Strong Bones, Strong Body, Stronger Second Half with Dr Jocelyn Wittstein - Part 2

In this continuation of their conversation, Dr. Jocelyn Wittstein and Dr. Mary Claire Haver shift from understanding why menopause affects bones and joints to what actually works for building stronger bones and preventing fractures. If you've been told your bone density is declining, or you're worried about falls and fractures, this episode delivers the practical protocols you need. Dr. Wittstein is a practicing orthopedic surgeon, researcher, and associate professor at Duke University specializing in sports medicine and the female athlete across the lifespan. She's also a former collegiate gymnast and mother of five. Her research focuses on frozen shoulder, ACL injuries in female athletes, and the musculoskeletal syndrome of menopause. As president of the Forum for Women in Sports Medicine, Dr. Wittstein is changing how we understand the intersection of hormones, movement, and independence in women's bodies. They tackle the questions women ask most. How much exercise is enough? What types build bone? Is jumping necessary? They discuss the LIFT More trial and EFOPS trial, research showing women in structured exercise programs had fifty percent reduction in fracture risk, even as bone density eventually declined. This reveals something crucial: preventing fractures goes beyond bone density numbers alone. Guest links: Jocelyn Ross Wittstein, MD https://www.dukehealth.org/find-doctors-physicians/jocelyn-ross-wittstein-md (Duke Health) Jocelyn Wittstein, MD https://www.instagram.com/jocelyn_wittstein_md/ (Instagram) Duke Female Athlete Program https://www.dukehealth.org/treatments/female-athlete-program Milken Institute Women’s Health Initiative https://milkeninstitute.org/health/public-health/womens-health Books: “The Complete Bone and Joint Health Plan: Help Prevent and Treat Osteoporosis and Arthritis,” https://www.amazon.com/Complete-Bone-Joint-Health-Plan/dp/1682689417 by Dr. Jocelyn Wittstein and Sydney Nitzkorski, MS, RD “The New Perimenopause,”⁠ https://thepauselife.com/pages/the-new-perimenopause-book by Dr. Mary Claire Haver ⁠"The New Menopause"⁠ https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/059379625X/ref=sr_1_2?adgrpid=190238689390&dib=eyJ2IjoiMSJ9.djG88jtefTqLpTg36Li8QMNmXkpzLIfbFdY438Vro2vit_rKymy65UpF10hk_VTrxmazFUemwk7ywlmqHYY80j-V3LaeSD824-02PCtdlS8Fzp1XPcZs68nYHCL4V_ZdZBTJya---9Ng5PtKdOf-U3ENtuDXbDw68ULSk2wNk6Lt6mEhIPkuLM7FhztUzBJZ0wNBUQCSs6Pk1ZhoV2JDlzRapnMjnZgOq7PBA7Wy2KM._ZZSn21KJ43AyMvvSvI9_Hs3q74tpMBoCJ2zwi9enkc&dib_tag=se&hvadid=779626799212&hvdev=c&hvexpln=0&hvlocphy=9004331&hvnetw=g&hvocijid=16430100151400627515--&hvqmt=e&hvrand=16430100151400627515&hvtargid=kwd-2465259580440&hydadcr=15551_13558570_10211&keywords=perimenopause+book+mary+claire&mcid=ab159bad5384301d948e659e4b52f68d&qid=1774909744&sr=8-2 by Dr. Mary Claire Haver https://thepauselife.com/blogs/the-unpaused-podcast/strong-bones-strong-body-stronger-second-half-with-dr-jocelyn-wittstein-part-2

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:09Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. In our last episode of UnPaused, we started a conversation with Dr. Jocelyn Wittstein about what really happens to our joints, bones, and muscles as we move through midlife, why osteoarthritis hits women harder, why frozen shoulder seems to love this life stage, and how hormones weave through all of it. It was one of those conversations that made a lot of invisible dots suddenly connect, and we had far too much to talk about for just one episode. So today, we're back with part two.

• 0:54Dr. Mary Claire Haver?

  Dr. Wittstein is a practicing orthopedic surgeon, researcher, and associate professor of orthopedic surgery at Duke University. Her work focuses on female athletes across the lifespan: post-traumatic arthritis, frozen shoulder, and what she calls "the musculoskeletal syndrome of menopause." She's president of the Forum for Women in Sports Medicine, a core leader in the Duke Female Athlete Program, and a member of the Milken Institute Women's Health Innovation Initiative, and co-author of the Complete Bone and Joint Health Plan. She's not just treating fractures in patients. She's asking the bigger questions about why women's joints and bones behave the way that they do, and what we can actually do about it.

• 1:37Dr. Mary Claire Haver?

  In this episode, we get into hormones, pain, and cartilage in a way that most of us have never heard before. Jocelyn explains how estrogen and progesterone modulate pain, why fibromyalgia and diffuse joint pain so often show up in midlife women, and the role testosterone plays in arthritis risk for women. She walks us through her current research to understand how aging and sex hormones change the resilience of our joints, and whether hormone therapy might one day help narrow the arthritis gap between women and men. And perhaps most important, she outlines a real-world prevention plan. Including what she does to protect her own bones and joints. This conversation is detailed, hopeful, and incredibly actionable.

• 2:22Dr. Mary Claire Haver?

  If you missed part one, I hope you'll go back and listen. And if you're ready to rethink how you move and take a 360-degree approach to protecting your bones and joints, then you need to listen to this conversation.

• 2:37Dr. Mary Claire Haver?

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• 3:18Dr. Mary Claire Haver?

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• 3:46Dr. Mary Claire Haver?

  All right, let's move on to pain. Hormones, pain, and musculoskeletal health. So you've talked about estrogen and progesterone as pain modulators. How does that work? How do you think these hormones actually influence our pain?

• 4:00Speaker 01

  And this isn't my own research, just things that I, you know, read that make sense. There's a study out of, and again, a lot of this relates to animal data, which is where we learn so many of these things. And maybe hopefully eventually apply to humans and learn more. There was a study done on UCSF on mice looking at... Basically, cells located like centrally in the spinal cord and showing that estrogen and progesterone stimulate these cells to create like an endogenous analgesic, basically.

• 4:32Dr. Mary Claire Haver?

  Okay.

• 4:32Speaker 01

  You know, like a

• 4:33Dr. Mary Claire Haver?

  Which is a

• 4:34Speaker 01

  Pain reliever.

• 4:34Dr. Mary Claire Haver?

  Pain reliever.

• 4:35Speaker 01

  You know, so suggesting that maybe there's like some central pain modulating effect.

• 4:41Speaker 01

  There are some studies on people with fibromyalgia showing relationships between progesterone levels and pain.

• 4:48Dr. Mary Claire Haver?

  What is fibromyalgia?

• 4:49Speaker 01

  That's a tough thing because the actual definition of fibromyalgia relates to these very specific number of painful points on, you know, myofascial tissue. I think we'll learn more about fibromyalgia over time because I have wondered, we see it a lot in men, a lot of menopause women get diagnosed with fibromyalgia.

• 5:07Dr. Mary Claire Haver?

  So some people, Vonda, you know, has stated in, you know, to me that she wonders how much of fibromyalgia is just musculoskeletal syndrome of menopause. I mean, it's a, it's a clinical definition based on you're having pain in certain areas.

• 5:21Speaker 01

  In myofascial tissue.

• 5:22Dr. Mary Claire Haver?

  She thinks a lot of it, rather than just being this de novo condition, could just be a symptom of menopause.

• 5:28Speaker 01

  Yeah, it could be. I mean, we see, I do see many more women with fibromyalgia than

• 5:33Dr. Mary Claire Haver?

  I didn't know any men had it.

• 5:34Speaker 01

  I, I, yeah, I think, I'm, I think, I don't know if I have any, yeah, it's definitely more common in women and it may be something I think we understand more over time. Again, these things get named something and, you know, do we figure out what they are later? I also have a lot of women who get worked up for rheumatologic conditions because they have this new onset joint pain many times, but x-rays that don't look abnormal yet and they're just having, you know, a lot of polyarthritis. And I sometimes think that is just related to systemic inflammation. And even, you know, some of the earlier studies from the Women's Health Initiative did show reduction in number of and severity of pain and, you know, painful joints with hormone

• 6:16Speaker 01

  therapy that included esterdial and then even like rebound or worsening of joint pain with withdrawal of that.

• 6:21Dr. Mary Claire Haver?

  When they stopped it.

• 6:22Speaker 01

  And there are like some systematic reviews of menopause analyses that don't clearly show a relationship of joint pain and use of menopausal hormone therapy. And I think even the Menopause Society has a statement like that on their website, like, you know, that we need more research in this area. And I'm studying that now, but I do think we need to understand that, that better. But there's got to be something if women have this really disparate Rate of especially like knee arthritis at age 50 is just, you know, there has to be.

• 6:50Dr. Mary Claire Haver?

  Comes out of nowhere.

• 6:51Speaker 01

  Yeah.

• 6:51Dr. Mary Claire Haver?

  So it's a combination, you feel of your, the tolerance to pain. You're saying, you know, we have less of an analgesic effect.

• 6:58Speaker 01

  Right.

• 6:58Dr. Mary Claire Haver?

  Combined with increasing inflammation.

• 7:00Speaker 01

  Yeah.

• 7:01Dr. Mary Claire Haver?

  From estrogen withdrawal.

• 7:02Speaker 01

  Yeah.

• 7:02Dr. Mary Claire Haver?

  Does testosterone have a part anywhere in here?

• 7:05Speaker 01

  There's some.

• 7:05Dr. Mary Claire Haver?

  We don't tank our testosterone like men.

• 7:07Speaker 01

  Yeah.

• 7:08Dr. Mary Claire Haver?

  Like estrogen and progesterone do.

• 7:10Speaker 01

  More gradual decline.

• 7:10Dr. Mary Claire Haver?

  It's a more gradual with age.

• 7:12Speaker 01

  Yeah, there's some data coming out that seems to relate. Um, there was a, um, a large study that looked at, um, women and men over time. I think it had like 9,000 subjects in it, about 5,000 women. And they followed them over time with sex hormone levels and rates of arthritis. And, uh, they did see a correlation with, uh, lower testosterone levels in women over time in terms of risk of knee and hand arthritis, but they did not see that correlation in men. So yeah, we're seeing some, um, I think more research about testosterone in women later in life potentially being also related to knee and, and hand arthritis, which are of course very common sites.

• 7:56Dr. Mary Claire Haver?

  Yeah.

• 7:56Speaker 01

  Yeah, I'm trying to get at the answer to that. I'm doing a study or, or trying to, um, launch a study that we've done a lot of the preliminary parts for that will really look at early changes in cartilage in women and men, you know, in the early 50s as well as correlating with testosterone and estradiol and progesterone levels, using some of those models we built from the ACL research, actually, on these models we make, uh, where we, um, yeah. And if anyone is listening to this and wants to be my research fairy godmother and wants to give me $3 million to solve this arthritis versus, and men versus women, I have the study. So we took our same, all the work we did on the machine learning to build the models of the knees where we have all the cartilage traced all over the different parts of the

• 8:41Speaker 01

  knee and, um, we use a very similar model that we use to study post-traumatic arthritis in ACL torn knees, which is where we bring people in and we have them like rest for 30 minutes so their cartilage is fully rested. We do a resting MRI of their knee. And then, uh, that shows us the thickness of their cartilage all over. Then we have them walk for 30 minutes on a treadmill, which compresses your cartilage and your, the cartilage is the smooth gliding surface of the knee. Compresses it and then we put them back in the MRI scanner and we kind of rescan them with this one sequence every six minutes for like 30 minutes. And over the course of those 30 minutes, we see how much the cartilage rebounds to its normal thickness. And then we generate a curve and it tells us how many minutes it would take for the cartilage to go back to normal.

• 9:26Speaker 01

  So like in a normal person, it'd be like 25 minutes. And people who've had ACL tears, even just like one or two years after their injury, because they're so prone to developing arthritis over time from the trauma, it takes like, you know, more than an hour. It takes a long time. So we're applying this same tool that we developed for post traumatic arthritis after ACL injury, except for the injury is not the ACL tear and PTOA or post traumatic arthritis. It's aging, sex hormones.

• 9:51Dr. Mary Claire Haver?

  Yeah.

• 9:52Speaker 01

  Plus or minus hormone therapy. And so then we'll have their testosterone, their estrogen, their progesterone levels, and we will see how the early signs of arthritis are appearing in men versus women with and without hormone therapy with test, you know, knowing their levels. Basically, you know, my hypothesis is that I do think that, um, you know, maintaining or supplementing, you know, the estrogen levels will preserve that resiliency of the cartilage. That's my hypothesis. I could be wrong.

• 10:21Dr. Mary Claire Haver?

  So that it's could be preventative potentially.

• 10:24Speaker 01

  Right. And if we can, if we can, that's what we're studying. We want to know, because this isn't clearly answered. We want to know, is hormone therapy that may include estradiol, testosterone, progesterone, are these things protective of the cartilage, especially in women, so that we can narrow that gap, that 35% difference in knee arthritis? If we do end up showing that the resiliency or that ability of the cartilage to rebound is restored or maintained or related to estradiol and progesterone levels, you know, that may be another indication or it may expand our thoughts about like, what is hormone therapy for? But we haven't clearly shown, and a lot of the old research, again, is on like different forms of hormone therapy.

• 11:05Dr. Mary Claire Haver?

  Right. And only for the presence or absence of hot flashes.

• 11:08Speaker 01

  Yeah. Or related to arthritis, though. It's kind of. It's not necessarily looking at the actual health of the cartilage. And so we're, yeah, so that we've submitted another grant to the NIH. I just applied to another private foundation. And yeah, so if anyone wants to help me solve arthritis in women, call me. You can come to our lab. I can show you how we do everything. And I really, really hope we get money for this because that is one of the studies I'm extremely excited about.

• 11:34Dr. Mary Claire Haver?

  You mentioned that in your previous writings that, and help me say it, EFOP trial? Mm hmm. EFOP. Which studied the effect of long term exercise on bone density, fracture risk, in osteopenic women, different than the, than the Lefmore.

• 11:49Speaker 01

  Mm hmm.

• 11:49Dr. Mary Claire Haver?

  Trial. Did it show fracture prevention?

• 11:52Speaker 01

  Yes. One of the reasons why I like the EFOP trial is, you know, we have all these studies that show, okay, jumping helps with hip bone density. Strength training helps, you know, improve especially lumbar spine bone density. Again, what do we really want to prevent? Like, yes, maintaining bone density is great and nice. And we presume in most cases, like we know from many medications, you know, that improving bone density reduces fracture risk. But what that trial did was they followed women. Um, I think most of them were on average when they enrolled them like 55. And then they followed them for 16 years. So now after like age 70 ish.

• 12:24Dr. Mary Claire Haver?

  Mm hmm.

• 12:24Speaker 01

  This is really interesting. I mean, they, they were, they had these, you know, supervised sessions and independent sessions. And they carried this out like all this time. And then they followed them for, they followed their bone density over time, but they also followed obviously their fracture risk. And so there are a lot of trials that really show you the impact of an exercise program on like long term fracture risk.

• 12:46Dr. Mary Claire Haver?

  Mm hmm. Because it takes a long time to measure.

• 12:48Speaker 01

  Yes. Again, I just feel like we, we don't, sometimes I feel like, why don't we have these trials in the United States? That are this, some of them are just not this good. But, but in any case, what they found was over time that the women who participated in the exercise group as compared to the control group had approximately 50% reduction in fracture risk.

• 13:06Dr. Mary Claire Haver?

  Yeah.

• 13:07Speaker 01

  But interestingly, near the end of the trial, you know, at first, the women who were doing the strength training, it included strength training and impact, and they kind of used periodizations. It wasn't always intense. Sometimes it was like less intense, but they did have periods of higher intensity. And what they found was obviously a major reduction in fracture risk. And earlier on, there were larger differences in bone density. The exercise group was like gaining, whereas the other group was losing, as you would expect.

• 13:31Dr. Mary Claire Haver?

  As we know, yeah.

• 13:32Speaker 01

  But over time, those gains like trailed off. And near the end of the study, you know, the exercise group was losing bone density, but at a slower rate.

• 13:41Dr. Mary Claire Haver?

  Okay.

• 13:41Speaker 01

  But my point is, and why I like that study so much, is it shows the effectiveness of exercise for fracture prevention, even as bone density is declining, maybe at a slower rate. But there's more to exercise than just the bone density. It's like your coordination and your balance.

• 13:55Dr. Mary Claire Haver?

  And there's more to fracture than just your bone density.

• 13:58Speaker 01

  Yes, yeah.

• 13:59Dr. Mary Claire Haver?

  So if you don't fall, if you're more, if you're less stiff, if you are...

• 14:03Speaker 01

  You have better mobility, better balance, like less likelihood of falling. Yeah. So I like that trial because I think they did such a good job of following through with the fracture risk.

• 14:12Dr. Mary Claire Haver?

  All right. So back to fractures. I get this question all the time, and our clinic has dug into what research is available, but I'd like to hear it from you. How much estrogen, estradiol levels specifically, is needed for bone protection?

• 14:26Speaker 01

  Yeah. So this is a very interesting question. I read about this a lot. And I think the confusion around this question comes from, there was a study that looked at markers of bone turnover and associated levels of estrogen. And they found that if the estradiol level was 60 picograms per ml or higher, basically, there was the greatest reduction in markers of bone turnover. So basically, breaking down bone.

• 14:53Dr. Mary Claire Haver?

  So for our listeners, you know, bone is not static. It is constantly turning over and until 30 ish, maybe in our late twenties, we are laying, we're building more bone than we're chewing up, but we're constantly like, your bones turn over every 10 years.

• 15:08Speaker 01

  Remodeling.

• 15:09Dr. Mary Claire Haver?

  We remodel.

• 15:09Speaker 01

  Yeah, we're remodeling.

• 15:10Dr. Mary Claire Haver?

  Um, our muscles do something similar too. So when we go through menopause, we, and with aging, we accelerate how much we chew versus what we lay down and in menopause, it goes crazy where we chew up way more bone than we lay down and that leads to bone loss and then osteoporosis.

• 15:25Speaker 01

  And, and even maybe in perimenopause.

• 15:27Dr. Mary Claire Haver?

  Oh, yeah. Massive acceleration in perimenopause.

• 15:30Speaker 01

  And I read a study recently that showed that there are faster and slower bone losers in perimenopause and just looking at basically the people who had the greatest bone loss or acceleration of bone loss in perimenopause were the women who had the lowest frequency of ovulation, like they're, you know, had a, obviously as we get towards menopause.

• 15:51Dr. Mary Claire Haver?

  So they have lower estradiol levels.

• 15:52Speaker 01

  Yeah, yeah. They have like, you know, less, you have less cycles, but people who have like this longer period of more spread out cycles were the people who lose more bone in perimenopause. So it's like, you know, that prolonged decreased frequency of cycles is kind of a marker for being a fast bone loser in, in perimenopause.

• 16:10Dr. Mary Claire Haver?

  So the bone turnover marker.

• 16:12Speaker 01

  Oh, yes. Bone turnover marker.

• 16:13Dr. Mary Claire Haver?

  Is as we're chewing up bone and laying down bone, there's little chemicals that get excreted into the blood. So we can say, oh, she's going through a lot of bone turnover.

• 16:22Speaker 01

  Bone loss, yep.

• 16:23Dr. Mary Claire Haver?

  So that's a way to kind of measure how these medications are working without having to wait two years for a bone density scan.

• 16:28Speaker 01

  So this, this study showed that if you were at least at 60 picograms per, per ml, you had the greatest reduction in those markers. So suggesting you're having the least bone loss. And then once you got to 90 or higher, there was no difference, which makes sense because 80 is the level and luteal phase of many women who are menstruating. So why would you need to be higher than, than that? Probably not. So that sort of led to, I think has made people think, oh, we need to be at least 60. But on the other hand, there is also data that comes from all of the studies of Menostar, which is the ultra low dose transdermal estrogen, the 14 microgram dose, showing that using

• 17:12Speaker 01

  that and even people not even exceeding a level of 20 picograms per milliliter protects bone and reduces bone loss and even increases density in lumbar spine by like two and a half percent. And so. I think that kind of leads to this confusion of where do we need to be is more better.

• 17:30Dr. Mary Claire Haver?

  And there's in my world, in the menopause society and the OB literature, they're very hesitant. They do not want to measure estradiol levels. They're like, no, we treat hot flashes. You give her enough estrogen to treat a hot flash. But my bone people are like, just because you're protecting her from hot flashes does not mean her bones are necessarily protected.

• 17:50Speaker 01

  And I think maybe.

• 17:51Dr. Mary Claire Haver?

  They're very keen on dose.

• 17:53Speaker 01

  Yeah. And I don't want to like overstep my boundaries or my sphere of practice.

• 17:57Dr. Mary Claire Haver?

  But why do you think the hesitation?

• 17:58Speaker 01

  There was a trial, the ultra trial, where again, looking at Menostar, the 14 microgram dose, where if you looked at what level of estrogen women were at, they're all, like all these women under 20, which would be typical of menopausal women.

• 18:12Dr. Mary Claire Haver?

  You mean estradiol level of 20?

• 18:13Speaker 01

  Yes, estradiol level, yeah. Like the, that, there were within that.

• 18:18Dr. Mary Claire Haver?

  So that's how we define menopause to our listeners is an estradiol level less than 20. You're pretty much post-menopausal.

• 18:23Speaker 01

  But these post-menopausal women, there's even variation within that number under 20. So some people live like under five.

• 18:30Dr. Mary Claire Haver?

  Yeah.

• 18:30Speaker 01

  Some people are at 15, you know, so you could have these quartiles, let's say. And in the study of the Menostar dosing, one study found that

• 18:42Speaker 01

  the people who were in the lowest quartile had the greatest response to the Menostar. So they had the greatest reduction, you know, in their turnover markers. So I think maybe some of the concern about looking at levels is that people respond differently. Like some people just live at different levels. And then it's a relative change. So then if you're checking a level, what does the level mean for this person? Versus that person. And so I think that study actually made me think, well, maybe that's why people are hesitant.

• 19:10Dr. Mary Claire Haver?

  There's some nuance. Yeah.

• 19:11Speaker 01

  But on the other hand, if you look at dosing, I mean, For if you look at Femring, which is systemic estradiol, which can be protective of bone density, or you're looking at transdermal estrogen, if you compare the 50 microgram doses to 100 microgram doses, there really isn't a significant difference in the increases in bone density. They're very similar, but they're a little higher with the 100 microgram doses. So if someone is having side effects or symptoms like breast tenderness or whatever, and they don't have it at 50 micrograms, but they do it 100, you're not, you're probably not doing them a disservice to have them at the 50.

• 19:51Dr. Mary Claire Haver?

  Back them off, right.

• 19:53Speaker 01

  Because like, so if you look at the 14 micrograms versus 25 versus 50 versus 100 in various studies, like the 14 microgram dose over two years increased lumbar spine bone density like 2.5%, which is on par with Avista, you know, similar amount of increase. If you look at the 25 microgram dose, does a little more. If you look at the 50 and 100 microgram doses, you're seeing, you know, a 5-ish percent increase as compared to 2.5% with the Menostar. So obviously dose matters, but when you get to the 50 or 100, not that

• 20:26Dr. Mary Claire Haver?

  not different. Not much of a difference.

• 20:28Speaker 01

  As a North Peak surgeon, that's my understanding.

• 20:30Dr. Mary Claire Haver?

  There's nuance.

• 20:32Speaker 01

  Nuance, yes, nuance, yeah.

• 20:34Dr. Mary Claire Haver?

  And most of my, you know, the menopausey kind of people, we don't sit here and slap an estrogen patch on someone and be like, go and live, you know, it's like, if you want to protect your bones, you have to do all the things.

• 20:44Speaker 01

  Yeah.

• 20:45Dr. Mary Claire Haver?

  Which includes the lifestyle.

• 20:46Speaker 01

  Yeah, oh, yes.

• 20:46Dr. Mary Claire Haver?

  If you are not doing the lifestyle changes, including diet, including, you know, nutrition and lowering inflammation and all the things, you are not, this is probably not likely going to have, you know, not the greatest effect.

• 21:00Speaker 01

  Yes, diets with less inflammation, reduced risk of fracture, you know, you need adequate calcium, magnesium, vitamin D, all those things.

• 21:14Dr. Mary Claire Haver?

  In our clinic, we talk about lifestyle as well as HRT and of course, some of the other drugs, bisphosphonates, you know, if they're already diagnosed. But, you know, talk to me about the difference between exercise versus medications and, and what are the outcomes?

• 21:31Speaker 01

  Yeah. So certainly, I don't want to imply that you're never going to need a medication. Like if you have osteoporosis and, you know, your frac score says you have a more than 3% chance of having a hip fracture in the next 10 years, like you should probably be on some osteoporosis medication. What do all these things do for you, lifestyle versus medication or hormone therapy? I do like to kind of just level things a little bit and think about, you know, what are your returns on investment? So if we look at, you know, the timeline for your effort and what you might get out of it, if you're doing, like, let's say you initiate some impact exercise and, you know, over a six-month period, you might increase your hip bone density by 1%. That's a six-month investment. I mean, I think you should continue

• 22:14Speaker 01

  it, but you're, you've got, so imagine that, 6%, 1%. If you were doing the Lift More Protocol, for instance, and over an eight-month period, we would expect you to see a 3% increase in your lumbar spine. So think about that, that's eight months, 3%. If we think about estradiol therapy, over two or three years, giving you a 3% increase in your hip, 5% in your lumbar spine region, generally something like that. So that's three years of using a medication to get 5% increase-ish in your lumbar spine. You know, think about the impact of exercise. If you're doing an eight-month program and you're getting a 3% increase, that's really impactful. So I just want to emphasize the

• 22:59Dr. Mary Claire Haver?

  And

• 23:00Speaker 01

  the timeline.

• 23:01Dr. Mary Claire Haver?

  With the exercise.

• 23:02Speaker 01

  Yes.

• 23:02Dr. Mary Claire Haver?

  You're also getting so many other benefits.

• 23:05Speaker 01

  So many other benefits.

• 23:06Dr. Mary Claire Haver?

  For your insulin resistance.

• 23:07Speaker 01

  Yes, building your muscle mass, yes. And then medications like Zalendar, like the reclassed, if you know, the brand that, you know, once-per-year infusions of bisphosphonate, for example. And those are going to increase your hip bone density about 5%, your lum- your- your vertebral- your spine bone density about 7%. You're going to get a 70% reduction in fracture risk, say of the spine, 40% of the hip. You know, we don't have, like I said, with exercise, we don't have all those numbers. But so that would be like three years of getting a once a year infusion. So those numbers are larger. But again, like if you just look at the scale of them, like the lifestyle things do

• 23:44Dr. Mary Claire Haver?

  They add up.

• 23:45Speaker 01

  Quite a lot. And again, scale wise, it's hard to say, okay, for hormone therapy, if you look at a meta analysis, we know that this corresponding increase in bone density reduces our hip fracture risk by about 30%, or vertebral body fracture risk by about 40%. We don't have those exact numbers for like exercise and you can't really take the numbers from medication and be like, this percentage equals this much fracture reduction. It doesn't work exactly like that. But my point is, if you just look at the scale of these things, 1% gain is a really big deal, 3% gain is a really big deal. And if we think about that, I think it just helps people value these exercise interventions more.

• 24:22Dr. Mary Claire Haver?

  Okay.

• 24:23Speaker 01

  That makes sense.

• 24:24Dr. Mary Claire Haver?

  So my grandmother had multiple fractures, not hip, but she had forearm, had ribs, multiple falls, you know, spent the last three to five years with dementia and then the last couple of years completely bed bound and, you know. My mother is 88 and has Alzheimer's, so I'm sure her mother had it too.

• 24:43Speaker 01

  Yeah.

• 24:44Dr. Mary Claire Haver?

  And on New Year's Day, had a UTI, hallucinated, thought she heard my dad calling her, got out of bed, fell, broke her hip.

• 24:51Speaker 01

  Delirium.

• 24:52Dr. Mary Claire Haver?

  Has no cardiovascular issues whatsoever, so was perfectly fine to survive the surgery. And had her hip, you know, rotted and whatever the hell they did to it, and it still just scoots around in a wheelchair completely, you know.

• 25:05Speaker 01

  That's terrible.

• 25:06Dr. Mary Claire Haver?

  With her dementia.

• 25:07Speaker 01

  Yeah.

• 25:08Dr. Mary Claire Haver?

  So talk to me about how I can, what would you recommend for me for avoiding this fate? And I can handle the dementia, but talk to me about my bones.

• 25:17Speaker 01

  Yeah, the dementia, of course, you know, the benefits of exercise, which are huge. Like, that is the most protective thing women can do to prevent dementia is, is exercise for our brains. But, um, yeah, so for-

• 25:30Dr. Mary Claire Haver?

  Build me a, build me a protocol.

• 25:32Speaker 01

  Why would I recommend and what I do is a couple of days a week of heavier strength training, um, making sure you're doing like large muscle groups, again, similar to those lift more protocols, the balance work, I do some of that every day, flexibility work, uh, I like to, I don't have time to do like a yoga class every day, but I do incorporate that in my routines, um, again, because you do need joint mobility. And then, um, I always try to build in, I sometimes I'll use agility work within my cardiovascular exercise. So I use it as part of the cardiovascular exercise because if we don't habit stack, we just like run out of time in the, in the day.

• 26:09Dr. Mary Claire Haver?

  Yeah.

• 26:10Speaker 01

  And then, um, you know, dietary wise, you're a big fan of this, I know, and it's very important for actually reducing inflammation and helping our bones and joints is, um, a high fiber diet, getting, getting adequate fiber. And, and for me, that's a lot of variety of fruits and vegetables.

• 26:26Dr. Mary Claire Haver?

  And seeds and nuts and legumes.

• 26:28Speaker 01

  All of those things, yeah. Um, and those, those foods generate basically short chain fatty acids, which then impact the inflammatory pathways that contribute to bone resorption and your cartilage, you know, breaking down actually. And I don't want to get too basic sciency, but there's a lot of that, that happening.

• 26:46Dr. Mary Claire Haver?

  Yeah.

• 26:47Speaker 01

  And then, um, you know, I use creatine monohydrate, five grams per day. There is not a study showing that creatine specifically-

• 26:54Dr. Mary Claire Haver?

  Will grow bone, no.

• 26:55Speaker 01

  Grows bone. It doesn't directly, but there are studies that when combined with strength training, you know, you can increase your-

• 27:01Dr. Mary Claire Haver?

  Increase your gain.

• 27:01Speaker 01

  Your gain. And secondarily, that has benefits for, you know, bone health. Oh, back to the exercise part, jumping, yeah.

• 27:08Dr. Mary Claire Haver?

  Doing box jumps now.

• 27:10Speaker 01

  I, I love jumping. Now, the thing about box jumps is the jumping up is a soft landing and then people step down. You want the jumping down.

• 27:17Dr. Mary Claire Haver?

  Yeah, and I have the little, I got the weightless jumper.

• 27:20Speaker 01

  The, yeah, the one I showed you.

• 27:21Dr. Mary Claire Haver?

  But I, they keep hitting me. I, I think my wrist angle isn't right. So I just need to go back to a regular jump rope.

• 27:27Speaker 01

  Yeah, you can do regular jumping. So and again, the jumping, it doesn't have to be off a gigantic box. It could be an eight inch step. And there's a really smart lady named Tracy Glissold has done tons of basic science on how much impact is created from jumping off an eight inch step with a rebound or heel drops, which also create that that impact. Jumping for sure, a few days a week.

• 27:48Dr. Mary Claire Haver?

  Okay. What about, I'm on HRT, would you recommend that?

• 27:51Speaker 01

  And I think for sure, menopausal hormone therapy that includes estradiol is protective of bone density for those who are candidates for it, definitely. There is some reasonable evidence, I think, behind, and I think you've highlighted for there's something called Fortabone, which is a hydrolyzed type one collagen. That, you know, they have randomized prospective study showing.

• 28:11Dr. Mary Claire Haver?

  Improvements in bone. I was super excited. I was like, give me some of that.

• 28:14Speaker 01

  Yeah. And so I don't think that hurts anyone.

• 28:16Dr. Mary Claire Haver?

  Yeah.

• 28:16Speaker 01

  Yeah.

• 28:18Dr. Mary Claire Haver?

  What about, lots of questions I get on calcium, phosphorus, vitamin K. What are your thoughts on?

• 28:24Speaker 01

  I mean, most people have a hard time eating enough calcium. But yes, you want to get 1,200 milligrams of calcium per day, 400 milligrams of magnesium a day, 100 micrograms of vitamin K per day. Vitamin D, you're, you want to get at least 600 units per day. You should not exceed 4,000 units per day if you don't have a deficiency for various reasons and, you know, data that I've read, I do take 2,000 units a day. I'm not exceeding that upper limit of what's safe, but there are studies, correlative or not, that show, you know, vitamin D supplementation reduces risk of, or is associated with less risk of dementia and depression.

• 29:04Speaker 01

  Also, at that level, at at least 2,000 units per day is correlated with benefits for like reducing joint pain. So there are some side benefits of it. So while you do need about 600 units per, international units per day, I do take the 2,000. So those are important aspects as well, the dietary aspects.

• 29:22Dr. Mary Claire Haver?

  I have a hard time absorbing, I guess. So I take four.

• 29:25Speaker 01

  Oh, yeah, a lot of people do. And then low in diets that are like less inflammatory. So there's something called the dietary inflammatory index, which unfortunately they're not like a

• 29:34Dr. Mary Claire Haver?

  That's what I built the Galveston diet based on was that because I went back for nutrition.

• 29:38Speaker 01

  Yeah.

• 29:39Dr. Mary Claire Haver?

  And so that dietary index score, you know, we used to have a little quiz you could take on our website.

• 29:44Speaker 01

  Oh, I've taken the quiz.

• 29:45Dr. Mary Claire Haver?

  That would grade. Yeah, it's based on that. So it's the poor man's version of that.

• 29:49Speaker 01

  And, and there are studies correlating, you know, a less inflammatory diet with less risk of, of fractures. So, so that is another reasonable thing to do.

• 29:59Dr. Mary Claire Haver?

  So back to my mom for a little bit. You've talked in the past about this connection between UTIs, like general urinary syndrome and menopause and hip fracture.

• 30:07Speaker 01

  Yes.

• 30:08Dr. Mary Claire Haver?

  I think it's worth for our listeners.

• 30:09Speaker 01

  I think this is underappreciated.

• 30:11Dr. Mary Claire Haver?

  I know this is what happened to my mom. You know, she was a setup.

• 30:14Speaker 01

  I've had so many people with this story or tell me this is what happened to their mom. So big picture, and I'm not saying this to scare people or anything, but when you, when you hear about hip fractures, which of course 75% of them occur in women, and then, you know, statistically speaking, just if you have a hip fracture, depending on the study or population you're looking at, the one year mortality rate is, some studies 15%, some studies 30, or two years out.

• 30:40Dr. Mary Claire Haver?

  I like to quote the 30.

• 30:41Speaker 01

  A third of women. Yeah. I know. I try to always give nuanced numbers because some of the numbers sound more scary than others. It's not always 30, but it can be 15 to 30% in a year. So, you know, we don't want people to have this happen, but like what is causing death? Actually, a lot of it is, it can be urossepsis, a post-operative urinary tract infection. So you have this hip fracture. Sometimes you've needed a Foley catheter. There's urinary retention from pain. People can't get out of bed. And I think, aside from the fact that urinary tract infections are the number one complication after hip fracture surgery, and it can lead to readmissions, urossepsis, septic shock, things like that. I think many of them are actually present, you know, prior to the hip fracture. And so people who have general urinary syndrome

• 31:26Speaker 01

  or menopause, they may have increased urinary frequency, they may have, you know, recurrent UTIs. And what happens if you have that and you're an older woman, you're getting up in the middle of the night, a little confused, a little delirious, more than you normally would, and they trip and fall. I mean, almost every time you get called by the emergency room for hip fracture, it's like in the middle of the night. I should actually look and see if there's a delay in this, but I think most fractures happen at night. And, and it's so often the story.

• 31:52Dr. Mary Claire Haver?

  I treat a GSM.

• 31:53Speaker 01

  Yeah, getting up, tripping, falling. And then so there's, there are patients that are diagnosed with a urinary tract infection pre-operatively. You're not gonna like, you can't delay surgery because outcomes are worse, survival is worse if you delay more than a day or two. And so you've got these people who either have the infection pre-op or develop it post-op. And it delays, you know, they're in the hospital for longer. Women who have a urinary tract infection diagnosed at the time of hip fracture have like four times the rate of septic shock post-operatively as compared to those who weren't diagnosed with the pre-op. I actually think many of them are under diagnosed pre-op. So I think it contributes to the falling, contributes to the urosepsis after, probably, you know, contributes to, to death.

• 32:35Speaker 01

  And I, we know that vaginal estrogen prevents urinary tract infections.

• 32:41Dr. Mary Claire Haver?

  Fifty percent.

• 32:42Speaker 01

  Yeah, prevents a lot of them. And so if we could reduce those, I swear we would reduce hip fractures and we would definitely reduce urosepsis. It's not like you can just give someone vaginal estrogen right after hip fracture surgery and expect them to have less UTIs because it takes six weeks or so to be effective.

• 32:57Dr. Mary Claire Haver?

  To grow back the mucosa.

• 32:58Speaker 01

  To change the microbiome. So we're not gonna like magically make someone not get UTIs by putting them on that right after surgery. But I do think we should actually educate hip fracture patients. Hey, you have recurrent UTIs. I don't want you to break your other hip. You might benefit from being on vaginal estrogen. And that's something I'm actually working on with our trauma team right now. We're looking at how frequently our hip fracture population, we're looking at our last 500 hip fractures in women and how many of them were on vaginal estrogen? How many of them have the UTI pre-op and post-op? And if you look at reviews of hip fracture studies, you know, you'll see anywhere from like 10 to 40% of people having a UTI peri-operatively.

• 33:35Dr. Mary Claire Haver?

  Yeah.

• 33:36Speaker 01

  So it is, it is a really large problem.

• 33:44Dr. Mary Claire Haver?

  Since you're here this week while we're recording, this is the week that the box warning on vaginal estrogen has been struck and removed. And just the normal warnings are there as there should be. You know, for those listening, vaginal estrogen is preventative. It is, it can be prophylactic. It is safe and effective. Almost 99.9% of women can use it and probably should for, you know, keeping their, the risk of UTI at bay and keeping their vaginal and vulvar health, you know, in tip top shape. So they decrease their risk of delirium, of falling, of, and then a fracture, and then having a better post-op course if they do fracture. So I wanted to be clear about that. So women are going to want to know, what can I do for myself?

• 34:27Dr. Mary Claire Haver?

  You know, how can they better advocate for themselves when their musculoskeletal pain isn't taken seriously?

• 34:31Speaker 01

  I know, I can't tell you how many times I see a patient who feels like they haven't been heard when their x-ray is normal or their MRI is normal. Or even if someone does recognize that they have frozen shoulder, they may hear, well, that just happens to women. You know, just recognizing, yes, it happens to women, but is there anything else we can do? So I, I think health literacy is so important. And I mentioned to you earlier when we were chatting, I actually had like never even been on Instagram before January. And my 19-year-old daughter, Chloee, who is Chloee on Canvas on Instagram, oh, she's a cute little artist, but she helped me make that page.

• 35:13Speaker 01

  And I'm using it for health literacy because I think if people have awareness, they can be, you know, more of an advocate for them, for themselves. And I, like, I, I wrote this book with my co-author, Sydney Nitzkorski, Complete Boner Joint Health Plan, because people just don't understand their bodies. Like, they don't understand arthritis and osteoporosis.

• 35:35Dr. Mary Claire Haver?

  Let me plug your book. It's excellent. You open it up, it's recipes, it's exercises. It is literally a how-to manual from the ground up on how to protect your bones and joints. So if you're like, okay, what do I do? 90% of it is pictures of people doing exercises and recipes.

• 35:51Speaker 01

  And, and we tried to explain, like, what is arthritis? What is osteoporosis? What are the things you can do to change your course? Because, but again, so it's not only for women, but because arthritis is more of an issue for women and osteoporosis is, like, I do have a lot in there explaining that. Because I, I just think if people don't understand, like, if women don't understand that... Yes, I am going to be more prone to arthritis than a man at age 50. And I am going to be more prone to frozen shoulder. Um, yeah, I think just having an understanding of that can help them advocate more for themselves.

• 36:22Dr. Mary Claire Haver?

  Or not let it go for so long.

• 36:24Speaker 01

  And not let it go for so long.

• 36:25Dr. Mary Claire Haver?

  Because I think a frozen shoulder, getting in there early is key.

• 36:27Speaker 01

  And like, just taking an index of your own symptoms, like, are you having this increased joint pain or your frozen shoulder at the same time that you're having like vasomotor symptoms and general urinary symptoms? And like, talk to your women's health doctor about that. I love my male orthopedic surgery partner so much. And I have actually, so many of them are now talking to women. Um, I don't want to pick on my husband, Tal, but he's also an orthopedic surgeon. And we actually work with, we're like a rotation for our fellowship. So one fellow will come and work with both of us at the same time. And

• 36:57Dr. Mary Claire Haver?

  He supports medicine, too?

• 36:59Speaker 01

  Yes. One day, one of the fellows told me, uh, I think you need to help Dr. Lassiter. He's talking to women about the change. But I said, no, that's so great. He's asking women with shoulder pain about their symptoms.

• 37:13Dr. Mary Claire Haver?

  Yeah.

• 37:14Speaker 01

  And texting me, how do I refer to women's health? And, and some of my fellows are now doing this. And so I just think that because men don't go through menopause, like, they're not going to experience this. They just, they don't have the same lived experiences. They, they may have less awareness of this connection. But I, I think, you know, I'm trying to educate my

• 37:32Dr. Mary Claire Haver?

  And you're, you're

• 37:33Speaker 01

  my trainees. And there, I can't tell you how many of my, you know,

• 37:35Dr. Mary Claire Haver?

  Her Instagram is excellent.

• 37:37Speaker 01

  My male orthopedic residents are, they come out of a room telling me someone's like, menopausal history and whether or not they're on hormone therapy as part of the orthopedic history, which is really cool. But yeah, but for patients, I think, if you're, if you're feeling dismissed, or someone isn't listening to you, I mean, it's okay to get another opinion. Like, don't feel like you're, you know, stuck with, with one person. And I just, I think what happens is, um, it's hard when an x-ray is normal and MRI is pre-normal, but you're having increased joint pain. You know, we've talked about some of the things you can use, an anti-inflammatory diet, certain supplements, things like that. But I just think Taking a look at the whole person.

• 38:13Dr. Mary Claire Haver?

  Yeah.

• 38:13Speaker 01

  And collaborating. Stop siloing, collaborate with women's health. I'm not saying that magically going hormone therapy is going to make your knee pain feel better. And that's what we're trying to study. But I think we need to kind of look at women as a whole person, not like a knee.

• 38:26Dr. Mary Claire Haver?

  And stop siloing women's health to the bikini area.

• 38:29Speaker 01

  Yeah.

• 38:32Speaker 01

  Yeah, exactly.

• 38:33Dr. Mary Claire Haver?

  Well, I'm so happy you came with us today. You've educated our listeners so much. And I will go through on the show notes, they will have how to find you on social media, how to buy your book and how to find you. Get ready, because you're about to get a lot more referrals for frozen shoulder it to get ready.

• 38:49Speaker 01

  Well, thank you for having me. And I like to say I am only an orthopedist. I am not an expert in all things women's health, but.

• 38:58Dr. Mary Claire Haver?

  You're changing the world. You realize this.

• 38:59Speaker 01

  The most meaningful research relationships are my cross collaborative ones. You know, with my women's health partners, with my biomechanics PhD, you know, with the PhD who does all of the biomarkers with me. I mean, we really have to be cross collaborative to change, get rid of these disparities.

• 39:20Dr. Mary Claire Haver?

  Yeah, excellent. Are you looking forward to menopause?

• 39:23Speaker 01

  I mean, I'm not fearing it. Funny story, my youngest, my now 18 year old son was like, menopause sounds really terrible. And then my 20 year old daughter said, I really don't want to go through menopause. And they're just talking. But I think I'm almost 48. And I, I feel like I'm getting into like a phase of life where I can have so much more, I don't know, like freedom of thought and independence in time. And I mean, I had my kids pretty early, so I do have more time now. But I don't dislike aging, you know? I, I changed some of the ways, some of my, I don't exercise exactly in the same ways I used to.

• 40:06Speaker 01

  So I don't do backflips on the floor, only on a trampoline. But I, you know, I, I'm not fearful of it. I feel very, I feel empowered by the knowledge I have, but I have a strange amount of niche knowledge and I love to share it with people.

• 40:20Dr. Mary Claire Haver?

  Well, and I think that you sharing that knowledge with, with your students, but also on social media is going to continue to just elevate this conversation and empower women in a way that we haven't been able to in medicine before.

• 40:37Dr. Mary Claire Haver?

  As a reminder to our audience, you can follow Dr. Wittstein on Instagram at JocelynWhitsteinMD. Her book, The Complete Bone and Joint Health Plan, is available on Amazon. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at DrMaryClaire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. My upcoming book, The New Perimenopause, is available for preorder on Amazon. If you're loving this podcast, be sure to click Follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would

• 41:18Dr. Mary Claire Haver?

  be so grateful. You can also follow full episodes on YouTube at Dr. Mary Claire. UnPaused is presented by Odyssey in conjunction with Podpeople. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on UnPaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.