Latest / The Dr Louise Newson Podcast / 24 - Bone health, hormones and the real risk of osteoporosis

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24 - Bone health, hormones and the real risk of osteoporosis · The Dr Louise Newson Podcast

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On my podcast today, I'm with Doctor Doug Lucas, who's from
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the US. He's an orthopedic surgeon and a
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bone and hormone specialist, and we really talk a lot about
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osteoporosis, what it is, what it means to have it, the risks
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of having it, and how we can prevent it.
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We talk about hormones, we talk about exercise.
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It's so important because osteoporosis really is common as
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we age. So have a listen and hope you
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learn. So Doug, we're here to talk
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about bones mainly. And I've been quite vocal in the
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past saying that one of the reasons that I take hormones is
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because I'm really scared of osteoporosis.
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But lots of people don't even know what osteoporosis is.
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And I'm actually, I'm less scared of having a fractured
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hip, but I'm more scared about osteoporosis of my spine.
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And I've doctored hundreds of women in the past with
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osteoporosis of their spine and they've been very disabled.
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They've been deformed in their shape, but they've also been in
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a lot of pain. They're on morphine, they're on
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laxatives, they're on anti sickness.
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Every time they cough and sneeze, it could be another
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little micro fracture. So osteoporosis is a real
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condition, but it's I think quite a scary diagnosis that
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people just like a brushing under the carpet.
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They're not, it's not sensationalized enough really.
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So you are a bone expert. I'm really keen just to really
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unpick and go back to the basics, like our bones are more
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than just a skeleton that hold up a body, aren't they?
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Oh, my gosh, absolutely. Yeah.
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So my, my journey as an orthopedic surgeon really taught
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me a lot about bones, what they are, how they heal, I mean,
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literally how they feel, right. But as I exited out of
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orthopedics, I got into the space of prevention, integrative
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medicine, hormone optimization. And then I really realized that
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we're looking at osteoporosis in totally the wrong way.
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We get so wrapped up in this idea of the DEXA, the T score,
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the diagnosis of osteoporosis. And you're absolutely right, it
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is an anxiety provoking diagnosis for a lot of people
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and unfortunately a lot of times unnecessarily.
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But it comes down to me for a, from a definition perspective,
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we need to look at it absolutely the another way.
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We need to look at it as an imbalance of bone metabolism.
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We're all taught in medical school that there's cells that
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breakdown bone and there's cells that build up bone, and we can
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talk about how hormones have an impact on those.
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But if you think about it in the simplest way, which is your
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bones are always turning over, you have a new skeleton every 10
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years. The dynamic nature of that, of
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that organ system is remarkable. And you're right, nobody talks
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about it. So I like to look at
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osteoporosis now as not just a T score, not bone density or even
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fracture risk. It's really just an imbalance of
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bone metabolism over time. Depending on where you start and
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how fast you breakdown, eventually you will develop
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osteoporosis. It's just a math equation.
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So the cool thing about looking at it like that, though, is that
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if you think it's an imbalance of BOW metabolism, then all we
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have to do to improve it, to reverse osteoporosis is change
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the imbalance of BOW metabolism, do more build up, do less
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breakdown. And there's a ton of tools we
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can use to do that. Yeah.
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And that is so important looking at, you know, how these cells,
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the osteoclasts, the osteoblasts work because we've got to look
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after our bones, our bodies, all our tissues and organs, because
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we want to keep them healthy. And that you say, the bones are
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so dynamic. They're repairing the building.
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We're getting new cells all the time, new bone.
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But we want them to be as good as possible.
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But we also, there's this thing, isn't there?
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I think that people think if it's really stiff and hard, then
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it's very strong. But we want a bit of flexibility
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in our bones as well, don't we? Yeah.
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So it's really interesting thing in the, in the space of
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orthopaedics, you know, we, I think we all think of our
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structure as this just rigid thing, but actually bones are
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pretty flexible in the way that they are actually, you know,
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laying down the new bone, laying down the, the actual like
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spiculos of bone on the inside. It's all based off of load.
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Your bones are always responding to your load and your femur,
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that big thigh bone, you can actually bend it.
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If you grab onto each side of it, you can actually bend it and
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see it flex. So every time we walk,
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everything we do, your bones are bending and flexing and they're
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responding to that stress. And, you know, there's so many
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factors that we can talk about that affect our bones, but even
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very basic, lots of people think about calcium and their bones,
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but vitamin D, the sunlight vitamin, people sort of know it
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probably has an effect on bones. But it's really important, isn't
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it? Yes, it's one of the strongest
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associations. When you look at the literature,
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it's interesting. We talk a lot about calcium, but
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it's not, I mean, calcium deficiency is pretty rare in the
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in the Western world. And you see it in children who
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are malnourished. We don't see this in adults and
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in children it's the different disease, right?
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Like this is Ricketts, this is vitamin D deficiency, right?
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This is bone metabolism dysfunction disorder in adults.
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It's not a calcium deficiency for the vast majority of people,
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but it can be a vitamin D deficiency because without
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vitamin D, your body can't utilize the minerals.
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And it's not just calcium either.
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It's the calcium, it's the magnesium, it's the vitamin K,
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It's the boron. I mean, it's all of it, right?
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Vitamin D is the gateway to a lot of that.
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So if you're vitamin D deficiency, yeah, you're gonna
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have a really hard time building bone.
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Yeah. And that's really important
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because, you know, I'm very interested in preventing
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diseases. I know you are.
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And I'm very interested in inflammation in the body, and I
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know you are as well. And there's a lot of talk about
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osteoporosis being associated with all these other disorders
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and diseases. And of course they are.
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But the root cause is often, you know, increased inflammation in
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the body, but also a lot of the root cause can be vitamin D
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deficiency. And I was taught many years ago
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by a hospital doctor, Louise, people with chronic disease,
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it's an association, not a 'cause it's like a marker of
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poor health is low vitamin D. And I'm like, well, hang on,
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maybe it's more than an association.
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Maybe there is it is related. And my, I spoke to my husband
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recently and I said, do you ever measure vitamin D levels in
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hospital? He said no, because it's always
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low. What's the point?
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What? But it's it's so cheap and it's
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so easy. Like we should all be thinking
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about vitamin D as an anti-inflammatory hormone,
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really. Which is what it.
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Is yeah, yeah, yeah, yeah. It's funny.
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So then did you ask him the follow up question, which is,
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well, if you know that it's universally low, are you
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universally treating it? Of course I did and you can
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guess the answer. Yes.
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No. But that's because in medicine
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you become very rigid in the way you think because he's not a
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orthopaedic surgeon, he's not a general physician.
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He's a, you know, a urologist. So it's like, oh, that's not my
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area of medicine. Of course it is, Paul.
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Like we should be looking very holistically and it's very easy
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to do. But as AGP we weren't allowed to
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prescribe vitamin D for our patients.
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And I worked in quite a deprived area, so people would prioritise
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the food for the kids rather than vitamin D And I get that.
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But I think it's we should be looking at ways to keeping our
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bones really healthy. Well, so I did a little research
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on this recently because I remember back in an orthopaedic
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residency, some of my mentors were studying vitamin D
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deficiency. And it was clear as day, if
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you're vitamin D deficiency, you're not going to heal your
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bones very well, if at all. But yet there's the guidelines,
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the recommendations. I just read this yesterday.
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The Endocrine Society here in the US still says the the
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benefit of testing vitamin D does not outweigh the, you know,
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the financial burden of doing so.
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It's a $5 test. I mean it's.
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It seems bad because how much is a hip fracture to be repaired?
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You know, it's more than $5, isn't it?
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Yeah. Well, it's $100,000, you know,
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and you know, you mentioned at at the start, you know, you're
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worried about spine more than hip.
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Having treated both spine and hip fractures, I know you see it
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clinically this the burden that comes with spine fractures and
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that's a very real, But if you break a hip, you have a 30%
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mortality rate in the next 12 months.
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You have a 60% chance of losing your independence was a big
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deal. That 10%, that sort of sitting
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there that I didn't talk about, that 10%'s not the same either.
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I remember one patient of all the hip fractures that I
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treated, and we're talking thousands.
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One patient that seemed to bounce back One.
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Yeah, I, I, I said this to someone recently.
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If I was choosing the different diagnosis, you know, I sometimes
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play my mind, how would I feel if I had X or Y condition?
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And if I had breast cancer or if I had osteoporosis with a hip
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fracture due to osteoporosis, my prognosis would be worse with
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the osteoporotic hip fracture. But if I said to my friends, oh,
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I've just been diagnosed, I've just had a hip fracture, oh,
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what a shame. Hope you get better.
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If I say I've had breast cancer, this is just catastrophic.
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And I'm not belittling either, but I just think the sort of
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word on the street is, oh, never mind, it's fixable, but it
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effects all our bones in different ways.
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It loses independence. And like you say, there's
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there's a high mortality from an osteoporotic hip fracture.
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Absolutely. So there's not just vitamin D,
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We've said vitamin D is a hormone, which it is, but there
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are other hormones in men and women that are really important
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for our bones, aren't there? Absolutely.
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Yes, let's get into this. So I'm very interested in the
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history of medicine and the history of hormones.
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And I was reading a book recently and it was they were
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describing Professor Albright in 1941, who was a great picture of
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this spine that just you can see through it, basically.
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I'm sure you've seen the same picture.
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And he wrote about, he's a very eminent Dr. and he wrote about
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osteoporosis and estrogen. And they knew that there was an
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association with menopausal women not having estrogen,
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having osteoporosis. And not long after, they
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realized that women who took HRT had stronger bones.
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And now HRT is licensed as a preventative treatment for
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osteoporosis, isn't it? Right.
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Yeah, I mean, this is such an interesting space when you read
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the literature. And this is one of the reasons
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why when I left the conventional model and I started my own
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practice, I very quickly niche down into bone health and I very
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quickly started talking a lot about HRT because when you read
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the literature, what we do in practice does not follow the
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literature, at least over the last 20 years.
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And so you hear, I hear all these stories because I have, I
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have a clinical practice, I've got a community, an
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international community of people improving their bones.
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And then I have a YouTube channel that is global.
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We get thousands of comments every month.
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So I have like a pretty good pulse on what's happening in
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the, in the bone health community.
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And I, I heard over and over again, out of the gate, you
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know, my doctor won't prescribe this for me.
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I'm worried about my bones. They say we don't use it for
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bones. But as you said in the in, in
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Europe, in the UK, in the US, it is FDA approved, licensed for
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use to prevent osteoporosis. Because we know that it very
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clearly has a powerful impact not only on slowing down
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breakdown, which is what people talk about, but also on the
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build up side. It's one of the rare things that
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works on both sides of that equation in a positive way.
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It is extremely powerful. And if you look at it compared
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to the bone drugs, the pharmaceuticals, right, when you
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compare estrogen to the pharmaceuticals, it is a night
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and day, the potential benefit that estrogen, specifically
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estradiol have for the bones. And yet we don't use it for
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treatment. And most women who go to their
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doctors and say I'm interested in this because I have
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osteoporosis are told that we don't use it for that.
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Yeah, and I can't work that out in some ways because as a GP for
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many years I was encouraged to prescribe blood pressure
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lowering treatment because if we reduce blood pressure it reduces
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risk of a heart attack and stroke.
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That's great. I was encouraged to prescribe
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statins if people had a higher risk of developing heart
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disease. So but often the cut off, it
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varied on the guidelines, but usually if someone's got about a
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20% risk of a heart attack, then you look at their blood
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pressure, you look at their glucose, you look at their
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cholesterol. In women, primary prevention
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with statins is very scanty data because the studies haven't
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really been done, but we would still do it.
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So on average, we people say one in two women who are menopausal
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will develop osteoporosis. So that's 50%, isn't it?
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So we've got a drug, you can see where I'm going here, can't you?
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Like, and it's and it's cheap. But then like people have been
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scared for the wrong reasons. Now, the WHI study that scared
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the whole world of HRT and still is, the Women's Health
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Initiative study, actually, one of the good things it showed was
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that women who took hormones even when they started them in
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their 60s, guess what? What?
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You know, it showed that they had a lower incidence of
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osteoporosis, didn't it? Yeah, I mean it, it actually
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showed fracture reduction. I mean, this is actually hard to
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do in studies because it was large enough.
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Yes. And they followed them long
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enough. The oral, you know, conjugated
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equine estrogen Premarin used in the Women's Health Initiative
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showed a 41% reduction in risk of hip fracture specifically,
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which is a big drop. So say that again, 41%. 41% and
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this is with Premarin which is conjugated equine estrogen,
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which has very little estradiol and it is losing market share
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because it's not a great product.
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But yet even that not so great form of estrogen had a
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tremendous impact on hip fracture risk.
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And that, I think, is really, really important.
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And, you know, a lot of my work is about choice and education.
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But if I knew there was a medicine I could take that had a
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41% risk reduction of a disease, I'm got one in two chance of
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getting and one in three chance of an osteoporotic hip fracture.
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Like surely as a patient that we don't need to know anything else
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about hormones. You know, it's and it's basic
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Physiology because we've already said these hormones work in our
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bones. We're just replacing them,
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aren't they? Yeah.
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Let me play devil's advocate because this is what the the
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doctors who treat, you know, the fracture lays on doctors and the
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doctors that use the the the bisphosphonates and the Prolia.
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This is their counter to that. If you look at even like that,
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let's call the newest, the newest, the greatest drug for
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bone health evenity in the USI don't know what it's called in
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in the UK if it's the same, but rumososumab is the the generic
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and this drug is has AI think it's 70 like a 74% reduction in
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fracture, right? So you could say, oh, well, it's
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better. But the thing about the drugs
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compared to using estrogen specifically is that estradiol
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you can continue to take, I mean potentially indefinitely.
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We can talk about what happens if you ever stop it, but
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potentially for the rest of your life.
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Whereas the drugs that are having an impact on bone
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metabolism, you could only take Evenity for one year.
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You can take the bisphosphonates for three to five years, and
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Prolia, we have safety data to 10 years.
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But even then, those drugs do not work with bone metabolism.
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They don't work with your dietary changes, your exercise
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changes, you know, any of the things that you're doing that
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are good for your bones, they work against it because they're
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shutting down bone metabolism. Estradiol actually enhances bone
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metabolism. And I think this is really
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important because I was reading the history of the
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bisphosphonates and these drugs because I'm very interested in,
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you know, how do you decide, how do you make these drugs?
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And they were drain cleaners actually, weren't they?
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And like, I don't know how someone decide initially it was
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the foam from soap, wasn't it? They realized that and then they
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made them as drain cleaners and then they converted them to a
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drug. But it's, they hang around in
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the bone and the blood, don't they?
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Even when you've stopped using them.
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But I was looking at the risks of them because there are risks
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of medication, especially when it's a synthetic chemical that's
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not designed for our body. And there is risks of, of heart
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failure. There's risks of atrial
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fibrillation, it's irregular heartbeat.
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There's risks of stroke, but that seems to be ignored, and
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those risks are greater than any risks of even the synthetic
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hormones, aren't they? Right.
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Yeah. I mean, we always, if we're
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gonna use the benchmark of the WHI, which is like we could talk
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about all the negatives of this study, right.
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But the medical community seem to accept that an incidence in
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or a risk, an increased risk of eight out of 10,000 patient
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years seems to be important enough for women, right.
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So if we're going to use that as the benchmark, then yeah,
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everything that you just said is wildly higher than that in these
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studies. And you didn't even mention the
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two that I really worry about, which is the atypical femur
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fractures and the osteonecrosis of the jaw, because those are
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around 1% of users depending on the study you look at.
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If you combine it with steroids like or corticosteroids,
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Prednisone, it goes up by 10X. I mean, these are real risks,
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right? These are absolutely frightening
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risks. And if you have osteonecrosis of
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the jaw and you can't heal, you know, a fracture of your jaw,
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talk about it. The life changer, right?
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You can't eat. So yeah, I mean, there are real
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risks to the drugs, but I'm not anti drug either.
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There is a time and a place for these drugs.
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But my perspective is, wow, if we can have a conversation about
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hormones and about lifestyle and prevent fracture that way, why
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aren't we having that conversation?
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I totally agree. I mean, the drugs in general are
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quite expensive as well, whereas hormones are cheap.
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So that in my mind as a patient is good.
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But the other thing is, I often say to patients, I don't know
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whether you agree, but I hope you do, is that when people are
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taking HRT to protect their bones and they have a full, the
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bones are like a plastic Tumblr. They'll probably bounce on the
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floor and then they'll, you know, shouldn't flutter.
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But when they're taking often the bisphosphonates, if they
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have a full, it's a bit like a champagne glass, It just
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shatters because the bone becomes very hard and rigid.
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And that is a real problem if you're trying to operate on that
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broken stiff bone. I mean, you know, more than me.
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It's a very different. Yeah.
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Yeah. So this is the way I look at
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bisphosphonates because you know, if you mentioned that they
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stick around in the blood and then the bone and they do these
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drugs go into the bone. They poison osteoclast, the
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cells that break down bone and they prevent them from working
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and they but they bind to that material.
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So then in order to get them out, you have to turn over that
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bone. But I already said this about
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the anti resorptive drugs. They shut down bone metabolism.
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So when we use bone turnover markers to look at how quickly
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are we breaking down and building up, they're both very
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suppressed. You have very little bone
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turnover. So what happens over time is all
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of the collagen that was laid down before you started the drug
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does go through the calcification and mineralization
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process. It becomes bone but just like
19:05
you know clearing out an old road before you put in a new
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road you have to do the work to clear.
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That's what the osteo class do before you can build O, then you
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end U just building, building, building, not clearing.
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And that becomes a dense. So it looks better on DEXA, A
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dense but fragile bone. And that's why we see these
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weird fractures, like atypical femur fractures, these other
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fractures that normally wouldn't happen in places where they
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wouldn't happen. And then surgically, yeah, this
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is a big deal because you go in there and it feels like chalk.
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I mean, it literally like like just scraping it, drilling in
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it. It has a totally different feel
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to it for people that have been on bisphosphonates for too long.
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And that is a real problem because it's not going to be
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good when you're thinking about recovery as well.
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You know, if you've fractured your wrist, you want to be
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getting back home. If you've fractured your hip,
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you want to be be able to walk independently.
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And a lot of people, men and women, it can really be the end
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of, like you say, their independence.
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And it will take longer to heal if you have these fractures,
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won't it? Yeah, that's right.
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So Easter, when we talk about HRT, a lot of people think about
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estrogen, estradiol, really important progesterone, the
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natural progesterone. We're very different to the
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synthetic progesterone like Meguxi progesterone acetate that
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was used in the WHI study because progesterone has really
20:26
positive effects on the bone as well.
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So we see a lot of women who've had a hysterectomy and their
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gynecologist say you don't need progesterone because you've had
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a hysterectomy. You don't have a womb to
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protect, but I sort of say, well, you've got bones and brain
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and cardiovascular system. Yeah, precisely.
20:44
So progesterone is important for a musculoskeletal system, isn't
20:48
it? Yeah, this is a toughy because I
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run up against the same wall, right?
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So many women come in, they've had a hysterectomy for whatever
20:55
reason and they're not offered progesterone or any type of
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progesterone. And I agree, same thing.
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I'm actually setting up my, my small practice was acquired by a
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bigger practice and I'm setting up all these new protocols.
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We're setting up the Women's Health protocols.
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And I just passed by the board. I said, look, we are going to
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have a discussion and recommend micronized progesterone for all
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women going on HRT because of the benefits to the brain, to
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the bones, to the nerves, right to the arteries.
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Because that literature is, is pretty clear now.
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Unfortunately progesterone is rarely studied alone.
21:28
It's always the Co the Co captain to estradiol and
21:32
studies. There are some but there's not a
21:33
lot. So I can't say, you know, for,
21:36
for a woman, let's say a woman off label using progesterone
21:38
without estrogen for bone health, because I see this
21:40
frequently because I talk about it a lot.
21:43
I can't say how much that's going to help.
21:44
I don't know. It's never been studied alone.
21:46
It makes sense physiologically. We know that progesterone or
21:50
osteoblast, the building cells have receptors for progesterone.
21:53
It should have a positive effect and we see it clinically, but I
21:56
can't attribute, you know, how much is coming from the
21:58
progesterone versus anything else that we're doing.
22:00
So I think progesterone is really important for a lot of
22:03
things. Again, sleep, brain, nerves, but
22:07
I can't, I can't put a number on it.
22:08
I can't say, Oh yeah, 10% improvement.
22:11
Yeah. And but we know we've got
22:13
progesterone receptors in the bones, in the osteoclast,
22:16
osteoblast. There's a reason that they're
22:17
there. So we, it makes sense really,
22:20
doesn't it? But also the other hormone that
22:23
is often forgotten about, especially in women, but I think
22:26
also in men, is testosterone. But you don't have an FDA
22:30
approved for women testosterone preparation.
22:33
But Even so, testosterone is branded as a hormone that will
22:37
help with libido. But yes, it will help with
22:41
libido for many women, but it really can help with the bone
22:44
strength. And again, we've known this for
22:45
a long time, but that data seems to just be ignored the whole
22:50
time, doesn't it? Yeah, this has been really
22:51
frustrating for me because I I practice all through telehealth
22:55
at this point. After I left orthopedics, the
22:57
beginning of the pandemic, we started the practice.
22:59
We didn't need a brick and mortar location.
23:02
So we got licensed in all 50 states in the US.
23:04
And then once you do that, like a brick and mortar does you no
23:06
good. So we've maintained telehealth.
23:09
The company that bought my company, Life MD, is all
23:11
telehealth, but we're restricted in the United States because
23:15
testosterone is as a controlled substance.
23:18
So it is controlled just like you would control
23:21
benzodiazepines, narcotics, you know, all of the things that
23:24
that should be controlled. Testosterone is the same way.
23:27
So we can only prescribe in about 30 out of 50 states
23:29
through telehealth, and even then we're probably pushing
23:32
pretty hard. It's really unfortunate because
23:35
when you look at the data around testosterone, and there was a
23:37
study that was just published last month, when you look at the
23:40
data around testosterone, it does so much more than improve
23:43
sexual function and libido in women.
23:45
But we run into the same issue because it's only, it's actually
23:48
not even FDA approved, but it's recommended for use only with
23:51
the diagnosis of HSTD, hypoactive sexual desire
23:54
disorder, right? That's the only thing that
23:56
doctors are allowed to write down in the chart.
23:59
If we say we're concerned about your muscle mass, we're
24:02
concerned about your brain fog, your sleep, your energy, we're
24:06
concerned about your vitality and we want to consider off
24:09
label testosterone use. They get crucified.
24:12
And so it, it has really put up like a big shadow over
24:15
testosterone use. But fortunately you've got some
24:18
big, big voices that are coming out talking about the use of
24:21
testosterone, what it's good for.
24:23
I don't know if you listen to the FDA panel in the US, the
24:26
expert panel, Oh, it was great. Oh my gosh, so many great
24:30
comments around the use of testosterone and how ridiculous
24:33
some of these restrictions are when it comes to bone.
24:37
There are studies in in men, There's two studies I can talk
24:40
about in women, but there are studies in men that show that it
24:42
increases bone mineral density. It doesn't.
24:45
This is the, again, devil's advocate side, as they say.
24:47
Oh well. The studies didn't show a
24:48
reduction in fracture risk, but they weren't big enough to show
24:51
a reduction in fracture risk, right?
24:52
They weren't big enough studies. And whenever researchers use
24:56
testosterone in studies, they always use these tiny like not
25:00
they're just trying to go take a guy who's hypogonadal, so total
25:04
testosterone under 300 and then push him up to like, yeah, not
25:07
like 354 hundred, you know, but this is not you gonadal.
25:10
This is not optimized testosterone.
25:12
So you get these tiny little doses and they say, well, the
25:15
effect wasn't that great. It's like, well, the
25:18
testosterone wasn't that great either, you know, So like we're,
25:20
we're not doing great studies. But even then they do show
25:22
increased bone mineral density in women.
25:25
There's only one study that I found where they use
25:28
testosterone and this was a pellet study.
25:30
So it was estradiol pellets and micronized progesterone with and
25:34
without testosterone. The testosterone group had
25:38
better bone density at the end of the study, but it was small.
25:41
It was appellate study. And so, you know, OK, this is
25:43
helpful, but we need better data.
25:45
The study that I mentioned that was just published last month
25:48
was a a big retrospective view. So it actually looked at an
25:51
older population, looked at the rate of fracture and who was on
25:55
testosterone, which is actually kind of hard to do.
25:57
It's not a lot of women of that age group are on testosterone,
25:59
but they were able to show that if you were on testosterone,
26:02
there was a significant reduction in hip fracture risk.
26:05
So it's, it's very real. And we have to get around the
26:08
stigma of testosterone is bad, it's dangerous, It needs to be
26:12
controlled. No, just like any drug, if it's
26:15
used appropriately, we can expect it to have the benefit
26:18
that it should have, which is improved bone health, reduced
26:21
fracture risk, improve muscle mass, you know, improved
26:24
cognitive function, likely improved vitality overall.
26:28
We see this in men, like all of the symptoms of aging get better
26:31
with testosterone, and it's true in women as well.
26:34
And then, oh, yeah, also it might have an impact on your
26:37
libido and your sexual function. And that's a great side effect,
26:41
right? But that's not the big picture.
26:43
We need to be using it for what it is known for, which is really
26:46
like the lifeblood of energy, the lifeblood of vitality.
26:49
Absolutely. And, and I think also, you know,
26:52
you're the same as, as a doctor as me, you often try medication
26:56
in people and you give them options.
26:58
And if it doesn't work or doesn't help, then they can have
27:01
something else. But there's no reason why people
27:03
can't have HRT, testosterone and a bisphosphonate or another bone
27:08
drug if they need it. So, you know, there's always
27:11
options for people. And I feel it's sad when people
27:15
are just given the the bone drugs without thinking about
27:18
hormones. Yeah, I, I may comment on that
27:21
real quickly because I hear a lot of doctors who are
27:24
prescribing the bisphosphonate drugs again, the fracture
27:26
liaison clinics, which have value, but they're not hormone
27:29
experts. And so I hear this a lot, which
27:32
is, well, we can't use HRT and bisphosphonates because the HRT
27:37
will make the bisphosphonates less effective.
27:40
And I know, I know where they're getting it from.
27:43
I do, because if you look at studies where they have combined
27:46
the 2, the bisphosphonate doesn't seem to do as well.
27:49
But they're taking the data the way that the way that they want
27:52
to, which is, oh, well, I want to use the drug, so I shouldn't
27:54
use HRT. But what they're missing is that
27:56
no, actually the HRT made the osteoclast function better,
28:00
therefore they had better bone turnover, therefore the
28:02
bisphosphonate didn't do what you expected it to do, because
28:05
their bone function is better and their outcomes ultimately
28:08
are better too. So yes, you can absolutely use
28:10
them together, but there are a lot of doctors saying no, no no.
28:13
It makes the bisphosphonates less effective.
28:15
So at the end of the day, it comes down to patient choice as
28:19
well. But I just sit here feeling
28:21
really frustrated and I'm really grateful for your time.
28:25
But you know, it's 2025. It was 1941.
28:28
Professor Albright talked about hormones.
28:33
So I'm just keen. I always ask for three take home
28:36
tips. I'm just keen for three things,
28:39
Doug, that you think are going to make a difference for women
28:43
and men thinking about hormones and bones so that in another 80
28:48
years we're not having this still ridiculous conversation.
28:51
Yeah, let's not make it to a century from that right?
28:54
Let's not make it to 2041 before this is resolved.
28:57
Yeah. So I'm, I'm on a mission to go
28:59
around the globe talking about bone health in a different way.
29:02
We need to look at bone health as a biomarker of health span.
29:04
So I'll try to make this into three points.
29:06
So one would be if you are a perimenopause or postmenopausal
29:11
woman and you are considering some kind of hormone
29:14
optimization replacement and you don't know what your bone
29:16
density and quality is, you have to get that information before
29:21
you have that discussion with your provider because you are
29:23
missing a massive piece of the puzzle.
29:25
So I'd say that's number one #2 would be if you are, I'll do
29:31
this one for number 2. So we need to image our bones.
29:34
DEXA is available. It's around.
29:37
There are other new devices that you can measure with as well.
29:40
There's an ultrasound device called REMS that measures both
29:43
density and quality. I would actually encourage you
29:45
to get both. So what I would say here for
29:48
number 2 is get all the data that you need.
29:51
Get both the DEXA, get a REMS. This is more available in the UK
29:54
than it is in the US, but get both so that you can have as
29:58
much information about your bones and then follow it over
30:00
time. If you're losing bone,
30:02
something's wrong. And that's what I mean by saying
30:04
bone health is a biomarker of health span.
30:07
If you're losing bone, something's off.
30:09
I can't tell you what it is. Could be hormones, could be
30:11
diet, could be a lot of things. But if you're losing bone,
30:13
something's wrong. So that's number two.
30:15
And then #3 is don't lose sight of this.
30:19
If you're measuring, if you're imaging, if you're optimizing,
30:22
you can use these things called bone turnover markers, which I
30:24
know are available in the UK, but not broadly.
30:28
P1 and P and CTX are out there. Those are the bone turnover
30:32
markers that we can use to understand what's happening with
30:34
bone metabolism. As we're doing the things in
30:37
between our imaging modalities, which are going to be every six
30:39
months for Rams, every 12 months for DEXA, we can use the bone
30:42
turnover markers in between to make sure we're headed in the
30:44
right direction. So lots to think about, but the
30:48
most important thing is getting the message out that hormones
30:51
have a role on bones. So thank you so much for your
30:53
time, Doug. It's been great.
30:55
Yeah. Thank you, Louise.