoporosis Foundation, that's
well over 55% of people.
(08:22):
So at least one in every twowhite women over the age of 50
will have anosteoporotic-related bone
breakage or fracture in herlifetime.
Now women of color may be lesslikely to develop osteoporosis,
but they're still potentially atrisk, and 10% of women of color
(08:46):
over age 50 have osteoporosisand an additional 30% have low
bone density.
So that does still put them atrisk for osteoporosis and
unfortunately, women of colorwho sustain a hip fracture are
more likely to die from it thanwhite women and, just like men,
are less likely to haveosteoporosis because they don't
(09:06):
lose their sex hormones.
They tend to develop denserbones and muscles compared to
women and they don't rapidlylose bone at midlife like half
of all midlife women do.
But if a man breaks his hip,he's actually more likely to die
than a woman.
So this is a serious problemfor our society, but too many
(09:27):
people just don't realize thatwomen and women of color and men
are potentially at risk forosteoporosis, so you might have
to speak up for yourself orswitch doctors.
Fast fact over 1.5 millionfractures per year are due to
osteoporosis.
Well, what if I exercise andtake calcium supplements?
(09:50):
Can I avoid osteoporosis?
Some people think if theysimply exercise, drink enough
milk or take a calciumsupplement that they will be
protected from osteoporosis.
Be protected from osteoporosisand certainly these what I call
hygienic lifestyle measures ofweight-bearing, exercise,
(10:10):
getting enough calcium in thediet, and supplements if needed
to augment the diet and separatevitamin D3.
And I usually like to add K2 tothat.
That's not potassium, it's K2,also known as M7.
It's not in very many foods.
If you like Asian, korean,japanese natto, well then you're
(10:32):
getting plenty of K2 in yourdiet.
But there's not that many foodsthat have K2.
Pork, dark chicken meat and afew cheeses Swiss, gouda, blue
and I like some of those foods,but I don't eat them every day.
And K2 is what helps drivecalcium into the bone as opposed
to getting deposited in thearteries.
(10:53):
So all of those things are agood start and they're necessary
, but they're not sufficient anda lot of women are perplexed
when I say that that's nottreatment.
And then I use the example ofwell, you know, if you were
having pneumonia or an asthmaattack and you came into the
emergency setting, we wouldn'tjust simply say, oh, you just
(11:14):
need some fresh air and oxygen.
Well, of course everyone needsfresh air or oxygen to breathe.
That's necessary, but it's notsufficient.
You might need something toopen up the lungs, you might
need antibiotics or steroids.
So that's treatment of adisease.
And I think, becauseosteoporosis is so common that
people just think, oh well, if Ijust have good hygiene and
(11:37):
lifestyle, that that will beenough and certainly it helps.
Just like when I see women whoare eating right and exercising
and they're frustrated thatthey're gaining weight or that
they haven't lost weight even,I'll say, if you weren't doing
those good things, it would beeven worse.
So I know sometimes that's notthe best consolation, but
(11:59):
knowledge is power and you andyour doctor should take into
account not just diet andexercise but your family history
.
Any biological blood relativeswith a history of hip fracture,
dowager's hump compression,fractures of the spine, wrist
fractures after age 40, all ofthose things are red flags.
(12:20):
Also, what is your body massindex or weight?
Women who tend to be veryslender, under 127 pounds tend
to have lighter bones.
Smoking is very bad on thebones as well as so many other
things.
A history of eating disorder,even if you've recovered from it
.
If you went a period of time inyour younger years restricting
(12:43):
calories maybe not having yourperiod that can affect your peak
bone mass Kidney stones.
If you've personally had ahistory of kidney stone, there's
a high chance it was calciumoxalate and that you're leaking
out too much calcium from yourkidneys.
And the answer to that is notreducing calcium in your diet,
like some people erroneouslytell men and women.
(13:05):
It's stopping that excessivecalcium leak, because 99% of our
bones, or rather our calcium,is stored in our bones and we
will always steal it out of ourbones to maintain that 1% level
in our bloodstream that we need.
And if our blood is beingfiltered by the kidneys and
(13:26):
leaking out calcium, not onlycan it lead to kidney stones,
which are very painful, but alsobroken bones.
Now, if you have a history ofwheat or gluten intolerance,
called celiac disease and wehave a great column on celiac
disease on ourspeakingofwomenshealthcom site
or even if you're just verygluten intolerant but not
(13:46):
necessarily have overt celiacdisease, this can certainly
affect your bone health and itcan irritate your intestines so
that you don't even absorbenough iron and vitamin D.
Now you can certainly getcalcium from food, particularly
if you like calcium-rich foods.
Certainly get calcium from food, particularly if you like
calcium rich foods.
But for some women, especiallyif they avoid dairy, they may
(14:09):
not be getting all their calciumthrough diet and it's even
slimmer chance that you'regetting enough vitamin D in your
diet, and we'll talk more aboutsupplements in a moment.
So bone basics you mightassociate bones with just a hard
, lifeless skeleton, like yousee at Halloween time, but this
is farther from the fact.
(14:30):
Your bone tissue is complex,living, active, regenerating
tissue and the bone's innermostlayer, the bone marrow, makes
cells that are blood cells thathelp keep us alive.
It's a very important organ andthe bones provide structural
(14:50):
support for our muscles.
They also protect our vitalorgans and, importantly, they
store calcium.
And our bones are not the samebones that we were in seven
years ago.
They're in a continuous cycleof repeated breakdown, buildup,
breakdown, buildup, known asremodeling, and during the phase
(15:11):
of the cycle called resorption,the bones release some calcium
into the blood, which results inbone breakdown.
In the formation phase, newbone is built up to replace the
old, potentially damaged bone.
Just like your skin, the skinthat you see on your arm is not
the same skin you had last month.
(15:32):
So this ongoing cycle ofreplacing old bone with new bone
gives the body the calcium itneeds in the bloodstream and
muscles, while keeping yourskeleton hopefully strong, and
muscles while keeping yourskeleton hopefully strong.
When the bone formation exceedsthe resorption, the bone mass
increases.
But if your resorptionbreakdown is faster than the
(15:54):
formation, which happens to halfof women when they lose
estrogen, then there's areduction in your bone mass and
when the bone mass iscontinually reduced, it leads to
osteoporosis.
Now I tell women if you're onlyplanning to live to age 50, 55,
chances are you've got enoughbone.
But when I see women, since thefield of menopause is really
(16:17):
anti-aging, we're trying toimprove not just the quality of
life, which is very important,of course, but also the
longevity and the functionality.
And too many women outlivetheir bones.
So what is a broken bone, not abroken bone?
Well, if you or your child hada broken bone that healed well,
(16:38):
all this talk about bonebreakage may strike you as a
little odd.
Bones break, they're set andthey heal right, not necessarily
when we're older.
Statistics show that almost 40%of older people who have a hip
fracture die within thefollowing year.
They can die from complicationsof the fracture or its
(17:01):
treatment or have beenimmobilized during that recovery
, and certainly those whosurvive have pain,
hospitalization, expense,rehabilitation and they also run
the risk of losing theirindependence.
And so when I see women ages 65plus, my focus changes in some
(17:23):
part in terms of plus.
My focus changes in some partin terms of screening for
diseases that might shortentheir lifespan.
The focus turns more tofunctionality and preserving
independence, and preserving andpreventing preserving their
independence and preventing themfrom having to go to assisted
living or a nursing home,necessarily.
So how is your bone mass builtup?
(17:46):
Well, from infancy up until age30 to even 35, we humans build
more bone than we lose, andafter 30 to 35, we hope to
maintain our bone density prettystable until later in life when
we try to prevent the rapidloss.
So think of it this way Each ofus maintains this lifelong bone
(18:08):
bank and we constantly makedeposits and withdrawals, and
this depends on our lifestylechoices, such as getting enough
calcium and protein, vitamin Dand exercise, and some of us who
have family histories ofosteoporosis who are naturally
very thin or small-framed or whoget any bone breakage after the
age of 40, may automaticallystart with a lower balance in
(18:31):
that bone bank and we have towork harder to keep it full.
The catch by age 30, which Iassume many of you are who are
listening when most of us havealready acquired most of our
skeletal mass, we can't reallymake any more significant
deposits, and we all know that.
Since, thankfully, most of uslive long enough to reach
(18:54):
menopause, that's the time whenthose ovaries stop producing
eggs and estrogen, which thencauses lack of the hormone we
need to protect our bone andthis, in half of women, rapidly
increases the rate ofwithdrawals from the bone bank
and over time, without treatment, the increased withdrawals do
take their toll.
(19:15):
So osteoporosis increases therisk of fracture and in the
serious cases can completelyreduce mobility, which brings
its own set of problems.
But the good news is that youcan increase bone mass during
midlife and certainly preventthe loss with hormone therapy in
the vast majority of women andor other non-hormonal
(19:37):
pharmacologic options that havebeen well studied and designed
for women and in some cases formen who are at high risk or
who've had actual bone loss.
So what are the risk factors forosteoporosis?
Well, you can't always tellwhether someone has osteoporosis
, especially when it's in theearly stages, and there's some
(19:57):
active midlife women who justdon't look the part.
And osteoporosis causes reallyno symptoms unless you break a
bone.
So just like we don't want towait until someone has a heart
attack to diagnose and assesstheir risk for heart disease,
the same thing is we don't wantyou to have a bone attack and
break your bone.
(20:17):
Certain women are definitelymore likely to develop
osteoporosis and frailtyfractures.
In fact, just being a woman,your risk for low bone density
automatically increases and themetabolic changes, such as the
menopause-related estrogen loss,increases your risk.
(20:39):
And if you've been ignoring yourdaily calcium and vitamin D
intake, you're not doing yourpart to give your bones the
basic building blocks.
So early awareness,weight-bearing exercise, such as
walking or lifting smallweights, and making sure that
your vitamin D 25 hydroxyvitamin D level is at least 32.
(20:59):
I like it higher than 50 forother reasons, but for bone
health you need at least 32.
You cannot tell if your calciumbalance is normal by simply
checking your blood work.
The only way to find out yourcalcium balance is to do a
(21:22):
24-hour collection of your urineon a typical day that you're on
your regimen.
Here are the risk factors forosteoporosis Estrogen deficiency
after menopause.
Having a thin or small, petiteframe.
A family history ofosteoporosis, especially a
history of a fracture in a closerelative.
A personal history of breakinga bone after age 40.
(21:45):
If you've had a history ofmissing your periods because of
hormonal problems, an absence ofa menstrual period excluding
pregnancy for several months ata time.
If you've had a history ofdisordered eating.
If you smoked cigarettes orused nicotine.
If you've imbibed too muchalcohol that's hard on the bones
(22:06):
.
If you've had a lifetime intakeof low calcium, low vitamin D.
If you've had kidney stonesbecause you're peeing out too
much calcium and it hasn't beentreated.
If you have an inactivelifestyle.
If you have advanced age age.
(22:29):
Now there are certainly chronicmedical conditions that also
dramatically increase the riskof osteoporosis rheumatoid
arthritis, autoimmune diseasesrequiring prednisone or steroids
, celiac disease, diabetes,anorexia nervosa, and there's
many medications that can bevery bad on the bones, including
glucocorticoids, which haveseveral mechanisms of action
(22:50):
that are harmful to bone healthlong-term.
The aromatase inhibitors whichtotally wipe out estrogen, such
as aromacin, also known asX-Mistane, or Femera, known as
Letrozole or Arimidex, known asAnastrozole, as well as
(23:12):
Depolupron, which is aninjectable treatment that
suppresses the ovaries Othermedicines that may stop monthly
periods or wipe out all estrogenputs women at risk for
osteoporosis.
Now, this is in contrast tohormonal contraceptives that are
taken continuously so that thewoman doesn't have like a
(23:35):
withdrawal period, but stillgive a daily continuous estrogen
and progesterone dose and mostwomen actually protects the bone
.
Now, if you have the presenceof some GI problem malabsorption
, celiac disease, wheat proteinintolerance that can also affect
(23:55):
your bone health.
So how do we assess bone health?
Certainly, your history isimportant, or family history and
exam looking to see if you'velost more than an inch and a
half of height from your maximumheight at age 21,.
Looking to see if you havehunched over, hunchback kyphosis
, which could mean compression,fractures of your upper thoracic
(24:17):
spine.
Your physician should helpdetermine whether you need a
bone density test based on yourclinical history and risk
factors.
A bone density test will do thefollowing it measures the
amount of calcium in your bonesand it compares it to the soft
(24:40):
tissue around the bones, thesoft tissue around the bones and
the amount of certain minerals.
How much calcium you have inyour bones is an indicator of
health and strength.
It helps assess your risk forfracture and it can be used in
serial fashion every two yearsto determine your rate of bone
(25:01):
loss or bone gain and monitoringthe effects of any therapy.
Now, generally speaking, thelower your bone density, the
higher your risk of fracture andosteoporosis.
Now a recent enhancement to justmeasuring the calcium in your
lower lumbar spine and yournon-dominant hip, once you're
(25:25):
over 65, we usually do both hips, because there's arthritis in
the lower spine and sometimes ahardening of the arteries of the
aorta, which falsely elevatethe bone density in your spine.
Sometimes we'll do the distalone third of the non-dominantray
exortiometry, dexa, andwherever you have your bone
(26:02):
density, the person reading thebone density should be ISCD
certified.
I am a certified bonedensitometrist and have
specialized in osteoporosis fordecades, and my techs bone techs
are also certified andcurrently although hopefully
that will change soon and againyou're listening to this in
(26:24):
March of 2023, I am the only onein my healthcare system that
has trabecular bone scoring.
Tbs and trabecular bone scoringis a software program that's
able to analyze the connectionsof your bone, because bone is
(26:44):
not just a solid block, it'sporous and there's
interconnections and your bonearchitecture is either assessed
as being normal, partiallydegraded or degraded.
So obviously the best categoryto be in is normal amount of
calcium, normal density andnormal architecture.
(27:04):
And the worst category, whichis very high risk for fracture,
is to not only have thin bonesand osteoporosis by the bone
density T-score, but also tohave completely degraded bone
and of course there's differentcombinations in between.
So what happens when you get abone density test?
(27:26):
Well, let me assure you it'squick and painless and there's
various methods of measuringbone density.
Some people use peripheralx-ray machines that just measure
the density in the wrist orkneecap or shin bone or heel,
but the best bone densities arecentral dual energy x-ray
absorptiometers or DEXAs, andthat gathers the density from
(27:49):
the hip, spine and potentialtotal body, which is the gold
standard of measurement.
During a test, you lay flat onyour back on a padded table and
a very precise x-ray machineprojects the beams onto the
target bone density area and theamount of the beam that's
blocked by the bone indicatesthe density and that enables the
(28:12):
physician to compare theresults with bone density
standards and you get two scores.
You get a score that comparesyou to 30-year-old Caucasian
women and a lot of my patientssay well, I'm not a 30-year-old
white woman, but the Z scorecompares you to people your own
age, sex and ethnicity and bodyweight.
(28:33):
So the Z score is not used fordiagnosis but it's used for us
to find out if you're more thana standard deviation and a half
below your peers, if there mightbe something more than just age
or menopause.
But the cut point fordiagnosing osteopenia,
osteoporosis or simply having anormal bone density is to
(28:55):
compare you to the 30-year-oldCaucasian average.
So bone density and thedecision for hormone therapy
Well, the estrogen and hormonetherapy can improve or stabilize
your bone health.
So knowing your status andknowing your rate of bone loss
can help.
Many recently menopausal womendecide, especially if they don't
(29:16):
have hot flashes or othersymptoms, that they want to
begin hormone therapy.
And, as I mentioned, there'sdifferent ways to measure bone
densities.
The portable ones tend to notbe quite as reliable as the
larger models.
But even the larger models, ifthey're removed from one room to
another, maybe aren't able tobe compared to your prior scan
(29:40):
and you cannot compare betweenscans.
You can go to one lab and get ablood sugar and go to a
different lab the next month andget a blood sugar and your
doctor may compare the trends.
But bone density is very highlyprecise and every day we take
out a phantom spine and scan itand we measure our text
(30:02):
precision of error, because ifyou got on that table 10 times,
there's going to be 10 differentnumbers and we need to know if
the scatter is significant, justlike if I take your blood
pressure 10 times when you'resitting down relaxed.
I'm not going to get the exactnumber every time.
(30:26):
So a woman that has severemenopausal symptoms hot flashes,
night sweats, can't sleep, isnot happy about her skin or hair
, or has vaginal dryness orchanges in bladder function or
sexual function she may wanthormone therapy anyway.
But it's important to know thatmost of these standard regimens
also prevent that rapid boneloss.
Now, when should I get a bonemineral density test?
(30:50):
Well, I recommend getting abone density test within two
years of menopause and mayberight at menopause if there's a
history of fracture or high riskor a family history, or
certainly in women who are onprednisone or steroids or
(31:13):
aromatase inhibitors, women thathave certain medical conditions
that put them at increased risk, women who've broken bones.
Now, scoring your test we talkedabout that T-score and Z-score.
So the T-score compares you toan ideal number, a typical
(31:33):
healthy 30-year-old female.
So if your bone density is thesame as an ideal, then your
score is zero, but if it's lessthan average, it's measured in a
standard deviation, that'snegative.
So most normal people arebetween minus one and plus one.
It's the old bell curve thatyou might remember from school,
(31:55):
and the World HealthOrganization lists criteria for
normal being above plus 1 to aslow as minus 1, whereas
osteopenia cut point is minus1.1 to minus 2.1.
Osteoporosis is a T-score equalto or less than minus 2.5.
And severe osteoporosis is whenyour T-score is minus 2.5 or
(32:20):
worse and you've had anosteoporotic fracture.
Now the National OsteoporosisRisk Assessment Trial did reveal
, though, that postmenopausalwomen who had peripheral
T-scores of minus 1.7 were atrisk for fracture.
This is why age body weighthistory, combined with a T-score
, can further quantify your riskof fracture and treatment needs
(32:44):
, and there is a score that wecalculate, called the FRAX score
.
I don't usually consistently doit in people under age 60,
because just based on your youngage, even if your bones are
thin, based on your young age,your fracture risk doesn't
necessarily hit the 20% fracturerisk in 10 years cut point or
3% risk of hip fracture in 10years.
(33:05):
So you just don't want to onlygo with a T-score.
There's a lot of things to takeinto account Now.
The Z-score compares your bonedensity to that of somebody your
own age, weight and ethnicgroup and sex, and it can be
used in premenopausal women, whogenerally don't need a bone
(33:26):
density test, but sometimes wedo it in transplant patients,
people on certain therapies,underweight persons.
And the Z-score can be used tocompare the postmenopausal woman
to her own peers.
And if your Z-score is minus1.5 or less certainly if it's
less than two that means you'renot only lower than the typical
(33:48):
30-year-old Caucasian woman, butyou're really low compared to
somebody your own age andethnicity, and this is a warning
sign that there could be otherthings or secondary causes of
osteoporosis.
So a Z-score of minus 1.5 orworse means that you should be
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assessed for vitamin Ddeficiency, low estrogen state,
an overactive parathyroidthere's four little tiny
parathyroid glands in yourthyroid gland overactive thyroid
hormone or simply taking toomuch thyroid replacement,
elevated cortisol levels or gutmalabsorption of needed
nutrients.
Multiple myeloma can causemultiple spine fractures,
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hormonal imbalances, use ofcertain bone negative bone
medications and that excessiveloss of calcium through the
urine, which in some people, isa common genetic defect called
hypercalciuria.
So get recommended dailyallowances of calcium, which is
at least a thousand milligrams.
If you're estrogen replete andif you're estrogen deficient or
have had some gut problems, youmight even need up to 1500
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milligrams of calcium, but youneed it in divided doses because
your intestines don't absorbmore than 300 to no more than
500 at a time.
Vitamin D it's not a vitamin,it's a pro-sterile hormone, and
I would definitely encourage youto listen to my second ever
podcast on vitamin D.
Now, the so-called recommendeddaily allowance is not based on
(35:25):
science.
It's 400 international units,which is barely enough to
prevent rickets In mostcountries.
Most experts agree that mostadult persons, especially over
40, should get at least one totwo thousand units, and people
with low levels may need up toten thousand units a day to fill
up their tank.
Now, the reason why fourhundred units was picked as the
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recommended daily allowance wasbased on mother knows best,
because moms used to have theirkids swallow a teaspoon of cod
liver oil every day to preventrickets, which is severe vitamin
D deficiency.
Vitamin D and weight-bearingexercises is tolerated.
So walking, lifting weights,jumping rope, using resistant
(36:14):
bands are all helpful.
It's important not to smoke andto avoid excessive alcohol use
and to bring in all yourprescription medicines and
supplements when you visit withyour physician and get a bone
mineral density when appropriateand if you need a follow-up
bone density, trying to get iton the same machine.
And if you're lucky enough tobe in an area where there's
(36:37):
experts in osteoporosis and theyhave that trabecular bone
scoring, that can be veryhelpful, because in the last
year I've assessed all the datain our Center for Specialized
Women's Health and we found that16% of the diagnoses got
changed either to a worsediagnosis or a better diagnosis
based on taking into account thetrabecular bone score and the
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actual bone architecture.
So, as I mentioned, over the ageof 40, sometimes our skin
doesn't make vitamin D.
Many of us work inside, many ofus like to use sunscreen to
reduce sunburn and skin agingfrom the sun, and some of us
live in Northern climates whereeven on a sunny day, like today
(37:23):
in March here in Cleveland, Icould run outside naked.
Not that I would, um, but I'mnot.
My skin's not going to makevitamin D because we're just not
at the right latitude.
So young people who don't wearsunscreen, who drink a lot of
vitamin D fortified milk andlike salmon and like to eat
mushrooms that have beensuntanned.
(37:43):
That has vitamin D in it.
Many times those folks mightget enough vitamin D, but in my
practice, most midlife women Isee, and even those that come
from the Sun Belt to visit me,especially if they're older,
even if their skin is damagedfrom sun exposure, I still see
very low levels.
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So when should I seek treatment?
Well, as I said before, I wouldgenerally and most folks
recommend a bone mineral densitytesting within two years of
menopause and earlier for peoplewith a family history of
osteoporosis, very low vitamin Dlevels or people who've used
long-term glucocorticoids 7.5milligrams of prednisone or more
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for three or more months.
And the decision to treat awoman for osteoporosis should be
based on the clinical riskfactors, the T-score, the
medical history, the FRAX and,importantly, if possible, the
bone architecture and also therate of bone loss over time.
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So a combination of good healthand exercise and possibly a
regimen of hormone therapy orother bone medicines, with or
without hormone therapy, may beprescribed.
But again, this is just generalinformation to keep you strong,
healthy and in charge.
It is not medical advice doesnot substitute for care with
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your physician.
So, bone therapies Well,depending on the severity of
life of the bone loss, we needto look at options.
And if you're at very high riskor you're rapidly losing bone,
we need to start hormone therapyor some other option.
And if you can't take hormonesor you don't want to, there's a
(39:30):
lot of options.
I mean, when I started in thisfield over 30 years ago, all we
had was estrogen, which you canonly use in postmenopausal women
, not men, and fluoride.
And fluoride makes the bonesdenser but it doesn't reduce
fracture.
So the density is not the wholestory.
And now we have several classesof medication and it's one of
(39:54):
the areas in women's healthwhere we actually have more
research in women than in men.
And sometimes men get the shortshrift.
Men with broken bones over 50or height loss or are on
medications that hurt theirbones.
Sometimes they don't get thesame attention women get.
So look out for the males inyour family if they're at risk
for osteoporosis.
(40:16):
So bisphosphonates they'reso-called anti-resorptive
treatments.
They slow or stop thedissolving of the bone tissue
without affecting the formationof new bone tissue.
So that means that you havemore formation over resorption,
so that your bone bank increasesover time.
And we have severalbisphosphonates.
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We use some off-label beforeFosamax or Alendronate, which
was the first one that hit themarket in 1995.
We have Actonel brand name, ageneric residronate.
It can be dosed 5 mg a day or 35mg weekly, or one of the more
popular ones is just 150 mg oncea month and that reduces all
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types of fractures spinevertebral, non-vertebral
fractures, which include thewrist, the pelvis, the hip and
the humerus arm bone.
And it's also approved toprevent glucocorticoid-induced
osteoporosis.
But when you only take it oncea month, you only get 12 times
to get it right, ladies.
And hardly any bisphosphonateis absorbed through the gut less
(41:25):
than 1%.
So if you're on an oralbisphosphonate you must take it
with plain tap water, notmineral water, not coffee, and
you really have to wait at least30 minutes and I usually tell
my patients 60 minutes withouteating any other foods except
for water, no other beveragesexcept for plain water and no
other medications.
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And you need to be upright,meaning don't take it in the
middle of the night and fallback to sleep and have it stuck
in your esophagus.
Now Boniva Ibandronate is alsoavailable in 150 milligram
monthly dose and was previouslygiven by injection every three
months, but it's not beenassociated with reductions in
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hip fracture so we don't tend touse it very often.
Now Fosamaxilendronate has beenon the market the longest and
it's got a 35 milligram weeklyprevention dose or a 70
milligram weekly osteoporosisdose and it does reduce spine
fractures and hip fractures andthere's a brand name that has
some vitamin D in it, whichgives either 2,800 international
(42:31):
units of vitamin D weekly or5,600 international units, which
really isn't that much, andmost insurances are just only
covering the generic form.
But the generics may beabsorbed at different rates and
I don't tend to be a fan of theoral generics and in anyone with
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Barrett's esophagus or a hiatalhernia or gastric distress, I
usually go to the injectablezolendronic acid, also known as
Reclast, and it's a fivemilligram dose given once a year
for osteoporosis In breastcancer patients or people with
cancer.
It's used in a lower dose morefrequently, called Zometa, and
it helps bring down calciumlevels.
(43:13):
But in 2007, the zoledronicacid was officially FDA approved
to treat postmenopausalosteoporosis and Paget's disease
and in 2008, it was approvedfor men and women who had
already had a hip fracture toreduce the risk of low trauma
fractures and in that group ofpeople it was associated with
(43:35):
the lower death rates.
And it has to be infused overat least 15 to 20 minutes.
So it does require the nursefinding a little vein and an
office visit.
But it's a solid agent.
We know you're getting it andabsorbing it and in those people
who broke a hip it reducesdeath rates.
(43:56):
Now you've got to have adequatekidney function, at least 35
cc's per minute.
So you need a creatinine and,for any patients who finish up,
any type of bone building agentlike an anabolic daily shot of
injectable PTH, which is now ina biosimilar option, or Timlos,
(44:18):
also known as abalaparatide,which is also another daily
injectable for two years.
And we have the newest bonebuilder which is an anabolic
agent and anti-resorptive.
It's's called Avenity, alsoknown as Romozumab, and that's
given by two monthly shots bythe nurse for a month for an
(44:39):
entire year.
So that would be 12 visitswhere you wouldn't have to give
yourself the shot like you dowith Forteo or Timlos or those
biosimilars.
Because if you're going to goto the expense and hassle and if
you're severe enough to requirebone building agents, we need
to solidify that and Ifrequently will use Reclast and,
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like I said, reclast has shownmortality reductions in older
men and women who've alreadybroken a hip.
So you have to get a calciumlevel and kidney function and a
vitamin D level for your firstinfusion at least 30 days in
advance, and every year or otheryear or even every third year
that you may be getting futurereclassed infusions.
You need to have adequatekidney function and you need to
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be well hydrated and somephysicians might recommend
either acetaminophen, known asTylenol, or ibuprofen, if no
NSAID intolerance or allergies,known as Motrin or Advil, the
day before, the day of and theday after the infusion, because
sometimes the first infusion, ifyour bones are really hungry
(45:49):
and needing to build up, youmight feel flu-like symptoms or
even like growing bone pain.
Now, of course, once we gothrough puberty and the
epiphyses close, we can't growtaller, but we can grow denser
and stronger.
So estrogen, as well as actiniland Fosamax and Reclast, have
(46:13):
been proven to reduce spinefracture and hip fractures.
Now Evista, which is raloxifin,which is an estrogen agonist
antagonist which reducesestrogen-positive breast cancer
diagnosis, does not reduce hipfractures in the studies but
does reduce spine fracture andhelps cholesterol.
So it's kind of a mild agent.
As I mentioned, I don't tend tofavor ibandronate or Boniva too
(46:37):
often just because it doesn'thave the hip fracture reduction
data.
Now, bisphosphonates orally areusually well tolerated but they
can be associated with somegastrointestinal upset and I do
see that more with generics andyou must take your calcium at a
different time and you mustavoid eating or drinking other
(46:58):
things because otherwise you'regoing to flush your medicine
down the toilet, because if youswallow it but you can't absorb
it, it literally ends up in yourpoop and down the toilet
instead of going to your boneswhere you need it.
So what's all this?
I hear about jaw problems.
So certainly there have beennews stories talking about this
(47:20):
very rare condition called ONJosteonecrosis of the jaw.
Sometimes people call it BRONJ,bisphosphonate-associated
osteonecrosis of the jaw, butthis has been mainly seen
primarily in people who havecancer or multiple myeloma, who
are getting chemotherapy,radiation, may have poor dental
(47:42):
status or diabetes and those whoare getting repetitive
intravenous bisphosphonates.
So just as the media promotedthe hormone hysteria over 20
years ago with the Women'sHealth Initiative, I think that
there's been some jaw necrosishysteria as well.
So I'm really disturbed when apatient tells me that her
(48:03):
dentist told her to choosebetween your teeth or your hips,
because it's absurd.
We need our hips and we needour teeth.
It's just another reason tofind someone who's well versed
in research relating to women,who can evaluate your whole
health, consider your personalhistory and family history and
come up with an individualizedbest regimen.
(48:24):
Actually, some research showsthat actinel, like estrogen, is
good for the teeth and gums.
There was a study done at CaseWestern Reserve University that
looked at postmenopausal womenwho had no bone therapy versus
those who had Actinil, and theysaw improvements in their teeth
and gums.
And so when I saw this research, I contacted one of the
(48:45):
periodontists and we'vepublished in the Journal of
Menopause where women withosteoporosis who were on any
kind of bone treatment hormones,non-hormones, bisphosphonates
or other agents who wereevaluated by three dimensional
CAT scan of the jaw byperiodontist dentists and had
grading of their teeth and gumsand plaque scores.
And what we found is that ifwomen were on any osteoporosis
(49:09):
treatment compared to those whowere not, they had better teeth
and gums.
And furthermore, in the HorizonPivotal Fracture Trial, there
was no increase in osteonecrosisof the jaw in postmenopausal
women receiving yearly reclassthrough IV compared to women
getting placebo injections.
So only a handful of cases havebeen reported and I do think
(49:36):
ONJ has been blown out ofproportion and the American
Dental Association hasguidelines and I think the
dentist by and large understandthis.
So the baseline risk for havingONJ is about one to two per
hundred thousand persons and ifyou're taking bisphosphonates
that risk might be two perhundred thousand.
(50:00):
So it really pretty much isvery close to placebo.
So it's not zero but an.
Embryologically the upper jawand the lower jaw are derived
from different tissue.
But if you have bad dentitionor you need teeth pulled or
extensive dental surgery, Ialways recommend women get this
(50:20):
taken care of before we startthem on treatment or if they're
on another excellentanti-resorptive agent, denusamab
, known as Prolia, which can bevery helpful for women who have
impaired kidney function,because it doesn't go through
the kidneys.
It's basically a monoclonalantibody that helps to make up
for the loss of OPGosteoporoterogen in the body,
(50:45):
and women lose OPG rapidly whenthey lose estrogen.
So I like to say Prolia orDenusamab is kind of like a
super estrogen acting on thebone without any effects
anywhere else.
And the one thing aboutintravenous reclast and also
Prolia is it seems like it isassociated with slightly reduced
(51:06):
breast cancer risk.
In fact, doctors treating womenfor breast cancer especially if
they're giving them agents thathurt their bones frequently
will give them Zometa, which isjust a lower dose of reclass, on
a more frequent basis.
So if you're on Prolia, itlasts for a little more than six
months and Medicare usuallyonly covers it for the
(51:29):
injections.
You have to be past six monthsand a day to get the next one,
and if you don't keep gettingyour injections and you're not
on any other treatment, therecan be rebound fractures.
Now we have a little bit moreresearch using bisphosphonates
and hormone therapy combined,because they've both been around
longer than Prolia or Denosumab.
(51:51):
In fact, I gave my firstinjection to a patient of Prolia
in June of 2010.
I think I was the first one inmy healthcare system to give
that first injection to a woman,and it was studied for 10 years
before it hit the market, andso it's been on the market now
for well over 12 years.
I have people going on theirlike 24th injection.
(52:13):
So what about calcitonin?
That was a treatment that weused myocalcin spray by nasal
spray and it's a naturallyoccurring hormone that helps
regulate calcium and bonemetabolism and it can improve
bone density and sometimesreduce fracture pain, which I
would primarily just use it forspine fractures, and it's
(52:36):
recommended only in women fiveyears past menopause.
But it doesn't have hipfracture reduction and some
reports have linked it to higherrisk of cancer.
And now that we haveproleodenosumab, which avoids
the kidneys where thebisphosphonates don't, we really
don't have as much of a needfor it.
So one of the other anabolicsthe newest one on the block is
(53:03):
Romo, also known as Avenity, andI will use this in women at
very high risk for hip fracture,women who need an anabolic,
women who don't want to givethemselves a daily injection,
and also I will not give it,though, if the woman has had a
(53:23):
heart attack or stroke withinthe 12 preceding months, because
one of the studies showedpotentially higher risk of this,
but several other studies didnot.
So I do think it's a very safeand effective bone building
option, but I tell all mypatients I'm not going to go
through the trouble.
Have you go through the trouble, go through the expense, have
(53:45):
my office staff do all thepaperwork to get these expensive
therapies if you're going tojust lose it at the end because
you don't solidify the treatment.
So if you're going to use ananabolic, you can't just say, oh
, my bone density is so improvedafter two years or one year of
this therapy, now I'm fine andgo off into the sunset because I
guarantee you when you comeback for a future bone density,
(54:07):
if you don't come back soonerbecause of a broken bone, you
will have lost everything yougained.
So you have to agree in mypractice generally to either IV
reclassed after you finish youranabolic, prolia denusamab every
six months plus a day shots, oran oral bisphosphonate.
And I think, for women withreally low T-scores, those at
(54:29):
very high risk, those who've hadfailed treatment, or people
that have multiple differentconditions that negatively
affected their bones, like, say,hormonal deficiencies, vitamin
deficiencies, celiac disease,hypercalciuria all these things
that can be treated and orreversed, but who have lost so
(54:51):
much bone who need to build upto a stable status, that's
another group of women.
So hormone therapy is FDAapproved for both
osteoprevention and management,for both osteoprevention and
management, and it's a goodtherapy to stop that rapid bone
(55:12):
loss.
If bone density low bonedensity is your major problem
and you really don't wanthormone therapy, then there's
other options for you theestrogen only arm of the Women's
Health Initiative, which usedconjugated estrogen and the
estrogen progesterone arm, whichused PremPro in women who had a
uterus, interestingly showedreductions in all types of
fractures in women takinghormone therapy and this is
(55:35):
really impressive because thisgroup of women who participated
in this study were not a groupdeemed to be at high risk for
osteoporosis.
Now they were women.
So again, women are at risk.
But in most osteoporosis trialsyou have to already have
osteoporosis to get into thetrial.
So estrogen currently is theonly agent we have that reduces
(55:56):
all types of fractures in womenof varying bone densities.
Now we can use uber low levelsof estrogen in the Menistar
patch 0.014 or half of a 25weekly or bi-weekly patch if
you're between the ages of 60and 80 and just have osteopenia
(56:19):
and a lot of women like thisoption if they don't have hot
flashes and they really don'twant to take progesterone and
have a uterus.
Although you still have to takeprogesterone for 12 days at
least once a year if you're onMenostar, but not every month,
the dose must be individualizedand if you have bone loss or hot
flashes then you might needmore hormones, but you don't get
(56:41):
the potential breaststimulation of progestogens.
Now not all women maintain bonedensity with hormones, and
certainly hysterectomized womenwho've had their ovaries out
many times, especially after age70 or 75, even if they've gone
(57:03):
decades with stable bone density, sometimes they do lose bone
and need additional treatment.
Now some women who've nevertaken hormone therapy or they
took it for a while but had sideeffects of breast issues or
bleeding if they're not at superhigh risk for fracture or they
don't, maybe have osteoporosisyet they have osteopenia or
(57:23):
they're concerned about theirrisk of breast cancer and they
don't have a history of bloodclot.
Maybe they've taken the birthcontrol pill or had a pregnancy
or a c-section in the past.
Then relaxaphenavista, I thinkmany times is overlooked.
It's not the biggest guns totreat osteoporosis but it has
these other systemic benefitsand it's easy on the stomach.
(57:46):
It doesn't irritate the stomach, it doesn't go through the
kidney, so you don't have toworry about kidney function.
And in 2007, it was FDAapproved to reduce the risk of
estrogen positive breast cancerdiagnosis.
And it does affect cholesterolbeneficially too.
In the RUTH trial, which wasthe raloxifen use for the heart
trial women who were atincreased risk for heart disease
(58:08):
or diabetes.
They didn't show any reductionin their risk of heart disease
by taking raloxifan, but theydidn't have any increased risk
of stroke.
And women on standard oraldoses after age 65 do have one
extra case of stroke perthousand women.
In the Moores trial, themultiple outcomes of raloxifin,
which looked at women withosteoporosis, and in the STAR
(58:32):
trial, the study of tamoxifenand raloxifin, which compared
tamoxifen and raloxifin forreducing breast cancer risk,
these all showed reductions inbreast cancer diagnosis.
Now parathyroid hormone isavailable in the brand name
teraparotide, brand name Forteo,and that's a daily injectable
(58:55):
agent, and the little pen islike an insulin pen and needs to
be refrigerated, whereabalaparotide, also known as
Timlos, is very similar similarbut does not have to be
refrigerated.
And the PTH, which is producedin those four little parathyroid
glands next to your thyroid atthe base of the neck, is very
(59:18):
important for calcium and bonemetabolism, and these agents are
anabolic bone builders and it'san exciting option.
It's been on the market for along time.
In the past you could only useit for two years, but that has
been lifted.
If you've had bone radiation orPaget's disease, though, we
cannot use this class ofmedication, and that includes
(59:38):
women who had, you know, breastcancer with chest radiation, but
we do have other anabolics likethe Avenity Romo, which may be
an option.
But we do have other anabolicslike the Avenity Romo, which may
be an option.
Now, women who have menopausalsymptoms, who are on estrogen,
(01:00:06):
the therapy from the bone statusstill might want to finish five
years to reduce their risk ofbeing diagnosed with breast
cancer.
But, as I mentioned, if youhave Paget's disease or bone
radiation, you're not acandidate for Teo or Bondensity,
which is a biosimilar, orTymlos, which is a biosimilar or
(01:00:30):
timlos.
Now a lot of women come to measking me about natural
treatments like heavy metalsstrontium runolate, which is a
periodic element in the table ofelements, and it's been used in
Europe in postmenopausal women.
It goes under the brand nameProtolose, but it's not
available here in the UnitedStates, other than sometimes
people will get it inunregulated supplements, but I
(01:00:51):
don't recommend it because itinterferes with the reading of
the bone density just from thestrontium deposition in the
bones and it's a heavy metal.
And I think we have plenty ofother options.
Well, if, if I feel good, can Ijust stop using my bone therapy
?
Well, always consult aphysician about your therapy.
You don't want to just stop andtake a vacation off your
(01:01:14):
therapy, unless it's been deemedto be an appropriate time where
you're being monitored.
We talked about the supplementsof vitamin D3, which helps you
absorb calcium.
Talked about the supplements ofvitamin D3, which helps you
absorb calcium, and justremember that calcium and
vitamin D are like the buildingblocks.
I call them like the nails andthe two by fours.
If the worker people don't showup to use those building blocks
(01:01:37):
, you're not going to get thatextension made to your house.
Conversely, if the workerpeople show up and there's no
supplies, no calcium, protein,vitamin D, then you're not going
to be able to rebuild your bone.
If you need a calciumsupplement, I favor calcium
citrate because that's absorbedwith or without food, with or
without stomach acid, but it isa little more expensive than
(01:01:58):
calcium carbonate.
So the cheapest option is tochew a Tums after a meal if you
don't think you've gotten enoughcalcium.
Be sure to not take in more than1,500 to 2,000 milligrams of
calcium a day.
There's lots of non-dairy foodsthat are great for calcium
Seaweed, blackstrap, molasses,almonds, broccoli, canned fish
(01:02:21):
with bones, sardines, salmon,bone sardines, salmon, collards,
dried beans, kale and, ofcourse, spinach and all the
dairy products milk, low-fatyogurt, cottage cheese, ice
cream cheeses, especially thehard cheeses, and even if you're
(01:02:42):
lactose intolerant, you stillmay be able to digest certain
yogurts and hard cheeses.
And there's lots oflactose-free dairy products.
I really like the brand of milkthat's lactose-free and higher
in protein that has a longershelf life.
You could also get dairy yeastor lactase enzymes to help you
digest it, and now there's somany non-dairy milks like
(01:03:05):
coconut milk and almond milk andsoy milk that you get high
amounts of calcium without toomuch calories.
Now calcium levels need to bemonitored before getting Prolia,
especially for the firstinjection, if you're on the
injectable anabolics or ifthere's any reason to suspect
you've got some calciumimbalance.
(01:03:27):
If you've had kidney stones, Irecommend a 24-hour urine
calcium collection.
And cutting down on calciumwill not prevent kidney stones,
but taking hygrotin,chlorthalidone,
hydrochlorothiazide, maxide Manytimes we use these in very low
doses and that fixes the leak inthe kidney, so preventing bone
(01:03:53):
loss.
You have to be aware ofmedications that can be bad on
your bones and that includessome blood thinners, long-term
heparin medications used totreat seizures, which sometimes
are used in other patients forpain and mood stabilization.
Too much thyroid medicine,prednisone, steroids, many
breast cancer treatments, toomuch alcohol, tobacco, even too
(01:04:17):
much caffeine, can cause you towaste calcium in the urine and
certainly drinking a bunch ofsodas and diet sodas high in
phosphorus are not good.
So participate in sensible,weight-bearing exercise and
certainly exercise is a surefireanti-aging remedy that we have.
(01:04:37):
It's important to get aerobicexercise and weight-bearing
exercise and we'll have manypodcasts on this topic.
For women that haveosteoporosis who are engaged in
activities that might result ina fall, such as skiing, there
are specific hip pad protectorsthat can be worn If you've got
osteoporosis or risk forfracture.
Just everyone should be awareof slip and fall risk, like
(01:05:01):
loose rugs and electrical cordsand slippery surfaces, because a
fall, even if it doesn't resultin a bone fracture, can
certainly cause head trauma,bruising pain, require a doctor
visit and if you need assistivedevices because of orthopedic
problems or neurologic problems,it's very important to get this
(01:05:22):
assessed because we want you tobe strong and be healthy and be
in charge.
Thanks so much for joining me inthe Sunflower House.
I am your host and author ofthe Cleveland Clinic Guide to
Menopause and I hope yousubscribe to our Speaking of
(01:05:43):
Women's Health podcast.
Give us a five-star rating tohelp us move up in the charts
and please join us next time forChapter 13, abnormal Bleeding
and what to Do About it.
Welcome to the Speaking of Women's Health
podcast.
I'm your host and author of theCleveland Clinic Guide to
Menopause and I am back in theSunflower House with you going
over chapter 12.
This is March 2023, and this isabout boosting bone health, and
(00:31):
I'll certainly encourage you totune in to an April Speaking of
Women's Health CME podcast withone of our Specialized Women's
Health fellow graduates, a verysuccessful osteoporosis expert
physician, dr ChristyTuff-DeSapri.
So on to boosting bone health.
(00:54):
Midlife is a critical turningpoint for a woman's bone health.
There's a direct relationshipbetween menopause and the
development of bone thinningdisorder, termed osteoporosis.
In the five to seven yearsfollowing menopause, which is
the final menstrual period, orloss of making eggs and ovarian
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function, a woman can lose up to20 to 30 percent of her bone
mass, and when a womanexperiences early menopause, she
is especially at risk for rapidbone loss.
So this makes midlife a primetime to both prevent and treat
low bone mass, so that we canstay strong, healthy and in
(01:43):
charge in our later years.
And yet so many women don'trealize, or they're just not
advised by their health carefolks, to begin testing for bone
loss early.
Alyssa's experience is far toocommon.
This is Alyssa's story.
I'm 52 years old and I haveofficially entered menopause, so
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I thought it would be a goodidea to see a physician who
specializes in women's health.
But when my new doctorsuggested that I get a bone
mineral density, a BMD, alsocalled DXA, I was skeptical.
My former doctor always told methat getting a bone density
test before age 65 was just awaste.
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He said no risk factors, noreason to get the test.
Well, my new doctor explainedthat this was kind of
old-fashioned thinking.
She said that even without riskfactors, every woman should
have a bone mineral densityassessment within two years of
menopause.
She told me that being femaleis a risk factor for bone loss
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because of the metabolic changesand the marked estrogen
deficiency that we experienceafter midlife.
So I got the test my newphysician ordered, and the
results really surprised me.
I was diagnosed with osteopenia.
The doctor explained, though,that this didn't necessarily
mean I had a quote disease.
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It just meant that I have lowerbone density than other women
my age, and it also meant that Icould be losing bone and that
I'm potentially at higher riskthan an average woman for bone
breakage, also known as fracture, as I get older, if this new
doc hadn't tested my bonemineral density, I would just
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continue to assume that my boneswere strong, because you can't
see or feel a loss in bonedensity.
So it turns out that the pastdoctor's claim that I didn't
display risk was just dead wrong.
This brush off game that hegave me about not needing a bone
mineral density at my age waskind of scary, and I wonder how
many other women simply trustwhat they're told without
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getting another opinion.
So what is osteopenia?
Osteopenia is a conditioncharacterized by decreased
calcifications or deposits ofcalcium salts which are needed
to form bone.
And when you lose the calciumor you lose the architecture of
the bone, you have reduced bonedensity and this may warrant not
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just preventive but alsotherapeutic pharmacologic
treatment.
So being told that you haveosteopenia simply means that you
have less bone mass than theaverage woman, and having less
bone mass than average isn'tnecessarily a problem.
But it is important toestablish your baseline bone
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density because if you lose bonedensity rapidly, it's a problem
and needs to be addressed.
The less dense your bones are,the more likely you are to break
a bone.
So half of all women haveosteoporosis by age 55.
And I describe how much calciumyou have in your bones is kind
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of like how much money you havein the bank.
So if you have a lot of moneyin the bank, you can make
withdrawals at a much fasterrate than putting deposits in
before you go bankrupt.
So if, genetically or becauseof other medical conditions or
past hormonal or vitamindeficiencies or other conditions
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like celiac there's so manydifferent things that can
negatively affect your bone Ifyou tend to have less bone
density than average, you justcan't make as many withdrawals
as deposits, or you're going toreach a critical bankruptcy
phase, which is bone breakage.
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And so many women think thatbreaking a bone is just part of
aging, or because they fell offtheir bike or because they were
running on black ice.
But that's not so.
If the bones break after age 40, it's different than childhood,
when the bones are growing andsoft and haven't fully
mineralized and reached theirpeak bone density.
But in any person over 40, maleor female, if you break a bone
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it needs to raise a red flag.
So what exactly is osteoporosis?
Well, it is the loss of thebone density, mass and strength,
leading to both increasedporosity and vulnerability to
bone breakage.
So type 1 osteoporosis isrelated to menopause and is
generally almost alwayspreventable with hormone therapy
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or other non-hormonal agentsthat affect the bone breakdown
rate, whereas type 2osteoporosis is related to aging
and it affects older women overthe age of 65 as well as men,
but it's still modifiable andmanageable as well.
So our focus today is mainly ontype 1, and it's important to
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note that osteoporosis is not anormal part of aging.
It can be prevented and treated, though there is no specific
cure.
The key is to identify rapidloss in bone density during the
peri and postmenopausal years,especially those first five to
seven years, so that you cantake action to slow the process
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and, in some cases, stop it andeven rebuild bone.
This is very important, as it'sgoing to protect you from
debilitating bone fractures.
There's a number of approvedoptions to both prevent and
manage osteoporosis, one ofwhich is menopausal hormone
therapy.
If you've recently started intomenopause, knowing your bone
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status may affect your decisionabout whether to use hormone
therapy or use additionaltreatments or other treatments,
and whether to continue hormonetherapy treatments or other
treatments and whether tocontinue hormone therapy.
So who gets osteoporosis?
Well, 80% of people withosteoporosis are women, but
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osteoporosis is mistakenlythought of a disease of only
older white women or a problemof skinny, frail women.
But neither of theseassumptions is completely true.
In fact, in the United States,osteoporosis and low bone
density affect millions of womenand men over age 50.
So according to the NationalOsteoporosis Foundation, that's
well over 55% of people.
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So at least one in every twowhite women over the age of 50
will have anosteoporotic-related bone
breakage or fracture in herlifetime.
Now women of color may be lesslikely to develop osteoporosis,
but they're still potentially atrisk, and 10% of women of color
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over age 50 have osteoporosisand an additional 30% have low
bone density.
So that does still put them atrisk for osteoporosis and
unfortunately, women of colorwho sustain a hip fracture are
more likely to die from it thanwhite women and, just like men,
are less likely to haveosteoporosis because they don't
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lose their sex hormones.
They tend to develop denserbones and muscles compared to
women and they don't rapidlylose bone at midlife like half
of all midlife women do.
But if a man breaks his hip,he's actually more likely to die
than a woman.
So this is a serious problemfor our society, but too many
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people just don't realize thatwomen and women of color and men
are potentially at risk forosteoporosis, so you might have
to speak up for yourself orswitch doctors.
Fast fact over 1.5 millionfractures per year are due to
osteoporosis.
Well, what if I exercise andtake calcium supplements?
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Can I avoid osteoporosis?
Some people think if theysimply exercise, drink enough
milk or take a calciumsupplement that they will be
protected from osteoporosis.
Be protected from osteoporosisand certainly these what I call
hygienic lifestyle measures ofweight-bearing, exercise,
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getting enough calcium in thediet, and supplements if needed
to augment the diet and separatevitamin D3.
And I usually like to add K2 tothat.
That's not potassium, it's K2,also known as M7.
It's not in very many foods.
If you like Asian, korean,japanese natto, well then you're
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getting plenty of K2 in yourdiet.
But there's not that many foodsthat have K2.
Pork, dark chicken meat and afew cheeses Swiss, gouda, blue
and I like some of those foods,but I don't eat them every day.
And K2 is what helps drivecalcium into the bone as opposed
to getting deposited in thearteries.
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So all of those things are agood start and they're necessary
, but they're not sufficient anda lot of women are perplexed
when I say that that's nottreatment.
And then I use the example ofwell, you know, if you were
having pneumonia or an asthmaattack and you came into the
emergency setting, we wouldn'tjust simply say, oh, you just
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need some fresh air and oxygen.
Well, of course everyone needsfresh air or oxygen to breathe.
That's necessary, but it's notsufficient.
You might need something toopen up the lungs, you might
need antibiotics or steroids.
So that's treatment of adisease.
And I think, becauseosteoporosis is so common that
people just think, oh well, if Ijust have good hygiene and
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lifestyle, that that will beenough and certainly it helps.
Just like when I see women whoare eating right and exercising
and they're frustrated thatthey're gaining weight or that
they haven't lost weight even,I'll say, if you weren't doing
those good things, it would beeven worse.
So I know sometimes that's notthe best consolation, but
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knowledge is power and you andyour doctor should take into
account not just diet andexercise but your family history
.
Any biological blood relativeswith a history of hip fracture,
dowager's hump compression,fractures of the spine, wrist
fractures after age 40, all ofthose things are red flags.
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Also, what is your body massindex or weight?
Women who tend to be veryslender, under 127 pounds tend
to have lighter bones.
Smoking is very bad on thebones as well as so many other
things.
A history of eating disorder,even if you've recovered from it
.
If you went a period of time inyour younger years restricting
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calories maybe not having yourperiod that can affect your peak
bone mass Kidney stones.
If you've personally had ahistory of kidney stone, there's
a high chance it was calciumoxalate and that you're leaking
out too much calcium from yourkidneys.
And the answer to that is notreducing calcium in your diet,
like some people erroneouslytell men and women.
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It's stopping that excessivecalcium leak, because 99% of our
bones, or rather our calcium,is stored in our bones and we
will always steal it out of ourbones to maintain that 1% level
in our bloodstream that we need.
And if our blood is beingfiltered by the kidneys and
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leaking out calcium, not onlycan it lead to kidney stones,
which are very painful, but alsobroken bones.
Now, if you have a history ofwheat or gluten intolerance,
called celiac disease and wehave a great column on celiac
disease on ourspeakingofwomenshealthcom site
or even if you're just verygluten intolerant but not
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necessarily have overt celiacdisease, this can certainly
affect your bone health and itcan irritate your intestines so
that you don't even absorbenough iron and vitamin D.
Now you can certainly getcalcium from food, particularly
if you like calcium-rich foods.
Certainly get calcium from food, particularly if you like
calcium rich foods.
But for some women, especiallyif they avoid dairy, they may
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not be getting all their calciumthrough diet and it's even
slimmer chance that you'regetting enough vitamin D in your
diet, and we'll talk more aboutsupplements in a moment.
So bone basics you mightassociate bones with just a hard
, lifeless skeleton, like yousee at Halloween time, but this
is farther from the fact.
(14:30):
Your bone tissue is complex,living, active, regenerating
tissue and the bone's innermostlayer, the bone marrow, makes
cells that are blood cells thathelp keep us alive.
It's a very important organ andthe bones provide structural
(14:50):
support for our muscles.
They also protect our vitalorgans and, importantly, they
store calcium.
And our bones are not the samebones that we were in seven
years ago.
They're in a continuous cycleof repeated breakdown, buildup,
breakdown, buildup, known asremodeling, and during the phase
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of the cycle called resorption,the bones release some calcium
into the blood, which results inbone breakdown.
In the formation phase, newbone is built up to replace the
old, potentially damaged bone.
Just like your skin, the skinthat you see on your arm is not
the same skin you had last month.
(15:32):
So this ongoing cycle ofreplacing old bone with new bone
gives the body the calcium itneeds in the bloodstream and
muscles, while keeping yourskeleton hopefully strong, and
muscles while keeping yourskeleton hopefully strong.
When the bone formation exceedsthe resorption, the bone mass
increases.
But if your resorptionbreakdown is faster than the
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formation, which happens to halfof women when they lose
estrogen, then there's areduction in your bone mass and
when the bone mass iscontinually reduced, it leads to
osteoporosis.
Now I tell women if you're onlyplanning to live to age 50, 55,
chances are you've got enoughbone.
But when I see women, since thefield of menopause is really
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anti-aging, we're trying toimprove not just the quality of
life, which is very important,of course, but also the
longevity and the functionality.
And too many women outlivetheir bones.
So what is a broken bone, not abroken bone?
Well, if you or your child hada broken bone that healed well,
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all this talk about bonebreakage may strike you as a
little odd.
Bones break, they're set andthey heal right, not necessarily
when we're older.
Statistics show that almost 40%of older people who have a hip
fracture die within thefollowing year.
They can die from complicationsof the fracture or its
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treatment or have beenimmobilized during that recovery
, and certainly those whosurvive have pain,
hospitalization, expense,rehabilitation and they also run
the risk of losing theirindependence.
And so when I see women ages 65plus, my focus changes in some
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part in terms of plus.
My focus changes in some partin terms of screening for
diseases that might shortentheir lifespan.
The focus turns more tofunctionality and preserving
independence, and preserving andpreventing preserving their
independence and preventing themfrom having to go to assisted
living or a nursing home,necessarily.
So how is your bone mass builtup?
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Well, from infancy up until age30 to even 35, we humans build
more bone than we lose, andafter 30 to 35, we hope to
maintain our bone density prettystable until later in life when
we try to prevent the rapidloss.
So think of it this way Each ofus maintains this lifelong bone
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bank and we constantly makedeposits and withdrawals, and
this depends on our lifestylechoices, such as getting enough
calcium and protein, vitamin Dand exercise, and some of us who
have family histories ofosteoporosis who are naturally
very thin or small-framed or whoget any bone breakage after the
age of 40, may automaticallystart with a lower balance in
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that bone bank and we have towork harder to keep it full.
The catch by age 30, which Iassume many of you are who are
listening when most of us havealready acquired most of our
skeletal mass, we can't reallymake any more significant
deposits, and we all know that.
Since, thankfully, most of uslive long enough to reach
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menopause, that's the time whenthose ovaries stop producing
eggs and estrogen, which thencauses lack of the hormone we
need to protect our bone andthis, in half of women, rapidly
increases the rate ofwithdrawals from the bone bank
and over time, without treatment, the increased withdrawals do
take their toll.
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So osteoporosis increases therisk of fracture and in the
serious cases can completelyreduce mobility, which brings
its own set of problems.
But the good news is that youcan increase bone mass during
midlife and certainly preventthe loss with hormone therapy in
the vast majority of women andor other non-hormonal
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pharmacologic options that havebeen well studied and designed
for women and in some cases formen who are at high risk or
who've had actual bone loss.
So what are the risk factors forosteoporosis?
Well, you can't always tellwhether someone has osteoporosis
, especially when it's in theearly stages, and there's some
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active midlife women who justdon't look the part.
And osteoporosis causes reallyno symptoms unless you break a
bone.
So just like we don't want towait until someone has a heart
attack to diagnose and assesstheir risk for heart disease,
the same thing is we don't wantyou to have a bone attack and
break your bone.
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Certain women are definitelymore likely to develop
osteoporosis and frailtyfractures.
In fact, just being a woman,your risk for low bone density
automatically increases and themetabolic changes, such as the
menopause-related estrogen loss,increases your risk.
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And if you've been ignoring yourdaily calcium and vitamin D
intake, you're not doing yourpart to give your bones the
basic building blocks.
So early awareness,weight-bearing exercise, such as
walking or lifting smallweights, and making sure that
your vitamin D 25 hydroxyvitamin D level is at least 32.
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I like it higher than 50 forother reasons, but for bone
health you need at least 32.
You cannot tell if your calciumbalance is normal by simply
checking your blood work.
The only way to find out yourcalcium balance is to do a
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24-hour collection of your urineon a typical day that you're on
your regimen.
Here are the risk factors forosteoporosis Estrogen deficiency
after menopause.
Having a thin or small, petiteframe.
A family history ofosteoporosis, especially a
history of a fracture in a closerelative.
A personal history of breakinga bone after age 40.
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If you've had a history ofmissing your periods because of
hormonal problems, an absence ofa menstrual period excluding
pregnancy for several months ata time.
If you've had a history ofdisordered eating.
If you smoked cigarettes orused nicotine.
If you've imbibed too muchalcohol that's hard on the bones
(22:06):
.
If you've had a lifetime intakeof low calcium, low vitamin D.
If you've had kidney stonesbecause you're peeing out too
much calcium and it hasn't beentreated.
If you have an inactivelifestyle.
If you have advanced age age.
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Now there are certainly chronicmedical conditions that also
dramatically increase the riskof osteoporosis rheumatoid
arthritis, autoimmune diseasesrequiring prednisone or steroids
, celiac disease, diabetes,anorexia nervosa, and there's
many medications that can bevery bad on the bones, including
glucocorticoids, which haveseveral mechanisms of action
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that are harmful to bone healthlong-term.
The aromatase inhibitors whichtotally wipe out estrogen, such
as aromacin, also known asX-Mistane, or Femera, known as
Letrozole or Arimidex, known asAnastrozole, as well as
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Depolupron, which is aninjectable treatment that
suppresses the ovaries Othermedicines that may stop monthly
periods or wipe out all estrogenputs women at risk for
osteoporosis.
Now, this is in contrast tohormonal contraceptives that are
taken continuously so that thewoman doesn't have like a
(23:35):
withdrawal period, but stillgive a daily continuous estrogen
and progesterone dose and mostwomen actually protects the bone
.
Now, if you have the presenceof some GI problem malabsorption
, celiac disease, wheat proteinintolerance that can also affect
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your bone health.
So how do we assess bone health?
Certainly, your history isimportant, or family history and
exam looking to see if you'velost more than an inch and a
half of height from your maximumheight at age 21,.
Looking to see if you havehunched over, hunchback kyphosis
, which could mean compression,fractures of your upper thoracic
(24:17):
spine.
Your physician should helpdetermine whether you need a
bone density test based on yourclinical history and risk
factors.
A bone density test will do thefollowing it measures the
amount of calcium in your bonesand it compares it to the soft
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tissue around the bones, thesoft tissue around the bones and
the amount of certain minerals.
How much calcium you have inyour bones is an indicator of
health and strength.
It helps assess your risk forfracture and it can be used in
serial fashion every two yearsto determine your rate of bone
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loss or bone gain and monitoringthe effects of any therapy.
Now, generally speaking, thelower your bone density, the
higher your risk of fracture andosteoporosis.
Now a recent enhancement to justmeasuring the calcium in your
lower lumbar spine and yournon-dominant hip, once you're
(25:25):
over 65, we usually do both hips, because there's arthritis in
the lower spine and sometimes ahardening of the arteries of the
aorta, which falsely elevatethe bone density in your spine.
Sometimes we'll do the distalone third of the non-dominantray
exortiometry, dexa, andwherever you have your bone
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density, the person reading thebone density should be ISCD
certified.
I am a certified bonedensitometrist and have
specialized in osteoporosis fordecades, and my techs bone techs
are also certified andcurrently although hopefully
that will change soon and againyou're listening to this in
(26:24):
March of 2023, I am the only onein my healthcare system that
has trabecular bone scoring.
Tbs and trabecular bone scoringis a software program that's
able to analyze the connectionsof your bone, because bone is
(26:44):
not just a solid block, it'sporous and there's
interconnections and your bonearchitecture is either assessed
as being normal, partiallydegraded or degraded.
So obviously the best categoryto be in is normal amount of
calcium, normal density andnormal architecture.
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And the worst category, whichis very high risk for fracture,
is to not only have thin bonesand osteoporosis by the bone
density T-score, but also tohave completely degraded bone
and of course there's differentcombinations in between.
So what happens when you get abone density test?
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Well, let me assure you it'squick and painless and there's
various methods of measuringbone density.
Some people use peripheralx-ray machines that just measure
the density in the wrist orkneecap or shin bone or heel,
but the best bone densities arecentral dual energy x-ray
absorptiometers or DEXAs, andthat gathers the density from
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the hip, spine and potentialtotal body, which is the gold
standard of measurement.
During a test, you lay flat onyour back on a padded table and
a very precise x-ray machineprojects the beams onto the
target bone density area and theamount of the beam that's
blocked by the bone indicatesthe density and that enables the
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physician to compare theresults with bone density
standards and you get two scores.
You get a score that comparesyou to 30-year-old Caucasian
women and a lot of my patientssay well, I'm not a 30-year-old
white woman, but the Z scorecompares you to people your own
age, sex and ethnicity and bodyweight.
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So the Z score is not used fordiagnosis but it's used for us
to find out if you're more thana standard deviation and a half
below your peers, if there mightbe something more than just age
or menopause.
But the cut point fordiagnosing osteopenia,
osteoporosis or simply having anormal bone density is to
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compare you to the 30-year-oldCaucasian average.
So bone density and thedecision for hormone therapy
Well, the estrogen and hormonetherapy can improve or stabilize
your bone health.
So knowing your status andknowing your rate of bone loss
can help.
Many recently menopausal womendecide, especially if they don't
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have hot flashes or othersymptoms, that they want to
begin hormone therapy.
And, as I mentioned, there'sdifferent ways to measure bone
densities.
The portable ones tend to notbe quite as reliable as the
larger models.
But even the larger models, ifthey're removed from one room to
another, maybe aren't able tobe compared to your prior scan
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and you cannot compare betweenscans.
You can go to one lab and get ablood sugar and go to a
different lab the next month andget a blood sugar and your
doctor may compare the trends.
But bone density is very highlyprecise and every day we take
out a phantom spine and scan itand we measure our text
(30:02):
precision of error, because ifyou got on that table 10 times,
there's going to be 10 differentnumbers and we need to know if
the scatter is significant, justlike if I take your blood
pressure 10 times when you'resitting down relaxed.
I'm not going to get the exactnumber every time.
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So a woman that has severemenopausal symptoms hot flashes,
night sweats, can't sleep, isnot happy about her skin or hair
, or has vaginal dryness orchanges in bladder function or
sexual function she may wanthormone therapy anyway.
But it's important to know thatmost of these standard regimens
also prevent that rapid boneloss.
Now, when should I get a bonemineral density test?
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Well, I recommend getting abone density test within two
years of menopause and mayberight at menopause if there's a
history of fracture or high riskor a family history, or
certainly in women who are onprednisone or steroids or
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aromatase inhibitors, women thathave certain medical conditions
that put them at increased risk, women who've broken bones.
Now, scoring your test we talkedabout that T-score and Z-score.
So the T-score compares you toan ideal number, a typical
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healthy 30-year-old female.
So if your bone density is thesame as an ideal, then your
score is zero, but if it's lessthan average, it's measured in a
standard deviation, that'snegative.
So most normal people arebetween minus one and plus one.
It's the old bell curve thatyou might remember from school,
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and the World HealthOrganization lists criteria for
normal being above plus 1 to aslow as minus 1, whereas
osteopenia cut point is minus1.1 to minus 2.1.
Osteoporosis is a T-score equalto or less than minus 2.5.
And severe osteoporosis is whenyour T-score is minus 2.5 or
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worse and you've had anosteoporotic fracture.
Now the National OsteoporosisRisk Assessment Trial did reveal
, though, that postmenopausalwomen who had peripheral
T-scores of minus 1.7 were atrisk for fracture.
This is why age body weighthistory, combined with a T-score
, can further quantify your riskof fracture and treatment needs
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, and there is a score that wecalculate, called the FRAX score
.
I don't usually consistently doit in people under age 60,
because just based on your youngage, even if your bones are
thin, based on your young age,your fracture risk doesn't
necessarily hit the 20% fracturerisk in 10 years cut point or
3% risk of hip fracture in 10years.
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So you just don't want to onlygo with a T-score.
There's a lot of things to takeinto account Now.
The Z-score compares your bonedensity to that of somebody your
own age, weight and ethnicgroup and sex, and it can be
used in premenopausal women, whogenerally don't need a bone
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density test, but sometimes wedo it in transplant patients,
people on certain therapies,underweight persons.
And the Z-score can be used tocompare the postmenopausal woman
to her own peers.
And if your Z-score is minus1.5 or less certainly if it's
less than two that means you'renot only lower than the typical
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30-year-old Caucasian woman, butyou're really low compared to
somebody your own age andethnicity, and this is a warning
sign that there could be otherthings or secondary causes of
osteoporosis.
So a Z-score of minus 1.5 orworse means that you should be
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assessed for vitamin Ddeficiency, low estrogen state,
an overactive parathyroidthere's four little tiny
parathyroid glands in yourthyroid gland overactive thyroid
hormone or simply taking toomuch thyroid replacement,
elevated cortisol levels or gutmalabsorption of needed
nutrients.
Multiple myeloma can causemultiple spine fractures,
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hormonal imbalances, use ofcertain bone negative bone
medications and that excessiveloss of calcium through the
urine, which in some people, isa common genetic defect called
hypercalciuria.
So get recommended dailyallowances of calcium, which is
at least a thousand milligrams.
If you're estrogen replete andif you're estrogen deficient or
have had some gut problems, youmight even need up to 1500
(35:02):
milligrams of calcium, but youneed it in divided doses because
your intestines don't absorbmore than 300 to no more than
500 at a time.
Vitamin D it's not a vitamin,it's a pro-sterile hormone, and
I would definitely encourage youto listen to my second ever
podcast on vitamin D.
Now, the so-called recommendeddaily allowance is not based on
(35:25):
science.
It's 400 international units,which is barely enough to
prevent rickets In mostcountries.
Most experts agree that mostadult persons, especially over
40, should get at least one totwo thousand units, and people
with low levels may need up toten thousand units a day to fill
up their tank.
Now, the reason why fourhundred units was picked as the
(35:50):
recommended daily allowance wasbased on mother knows best,
because moms used to have theirkids swallow a teaspoon of cod
liver oil every day to preventrickets, which is severe vitamin
D deficiency.
Vitamin D and weight-bearingexercises is tolerated.
So walking, lifting weights,jumping rope, using resistant
(36:14):
bands are all helpful.
It's important not to smoke andto avoid excessive alcohol use
and to bring in all yourprescription medicines and
supplements when you visit withyour physician and get a bone
mineral density when appropriateand if you need a follow-up
bone density, trying to get iton the same machine.
And if you're lucky enough tobe in an area where there's
(36:37):
experts in osteoporosis and theyhave that trabecular bone
scoring, that can be veryhelpful, because in the last
year I've assessed all the datain our Center for Specialized
Women's Health and we found that16% of the diagnoses got
changed either to a worsediagnosis or a better diagnosis
based on taking into account thetrabecular bone score and the
(37:01):
actual bone architecture.
So, as I mentioned, over the ageof 40, sometimes our skin
doesn't make vitamin D.
Many of us work inside, many ofus like to use sunscreen to
reduce sunburn and skin agingfrom the sun, and some of us
live in Northern climates whereeven on a sunny day, like today
(37:23):
in March here in Cleveland, Icould run outside naked.
Not that I would, um, but I'mnot.
My skin's not going to makevitamin D because we're just not
at the right latitude.
So young people who don't wearsunscreen, who drink a lot of
vitamin D fortified milk andlike salmon and like to eat
mushrooms that have beensuntanned.
(37:43):
That has vitamin D in it.
Many times those folks mightget enough vitamin D, but in my
practice, most midlife women Isee, and even those that come
from the Sun Belt to visit me,especially if they're older,
even if their skin is damagedfrom sun exposure, I still see
very low levels.
(38:06):
So when should I seek treatment?
Well, as I said before, I wouldgenerally and most folks
recommend a bone mineral densitytesting within two years of
menopause and earlier for peoplewith a family history of
osteoporosis, very low vitamin Dlevels or people who've used
long-term glucocorticoids 7.5milligrams of prednisone or more
(38:27):
for three or more months.
And the decision to treat awoman for osteoporosis should be
based on the clinical riskfactors, the T-score, the
medical history, the FRAX and,importantly, if possible, the
bone architecture and also therate of bone loss over time.
(38:47):
So a combination of good healthand exercise and possibly a
regimen of hormone therapy orother bone medicines, with or
without hormone therapy, may beprescribed.
But again, this is just generalinformation to keep you strong,
healthy and in charge.
It is not medical advice doesnot substitute for care with
(39:07):
your physician.
So, bone therapies Well,depending on the severity of
life of the bone loss, we needto look at options.
And if you're at very high riskor you're rapidly losing bone,
we need to start hormone therapyor some other option.
And if you can't take hormonesor you don't want to, there's a
(39:30):
lot of options.
I mean, when I started in thisfield over 30 years ago, all we
had was estrogen, which you canonly use in postmenopausal women
, not men, and fluoride.
And fluoride makes the bonesdenser but it doesn't reduce
fracture.
So the density is not the wholestory.
And now we have several classesof medication and it's one of
(39:54):
the areas in women's healthwhere we actually have more
research in women than in men.
And sometimes men get the shortshrift.
Men with broken bones over 50or height loss or are on
medications that hurt theirbones.
Sometimes they don't get thesame attention women get.
So look out for the males inyour family if they're at risk
for osteoporosis.
(40:16):
So bisphosphonates they'reso-called anti-resorptive
treatments.
They slow or stop thedissolving of the bone tissue
without affecting the formationof new bone tissue.
So that means that you havemore formation over resorption,
so that your bone bank increasesover time.
And we have severalbisphosphonates.
(40:38):
We use some off-label beforeFosamax or Alendronate, which
was the first one that hit themarket in 1995.
We have Actonel brand name, ageneric residronate.
It can be dosed 5 mg a day or 35mg weekly, or one of the more
popular ones is just 150 mg oncea month and that reduces all
(41:02):
types of fractures spinevertebral, non-vertebral
fractures, which include thewrist, the pelvis, the hip and
the humerus arm bone.
And it's also approved toprevent glucocorticoid-induced
osteoporosis.
But when you only take it oncea month, you only get 12 times
to get it right, ladies.
And hardly any bisphosphonateis absorbed through the gut less
(41:25):
than 1%.
So if you're on an oralbisphosphonate you must take it
with plain tap water, notmineral water, not coffee, and
you really have to wait at least30 minutes and I usually tell
my patients 60 minutes withouteating any other foods except
for water, no other beveragesexcept for plain water and no
other medications.
(41:45):
And you need to be upright,meaning don't take it in the
middle of the night and fallback to sleep and have it stuck
in your esophagus.
Now Boniva Ibandronate is alsoavailable in 150 milligram
monthly dose and was previouslygiven by injection every three
months, but it's not beenassociated with reductions in
(42:06):
hip fracture so we don't tend touse it very often.
Now Fosamaxilendronate has beenon the market the longest and
it's got a 35 milligram weeklyprevention dose or a 70
milligram weekly osteoporosisdose and it does reduce spine
fractures and hip fractures andthere's a brand name that has
some vitamin D in it, whichgives either 2,800 international
(42:31):
units of vitamin D weekly or5,600 international units, which
really isn't that much, andmost insurances are just only
covering the generic form.
But the generics may beabsorbed at different rates and
I don't tend to be a fan of theoral generics and in anyone with
(42:52):
Barrett's esophagus or a hiatalhernia or gastric distress, I
usually go to the injectablezolendronic acid, also known as
Reclast, and it's a fivemilligram dose given once a year
for osteoporosis In breastcancer patients or people with
cancer.
It's used in a lower dose morefrequently, called Zometa, and
it helps bring down calciumlevels.
(43:13):
But in 2007, the zoledronicacid was officially FDA approved
to treat postmenopausalosteoporosis and Paget's disease
and in 2008, it was approvedfor men and women who had
already had a hip fracture toreduce the risk of low trauma
fractures and in that group ofpeople it was associated with
(43:35):
the lower death rates.
And it has to be infused overat least 15 to 20 minutes.
So it does require the nursefinding a little vein and an
office visit.
But it's a solid agent.
We know you're getting it andabsorbing it and in those people
who broke a hip it reducesdeath rates.
(43:56):
Now you've got to have adequatekidney function, at least 35
cc's per minute.
So you need a creatinine and,for any patients who finish up,
any type of bone building agentlike an anabolic daily shot of
injectable PTH, which is now ina biosimilar option, or Timlos,
(44:18):
also known as abalaparatide,which is also another daily
injectable for two years.
And we have the newest bonebuilder which is an anabolic
agent and anti-resorptive.
It's's called Avenity, alsoknown as Romozumab, and that's
given by two monthly shots bythe nurse for a month for an
(44:39):
entire year.
So that would be 12 visitswhere you wouldn't have to give
yourself the shot like you dowith Forteo or Timlos or those
biosimilars.
Because if you're going to goto the expense and hassle and if
you're severe enough to requirebone building agents, we need
to solidify that and Ifrequently will use Reclast and,
(45:05):
like I said, reclast has shownmortality reductions in older
men and women who've alreadybroken a hip.
So you have to get a calciumlevel and kidney function and a
vitamin D level for your firstinfusion at least 30 days in
advance, and every year or otheryear or even every third year
that you may be getting futurereclassed infusions.
You need to have adequatekidney function and you need to
(45:29):
be well hydrated and somephysicians might recommend
either acetaminophen, known asTylenol, or ibuprofen, if no
NSAID intolerance or allergies,known as Motrin or Advil, the
day before, the day of and theday after the infusion, because
sometimes the first infusion, ifyour bones are really hungry
(45:49):
and needing to build up, youmight feel flu-like symptoms or
even like growing bone pain.
Now, of course, once we gothrough puberty and the
epiphyses close, we can't growtaller, but we can grow denser
and stronger.
So estrogen, as well as actiniland Fosamax and Reclast, have
(46:13):
been proven to reduce spinefracture and hip fractures.
Now Evista, which is raloxifin,which is an estrogen agonist
antagonist which reducesestrogen-positive breast cancer
diagnosis, does not reduce hipfractures in the studies but
does reduce spine fracture andhelps cholesterol.
So it's kind of a mild agent.
As I mentioned, I don't tend tofavor ibandronate or Boniva too
(46:37):
often just because it doesn'thave the hip fracture reduction
data.
Now, bisphosphonates orally areusually well tolerated but they
can be associated with somegastrointestinal upset and I do
see that more with generics andyou must take your calcium at a
different time and you mustavoid eating or drinking other
(46:58):
things because otherwise you'regoing to flush your medicine
down the toilet, because if youswallow it but you can't absorb
it, it literally ends up in yourpoop and down the toilet
instead of going to your boneswhere you need it.
So what's all this?
I hear about jaw problems.
So certainly there have beennews stories talking about this
(47:20):
very rare condition called ONJosteonecrosis of the jaw.
Sometimes people call it BRONJ,bisphosphonate-associated
osteonecrosis of the jaw, butthis has been mainly seen
primarily in people who havecancer or multiple myeloma, who
are getting chemotherapy,radiation, may have poor dental
(47:42):
status or diabetes and those whoare getting repetitive
intravenous bisphosphonates.
So just as the media promotedthe hormone hysteria over 20
years ago with the Women'sHealth Initiative, I think that
there's been some jaw necrosishysteria as well.
So I'm really disturbed when apatient tells me that her
(48:03):
dentist told her to choosebetween your teeth or your hips,
because it's absurd.
We need our hips and we needour teeth.
It's just another reason tofind someone who's well versed
in research relating to women,who can evaluate your whole
health, consider your personalhistory and family history and
come up with an individualizedbest regimen.
(48:24):
Actually, some research showsthat actinel, like estrogen, is
good for the teeth and gums.
There was a study done at CaseWestern Reserve University that
looked at postmenopausal womenwho had no bone therapy versus
those who had Actinil, and theysaw improvements in their teeth
and gums.
And so when I saw this research, I contacted one of the
(48:45):
periodontists and we'vepublished in the Journal of
Menopause where women withosteoporosis who were on any
kind of bone treatment hormones,non-hormones, bisphosphonates
or other agents who wereevaluated by three dimensional
CAT scan of the jaw byperiodontist dentists and had
grading of their teeth and gumsand plaque scores.
And what we found is that ifwomen were on any osteoporosis
(49:09):
treatment compared to those whowere not, they had better teeth
and gums.
And furthermore, in the HorizonPivotal Fracture Trial, there
was no increase in osteonecrosisof the jaw in postmenopausal
women receiving yearly reclassthrough IV compared to women
getting placebo injections.
So only a handful of cases havebeen reported and I do think
(49:36):
ONJ has been blown out ofproportion and the American
Dental Association hasguidelines and I think the
dentist by and large understandthis.
So the baseline risk for havingONJ is about one to two per
hundred thousand persons and ifyou're taking bisphosphonates
that risk might be two perhundred thousand.
(50:00):
So it really pretty much isvery close to placebo.
So it's not zero but an.
Embryologically the upper jawand the lower jaw are derived
from different tissue.
But if you have bad dentitionor you need teeth pulled or
extensive dental surgery, Ialways recommend women get this
(50:20):
taken care of before we startthem on treatment or if they're
on another excellentanti-resorptive agent, denusamab
, known as Prolia, which can bevery helpful for women who have
impaired kidney function,because it doesn't go through
the kidneys.
It's basically a monoclonalantibody that helps to make up
for the loss of OPGosteoporoterogen in the body,
(50:45):
and women lose OPG rapidly whenthey lose estrogen.
So I like to say Prolia orDenusamab is kind of like a
super estrogen acting on thebone without any effects
anywhere else.
And the one thing aboutintravenous reclast and also
Prolia is it seems like it isassociated with slightly reduced
(51:06):
breast cancer risk.
In fact, doctors treating womenfor breast cancer especially if
they're giving them agents thathurt their bones frequently
will give them Zometa, which isjust a lower dose of reclass, on
a more frequent basis.
So if you're on Prolia, itlasts for a little more than six
months and Medicare usuallyonly covers it for the
(51:29):
injections.
You have to be past six monthsand a day to get the next one,
and if you don't keep gettingyour injections and you're not
on any other treatment, therecan be rebound fractures.
Now we have a little bit moreresearch using bisphosphonates
and hormone therapy combined,because they've both been around
longer than Prolia or Denosumab.
(51:51):
In fact, I gave my firstinjection to a patient of Prolia
in June of 2010.
I think I was the first one inmy healthcare system to give
that first injection to a woman,and it was studied for 10 years
before it hit the market, andso it's been on the market now
for well over 12 years.
I have people going on theirlike 24th injection.
(52:13):
So what about calcitonin?
That was a treatment that weused myocalcin spray by nasal
spray and it's a naturallyoccurring hormone that helps
regulate calcium and bonemetabolism and it can improve
bone density and sometimesreduce fracture pain, which I
would primarily just use it forspine fractures, and it's
(52:36):
recommended only in women fiveyears past menopause.
But it doesn't have hipfracture reduction and some
reports have linked it to higherrisk of cancer.
And now that we haveproleodenosumab, which avoids
the kidneys where thebisphosphonates don't, we really
don't have as much of a needfor it.
So one of the other anabolicsthe newest one on the block is
(53:03):
Romo, also known as Avenity, andI will use this in women at
very high risk for hip fracture,women who need an anabolic,
women who don't want to givethemselves a daily injection,
and also I will not give it,though, if the woman has had a
(53:23):
heart attack or stroke withinthe 12 preceding months, because
one of the studies showedpotentially higher risk of this,
but several other studies didnot.
So I do think it's a very safeand effective bone building
option, but I tell all mypatients I'm not going to go
through the trouble.
Have you go through the trouble, go through the expense, have
(53:45):
my office staff do all thepaperwork to get these expensive
therapies if you're going tojust lose it at the end because
you don't solidify the treatment.
So if you're going to use ananabolic, you can't just say, oh
, my bone density is so improvedafter two years or one year of
this therapy, now I'm fine andgo off into the sunset because I
guarantee you when you comeback for a future bone density,
(54:07):
if you don't come back soonerbecause of a broken bone, you
will have lost everything yougained.
So you have to agree in mypractice generally to either IV
reclassed after you finish youranabolic, prolia denusamab every
six months plus a day shots, oran oral bisphosphonate.
And I think, for women withreally low T-scores, those at
(54:29):
very high risk, those who've hadfailed treatment, or people
that have multiple differentconditions that negatively
affected their bones, like, say,hormonal deficiencies, vitamin
deficiencies, celiac disease,hypercalciuria all these things
that can be treated and orreversed, but who have lost so
(54:51):
much bone who need to build upto a stable status, that's
another group of women.
So hormone therapy is FDAapproved for both
osteoprevention and management,for both osteoprevention and
management, and it's a goodtherapy to stop that rapid bone
(55:12):
loss.
If bone density low bonedensity is your major problem
and you really don't wanthormone therapy, then there's
other options for you theestrogen only arm of the Women's
Health Initiative, which usedconjugated estrogen and the
estrogen progesterone arm, whichused PremPro in women who had a
uterus, interestingly showedreductions in all types of
fractures in women takinghormone therapy and this is
(55:35):
really impressive because thisgroup of women who participated
in this study were not a groupdeemed to be at high risk for
osteoporosis.
Now they were women.
So again, women are at risk.
But in most osteoporosis trialsyou have to already have
osteoporosis to get into thetrial.
So estrogen currently is theonly agent we have that reduces
(55:56):
all types of fractures in womenof varying bone densities.
Now we can use uber low levelsof estrogen in the Menistar
patch 0.014 or half of a 25weekly or bi-weekly patch if
you're between the ages of 60and 80 and just have osteopenia
(56:19):
and a lot of women like thisoption if they don't have hot
flashes and they really don'twant to take progesterone and
have a uterus.
Although you still have to takeprogesterone for 12 days at
least once a year if you're onMenostar, but not every month,
the dose must be individualizedand if you have bone loss or hot
flashes then you might needmore hormones, but you don't get
(56:41):
the potential breaststimulation of progestogens.
Now not all women maintain bonedensity with hormones, and
certainly hysterectomized womenwho've had their ovaries out
many times, especially after age70 or 75, even if they've gone
(57:03):
decades with stable bone density, sometimes they do lose bone
and need additional treatment.
Now some women who've nevertaken hormone therapy or they
took it for a while but had sideeffects of breast issues or
bleeding if they're not at superhigh risk for fracture or they
don't, maybe have osteoporosisyet they have osteopenia or
(57:23):
they're concerned about theirrisk of breast cancer and they
don't have a history of bloodclot.
Maybe they've taken the birthcontrol pill or had a pregnancy
or a c-section in the past.
Then relaxaphenavista, I thinkmany times is overlooked.
It's not the biggest guns totreat osteoporosis but it has
these other systemic benefitsand it's easy on the stomach.
(57:46):
It doesn't irritate the stomach, it doesn't go through the
kidney, so you don't have toworry about kidney function.
And in 2007, it was FDAapproved to reduce the risk of
estrogen positive breast cancerdiagnosis.
And it does affect cholesterolbeneficially too.
In the RUTH trial, which wasthe raloxifen use for the heart
trial women who were atincreased risk for heart disease
(58:08):
or diabetes.
They didn't show any reductionin their risk of heart disease
by taking raloxifan, but theydidn't have any increased risk
of stroke.
And women on standard oraldoses after age 65 do have one
extra case of stroke perthousand women.
In the Moores trial, themultiple outcomes of raloxifin,
which looked at women withosteoporosis, and in the STAR
(58:32):
trial, the study of tamoxifenand raloxifin, which compared
tamoxifen and raloxifin forreducing breast cancer risk,
these all showed reductions inbreast cancer diagnosis.
Now parathyroid hormone isavailable in the brand name
teraparotide, brand name Forteo,and that's a daily injectable
(58:55):
agent, and the little pen islike an insulin pen and needs to
be refrigerated, whereabalaparotide, also known as
Timlos, is very similar similarbut does not have to be
refrigerated.
And the PTH, which is producedin those four little parathyroid
glands next to your thyroid atthe base of the neck, is very
(59:18):
important for calcium and bonemetabolism, and these agents are
anabolic bone builders and it'san exciting option.
It's been on the market for along time.
In the past you could only useit for two years, but that has
been lifted.
If you've had bone radiation orPaget's disease, though, we
cannot use this class ofmedication, and that includes
(59:38):
women who had, you know, breastcancer with chest radiation, but
we do have other anabolics likethe Avenity Romo, which may be
an option.
But we do have other anabolicslike the Avenity Romo, which may
be an option.
Now, women who have menopausalsymptoms, who are on estrogen,
(01:00:06):
the therapy from the bone statusstill might want to finish five
years to reduce their risk ofbeing diagnosed with breast
cancer.
But, as I mentioned, if youhave Paget's disease or bone
radiation, you're not acandidate for Teo or Bondensity,
which is a biosimilar, orTymlos, which is a biosimilar or
(01:00:30):
timlos.
Now a lot of women come to measking me about natural
treatments like heavy metalsstrontium runolate, which is a
periodic element in the table ofelements, and it's been used in
Europe in postmenopausal women.
It goes under the brand nameProtolose, but it's not
available here in the UnitedStates, other than sometimes
people will get it inunregulated supplements, but I
(01:00:51):
don't recommend it because itinterferes with the reading of
the bone density just from thestrontium deposition in the
bones and it's a heavy metal.
And I think we have plenty ofother options.
Well, if, if I feel good, can Ijust stop using my bone therapy
?
Well, always consult aphysician about your therapy.
You don't want to just stop andtake a vacation off your
(01:01:14):
therapy, unless it's been deemedto be an appropriate time where
you're being monitored.
We talked about the supplementsof vitamin D3, which helps you
absorb calcium.
Talked about the supplements ofvitamin D3, which helps you
absorb calcium, and justremember that calcium and
vitamin D are like the buildingblocks.
I call them like the nails andthe two by fours.
If the worker people don't showup to use those building blocks
(01:01:37):
, you're not going to get thatextension made to your house.
Conversely, if the workerpeople show up and there's no
supplies, no calcium, protein,vitamin D, then you're not going
to be able to rebuild your bone.
If you need a calciumsupplement, I favor calcium
citrate because that's absorbedwith or without food, with or
without stomach acid, but it isa little more expensive than
(01:01:58):
calcium carbonate.
So the cheapest option is tochew a Tums after a meal if you
don't think you've gotten enoughcalcium.
Be sure to not take in more than1,500 to 2,000 milligrams of
calcium a day.
There's lots of non-dairy foodsthat are great for calcium
Seaweed, blackstrap, molasses,almonds, broccoli, canned fish
(01:02:21):
with bones, sardines, salmon,bone sardines, salmon, collards,
dried beans, kale and, ofcourse, spinach and all the
dairy products milk, low-fatyogurt, cottage cheese, ice
cream cheeses, especially thehard cheeses, and even if you're
(01:02:42):
lactose intolerant, you stillmay be able to digest certain
yogurts and hard cheeses.
And there's lots oflactose-free dairy products.
I really like the brand of milkthat's lactose-free and higher
in protein that has a longershelf life.
You could also get dairy yeastor lactase enzymes to help you
digest it, and now there's somany non-dairy milks like
(01:03:05):
coconut milk and almond milk andsoy milk that you get high
amounts of calcium without toomuch calories.
Now calcium levels need to bemonitored before getting Prolia,
especially for the firstinjection, if you're on the
injectable anabolics or ifthere's any reason to suspect
you've got some calciumimbalance.
(01:03:27):
If you've had kidney stones, Irecommend a 24-hour urine
calcium collection.
And cutting down on calciumwill not prevent kidney stones,
but taking hygrotin,chlorthalidone,
hydrochlorothiazide, maxide Manytimes we use these in very low
doses and that fixes the leak inthe kidney, so preventing bone
(01:03:53):
loss.
You have to be aware ofmedications that can be bad on
your bones and that includessome blood thinners, long-term
heparin medications used totreat seizures, which sometimes
are used in other patients forpain and mood stabilization.
Too much thyroid medicine,prednisone, steroids, many
breast cancer treatments, toomuch alcohol, tobacco, even too
(01:04:17):
much caffeine, can cause you towaste calcium in the urine and
certainly drinking a bunch ofsodas and diet sodas high in
phosphorus are not good.
So participate in sensible,weight-bearing exercise and
certainly exercise is a surefireanti-aging remedy that we have.
(01:04:37):
It's important to get aerobicexercise and weight-bearing
exercise and we'll have manypodcasts on this topic.
For women that haveosteoporosis who are engaged in
activities that might result ina fall, such as skiing, there
are specific hip pad protectorsthat can be worn If you've got
osteoporosis or risk forfracture.
Just everyone should be awareof slip and fall risk, like
(01:05:01):
loose rugs and electrical cordsand slippery surfaces, because a
fall, even if it doesn't resultin a bone fracture, can
certainly cause head trauma,bruising pain, require a doctor
visit and if you need assistivedevices because of orthopedic
problems or neurologic problems,it's very important to get this
(01:05:22):
assessed because we want you tobe strong and be healthy and be
in charge.
Thanks so much for joining me inthe Sunflower House.
I am your host and author ofthe Cleveland Clinic Guide to
Menopause and I hope yousubscribe to our Speaking of
(01:05:43):
Women's Health podcast.
Give us a five-star rating tohelp us move up in the charts
and please join us next time forChapter 13, abnormal Bleeding
and what to Do About it.
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