Osteoporosis: how to protect your bones during menopause and beyond
Bone density for women can plummet around the time of the perimenopause and menopause.
An estimated one in two women over 50 (and who do not take HRT) worldwide will develop osteoporosis. This puts women at high risk of bone fractures, which can have a major impact on health and wellbeing.
Here Chicago-based Dr Kristi DeSapri, who specialises in bone health, joins Dr Louise Newson to talk about what can increase the risk of your bones becoming weak, the role of hormonal changes in this and what to do about it.
Hear what the latest research says about the valuable role that HRT can play in protecting bones to keep you fit and strong in the future.
Dr DeSapri shares her top three tips for listeners worried about their bone health:
1. Find out how healthy your bones are and whether you could be at risk of fractures. This could include booking a bone density scan, or completing free online assessments and taking that information to your doctor
2. Increasing evidence suggests HRT can help protect bone health, so consider this treatment option to keep your bones strong
3. Find out about the importance of bone health so that you can be your own advocate – make sure you have the right information to make the right decisions.
Dr Louise Newson [00:00:09] Hello, I’m Dr. Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the Menopause Charity and the menopause support app called balance.
On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today on the podcast, I’ve got another American doctor, somebody who kindly reached out to me and we’ve got a lot of shared interests, and she’s called Kristi DeSapri, and she works in Chicago and has a special interest in bone health and women’s health and was initially trained as a gynaecologist. Welcome to the podcast.
Dr Kristi DeSapri: [00:01:10] Hi, thanks for having me.
Dr Louise Newson: [00:01:12] So it’s really interesting. Lots of people that I speak to, myself included, have sort of changed track with their careers. And if I’d met you 20 years ago and you’d said to me, oh, you’ll be running a menopause clinic, I would say, no, Kristi, don’t be ridiculous. I want to be an oncologist and treat people that have had cancer and certain things in life change, but also things that we learn from our patients, I think as well change our course. And I’ve always thought that medicine is a great passport for doing lots of things, actually. And I’ve always had a sort of portfolio career, which has been great. I’ve had lots of part-time jobs which have always come to more than full time. But variety is the spice of life and knowledge is power. And I think it’s wonderful to have quite a varied career because it keeps you on your toes quite a lot. So tell me about your background, how you’ve got to where you are now.
Dr Kristi DeSapri: [00:02:06] Absolutely. Yeah. So I’m a board-certified internist, and just like you started in a pretty traditional path. I always thought I would be an OB-GYN [obstetrician – gynaecologist] and really take care of women just at that time. And then in doing that for my first intern year, I realised two things. One, I do still love women’s health and I think it’s a very exciting field that has a lot of innovation and we obviously get to care for women at a very vulnerable time and also a time where we can spread a lot of good information and share a lot of our knowledge.
But I really wanted to take care of women more globally, really, women during the lifespan, from adolescence to… I have some patients as old as 99 and 100, which I love seeing. So I started in gynaecology and I’ve sort of worked my way through in medicine to internal medicine. And then I really focused and I knew that what I wanted to do what I, you know, stay in the field. And I focused and did a fellowship at the Cleveland Clinic, which was very diverse, really. There’s only about six fellowships in the country and it really focused on multidisciplinary women’s health care. So sort of those health care centres that we think are, which the universities are trying to create today, where it’s a mixture of your urogynaecologist, gynaecologists, breast surgeons, women like ourselves focused on menopause, metabolic changes, hormonal changes. I mean that’s really where my passion for bone health started. I really loved seeing those patients. I, as we talked before, I enjoyed the science of DEXA, which is dual energy X-ray absorptiometry and how we can translate those results through talking to our patients about their bone health, bone strength and fracture risk. And I just had some great mentors and I have, you know, along the way at the Cleveland Clinic and at the Bone Health and Osteoporosis Foundation, in private practice and then in academic practice. And so I’ve been in practice for more than 12 years. And with that, I’m taking those, you know, the same sort of windy career path that you did and starting my own practice in the suburbs of Chicago, which is bone and body women’s health, which is going to be just a practice focused on midlife concerns, hormonal, metabolic and particularly with a focus on bone health.
Dr Louise Newson: [00:04:09] That’s so interesting because osteoporosis really is a sort of hidden disease, actually. It’s something that’s not really spoken about enough, yet it’s very common, as you know, and it’s something that actually really scares me as a menopausal woman. I worry about my bone density because, you know, as some of you might know, if you do an X-ray, you’re not going to be able to know what your bone density is. And a lot of people don’t realise they have osteoporosis until they have a fracture. And a lot of people think, oh, well, it’s just a fracture, you know. I’ve got three daughters and two of them have had multiple wrist fractures when they’re young, but they bounce back within weeks. They’re fine. Doesn’t happen like that when we’re older, does it, when we have fractures?
Dr Kristi DeSapri: [00:04:52] No, absolutely. I mean, you’ve touched on so many things. I think the reason why is… I like a challenge, sounds like you do, too. And so osteoporosis and bone health really is a challenging field. Number one, like we said, osteoporosis is an osteopenia, which is the subset of low bone mass, are undiagnosed or largely undiagnosed. We know from, at least in the United States, in the Medicare beneficiary less than 25% of women will get to have a bone density after the age of 65, which is in this country where we recommend universal screening to be. And we know that many women have bone loss before that age and even at the time of menopause where we lose so much bone. So it’s an underdiagnosed condition. Again, you know, what we’re trying to prevent is fractures, which most people don’t understand what a fracture really is. They think of like being pulled out of a tree by their brother when they were younger and they broke their wrists. But we know the fractures of the hip, the spine, the wrist, the pelvis these are all fractures with very significant consequences, particularly hip fractures, which is the fracture I was trying to prevent the most. And we know that those are affecting women who are getting on in years or women in their 70s and 80s. And these can be very preventable by the diagnosis of osteoporosis, the evaluation and the treatment.
Dr Louise Newson: [00:06:07] That’s right. So there’s lots of reasons why our bones become thinner as we age. And it’s really important that we think about bones as not just something that props up our muscles and keeps us supported. Our bones are dynamically active, aren’t they? They’ve got cells that are building bone all the time and cells that are breaking down the bone. Our blood supply goes through our bones, there’s lots of nutrients there, our bones are very clever. And they do a lot more than people realise, don’t they?
Dr Kristi DeSapri: [00:06:37] Absolutely. So like we’ve talked about the skeletal ramifications of bone supporting muscle, connective tissue, etc. But right, these are metabolically active. We know that a large amount of our calcium, phosphate, other electrolytes that we think about all the time have a deposition in bone as well as they’re regulated by other hormones in the body like estrogen, parathyroid hormone. And all these things are in a very delicate balance. And so, you know, absolutely. I think when we think about what you mentioned, a dynamic process, I always share this cocktail party fact with my patients that 10% of your skeleton remodels every year, which means every ten years your whole body is remodelling. And I say, I do not like to decorate. So I always liken that to, you know, like house decorating. Think about if just like your whole house was redone every ten years, that’s significant. So we know that our bones are always remodelling, which is the process of removing old bone, modelling, which is putting down new bone, where there was quiescent bone before, which is what we’re doing in our adolescent years, and that slows down as we age. But there’s things that can prop those processes up. So yeah, very exciting field, bone physiology is very exciting for the right person.
Dr Louise Newson: [00:07:45] Absolutely. But tell us about why people get osteoporosis. We know that it’s more common in women than men. And actually some of the figures say that around one in two women over the age of 50 who aren’t on hormones will develop osteoporosis and one in five men. So very common, commoner than most types of cancer, actually. Yet we know a lot about cancer all the time. There’s a lot of research going on, a lot of money spent on cancer research, heart disease, but osteoporosis just seems to be a not very interesting condition that, certainly in the UK, not many people are that interested in. But tell us what the risk factors are then for osteoporosis.
Dr Kristi DeSapri: [00:08:24] Yeah, you touch on the prevalence and that’s absolutely true. You know, we know the end product of having low bone density osteoporosis, which is basically just loss of skeletal mass, loss of a skeletal bone mass, loss of bone quality, increasing your risk for fractures. How we capture that is looking at bone density. But, you know, again, fractures and we look at the numbers, right? 8 million women in the United States with osteoporosis, closer to 34 million with osteopenia or low bone mass. Worldwide, we know that 9 million women fracture annually, which is a fracture every 3 seconds. So a lot and I always share the statistic, too, with women before we go into the clinical risk factors, we all want to know when we get our next pap smears, that is very popular in the United States since the guidelines are always shifting, you know, when do we get our next mammogram? People want to do those things yearly. However, they don’t know their bone density. But more women have hip fractures than breast cancer, uterine and ovarian cancer combined. So we think about midlife women’s cancers and we put that in perspective. We need to think about osteoporosis at the top. And the clinical risk factors, as you mentioned, are just being female at age of menopause. This is so important, particularly for women with premature ovarian insufficiency, early menopause due to whatever cause, whether that’s just genetic, whether that is smoking, whether that is cancer related treatments, that is hugely important. And then there’s so many other clinical risk factors that are actually widely available for patients to read about. There is something that we use in the United States, and I know you use it since it originated in the UK, called the FRAX score. And so my patients come and they put in those clinical risk factors which are very simple age, height, weight, which determines your body mass index, which is fraught with some issues, but can help, a family history of fracture, particularly a maternal history or paternal history of hip fracture before age 70, certain use of medications like steroids or glucocorticoids and bone mineral density at the hip is evaluated as well as other factors. There is such a host of past medical history, surgical history, medicines, lifestyle factors that contribute to bone density. So the list grows and grows. So that’s why it’s important to either do your own health assessment or really in the United States it is recommended that at age 50 or menopause, someone does a bone health assessment, which is basically just talking, thinking about things that could affect your bone growth as well as your bone loss over time.
Dr Louise Newson: [00:10:50] And it’s so important, as many of you know, when I opened my clinic, I was very adamant that I wanted a DEXA scan in the clinic and everyone said, Louise, you’re mad. You know, you’re refurbing this clinic, you’ve spent every single penny and you’ve got a bank loan and now you’re talking about a DEXA scan. And I said, but I’m doing it not because I want to make money from the DEXA scan, and I don’t think I ever will because it’s quite expensive to buy one. But it’s about awareness. It’s about thinking of what happens to our bodies when we become menopausal without hormones. And I really feel very strongly that everybody, men and women, actually should have a DEXA scan around the age of 45 to 55 to see where we are. And it can be very common that people have their cholesterol measured. But a cholesterol level doesn’t always predict heart disease. There’s so many other factors as well. But actually having a DEXA scan is really the gold standard, isn’t it, of looking at your bone density. And it is really important because I’ve done bone densities on women who have no risk factors for osteoporosis who are actually quite fit and well and then have a scan and they show either osteoporosis, or osteopenia, and it’s given them an opportunity to then look about are they taking adequate vitamin D, are they exercising in the right way? Is there anything else that they can do? And sometimes it might be because they’re drinking a little bit more alcohol or maybe they’re more sedentary than they perhaps admit that they are. And making small adjustments when you’re healthy is so much better than doing a DEXA scan when you’ve had a fracture, isn’t it?
Dr Kristi DeSapri: [00:12:27] Right. And I think we’re talking about both of our countries, of the UK and the United States and worldwide, and the fact that prevention, an ounce of prevention, is better than just treating a secondary fracture. And you’re right. I mean, I think a lot of the guidelines are based on population-based studies, right. And not the individual risk in a study and not looking at patients’ individual risk, which is, again, we have to do these large-scale studies. But I think again, when you’re speaking about specific individuals, so that’s where we try and get this net of risk factors. Look at them as a sort of totality. And I always find that in those patients that I see, I can always find one or two risk factors.
I mean, when you really start asking about family history, you know, fractures of the spine. Oh, yeah. You know, my mom, she did start to lose height. Yeah. Then she did fall, you know, things like this. And also we forget about the bone growth years. The accrual of bone mass, we achieve peak bone mass between 25 and 35, but at puberty, you’re having a very dramatic bone growth. And so a lot of times what’s happening with our use of that time in terms of calcium, soda intake, nutrients, exercise, all of those things are very important. And, you know, I ask all my patients about that or were you a healthy child? It’s amazing what you’ll hear. And so I think. Right, calcium, vitamin D, I mean, these things they all have an interplay. Right? So I agree with you that we, in my clinic, the same thing we evaluate at any time someone is post-menopausal and we know that there’s a large set of women who undergo premature ovarian insufficiency, surgical menopause, now that we’re diagnosing more hereditary breast and ovarian cancers and we’re recommending prophylactic BSO [bilateral salpingo oophorectomy]. And the other thing is there’s a large population that also have idiopathic osteoporosis or just never achieved a peak bone mass, particularly petite females with a genetic predisposition. Their mothers had osteoporosis, but no one really checked it. And so some of that is just 70% of our bone mass is inherited. So I always tell them it’s nothing that you did wrong. Again, ethnicity matters. You’re Caucasian or perhaps you’re Asian ethnicity, people are going to have a lower bone density to start with. And that’s sometimes a little bit tricky, right? Because, you know, we don’t want to treat everyone the same. Particularly we know that there’s racial and ethnic differences and that women and the World Health Organization data and some of those databases are more based on a Caucasian database. So in those patients, sometimes we have to do some interesting calculations, look at the Z score, look at their total risk of a fracture and talk about preventative strategies. Just like you said, I think awareness is important and a DEXA scan is low radiation. It’s actually pretty low cost. Unfortunately, the reimbursement sounds like it’s the same in the UK. We are fighting very hard to improve the reimbursement at the hospital level as well at the clinic level, but it’s low radiation, low cost, very simple 10 minutes. I have people take off their bra so we don’t see the wire and things like that, but it’s a pretty simple test as far as tests go to gain a lot of information.
Dr Louise Newson: [00:15:24] Absolutely. And so, tell us about hormones. We know, like you say, if women have an early menopause, they have longer without the hormones, they have a higher risk of osteoporosis. Actually, women who have eating disorders or women who stop their periods for different reasons when they’re younger, even if it’s temporary, they still have an increased bone turnover. So we know that our hormones, especially estrogen, but also testosterone, have a very important fact on the way our bone stays strong, doesn’t it? So tell us a bit more about that.
Dr Kristi DeSapri: [00:15:56] Yeah, all the hormones, in fact, there’s the evidence with estrogen and progesterone, testosterone. I mean, all of these, cortisol, you know, effect. I mean, it’s just, you know, again, it leads to this interplay. But specifically, this is why, one of the reasons why women have a lower bone density to start with, right? We have smaller, thinner bones. We do not have the testosterone, which increases the bone mineral density. And men don’t have menopause. Right. And so they have a slower bone loss trajectory over their lifetime, of lower fracture risk for that reason. And because women have this menopause, this loss of estrogen like we just talked about a little bit, loss of testosterone, but that’s a sort of a more gradual decline. That drop in estrogen, particularly estradiol, which we know is probably the most potent estrogen that’s affecting the estrogen receptors in the bone. Both the trabecular bone, which is also called cancellous bone, which is more dominant in the spine and the femoral neck area, and then the cortical bone of the periosteal bone, which is more dominant in the total hip or the femur of the long bone. So at menopause, with that decrease of estradiol and the increase of FSH, we know that sort of that lovely balance of bone being formed and bone being broken down that I alluded to, which is called remodelling, is thrown off, is totally thrown off kilter. Either, you know, if you have young children or everyone knows the analogy of a sort of a teeter totter [seesaw]. And so what’s happening is basically, if we think about two sides, the estrogen declining is really throwing off the balance and breaking down more bone, both in the trabecular bone and in the cortical bone, we see a more precipitous drop in the bone density lost in the cancellous or trabecular compartments. And that’s why we’ll see sometimes an imbalance or discrepancy in bone mineral density losses in the spine. In fact, a lot of research is showing that through the menopause transition, which for some women is, you know, one to two years and other women it’s five to seven years that we can lose up to 20% of trabecular bone loss and close to 5 to 7% in the cortical or the hip bone mineral density. And we see that we know as clinicians, I know you’ve seen it and we know that thinner women lose more bone density, which could be of a family history, might be again, that might be another area where we’re going to see more of a drop in bone density. And again, I would say another area that, you know, that we could intervene. Interestingly, we know the dominant effect of the loss of estradiol is to throw off the imbalance of increase the antiresorptive effect, but potentially, you know, estrogen replacement is then going to get that balance back in order and in fact might even stimulate sort of a bone building effect, which we’ve seen in animal studies and in some bone biopsy, which is basically studies looking in more deeply at how estrogen is working at the physiologic level.
Dr Louise Newson: [00:18:35] Yeah, and it’s very interesting. I mean there is scanty research because obviously good quality women’s health research never exists other than in our dreams. But the studies that we do have have been very favourable looking at bone protection and building a bone with estrogen, which makes sense because we know physiologically how estrogen works in our bones and, and actually certainly in the UK, HRT is licensed as a treatment for osteoporosis and it’s actually licensed as a treatment for post-menopausal symptoms, but not for perimenopause. Yet we prescribe HRT for the perimenopause because studies show that the earlier a woman starts HRT, certainly the better she’ll feel because we’re treating her symptoms due to her hormonal deficiency. But also we know that it improves future health. Yet most people, when they have a diagnosis of osteoporosis, they’re not given HRT. And certainly many osteoporosis guidelines don’t mention HRT. And if they do, there’s always seems to be a sentence associated saying, but there’s an increased risk of heart attacks, breast cancer, all the things that we know are not true for most types of HRT. Right. So a lot of osteoporosis specialists are giving bisphosphonates which do have a role, absolutely, in the management of osteoporosis. But if I as a menopausal women had osteoporosis, I would really much prefer to take HRT than a bisphosphonate, which often can only be given for a finite number of years, they’re not without side effects. And they’re not going to have the benefits on our heart and our brain and symptoms the same way as HRT is. Would you agree?
Dr Kristi DeSapri: [00:20:19] Absolutely. I mean, I think, you know, we talked before that the Women’s Health Initiative, which didn’t do us any favours in terms of looking at the women. Again, these women were on average age 63 and showing some of the imbalances of breast cancer, although very negligible and when adjudicated really non-significant. But what it did show is that these women, again, on average in their age of 60, more than 20,000 women, that there was a reduction in both hip fracture and non-vertebral fractures and vertebral fractures. So we know that it works, right? We know that it works actually for the demographic of women that sometimes we sort of say like I think in the United States, when women are, we think particularly the North American Menopause Society and some of these other guidelines where we say no, when women are less than age 60 or within ten years of menopause, we know that there’s something called the timing hypothesis, particularly from a cardiovascular standpoint, that it is more favourable to start hormones during that window of time, potentially less favourable later. But we know from a bone health perspective that really both starting within the ages of right at menopause or perimenopause and menopause as well as women from the WHI, the largest randomised controlled study that we have, that estrogen in that demographic also reduced the risk of fractures. And I always say that those women, again, because they’re older and we know that for every 10% loss in T-score it increases your risk of hip fracture by 2.5 fold, which is significant. So those women that being older, higher risk for falls, still had a prevention benefit of reduction of fractures using hormones. So really women from their fifties now we should even extend that a little bit beyond, until the seventies, can still show a vertebral and non-vertebral and hip fracture benefit from hormone therapy. But like you said, it depends on who you’re seeing to treat your symptoms and who you’re seeing to treat or evaluate your osteoporosis. And I really think that we need to move beyond our sort of class system. And in terms of a patient sees that one doctor and they get one answer, another doctor, they get another answer to thinking particularly about women’s health. And even bone health is sort of a through the lifespan, right? Each decade of life, what are the risks, and the benefits? Look at the patient’s individual risk. These things are very important, because the reality is just, one other point about bisphosphonates and hormones, is that we know when we do some head-to-head studies of bisphosphonates and hormone therapy at standard doses, the bone mineral density effects are almost equal. And so really, we know that they’re both working on the remodelling system. That’s what I said before, preventing bone resorption. They’re both working on those active resorption cavities and trying to fill those spaces in. I mean, they do it pretty equally. So we need to sometimes reconsider the options we’re recommending.
Dr Louise Newson: [00:23:05] I totally agree. And I think also we need, as patients say menopausal, perimenopausal women, we need to be empowered with the information and work out which is better for us. And there are some women who, once they understand the differences, will choose one rather than the other. And I think this is really important as a clinician that people have choice. And it’s very interesting, isn’t it, how hormones work on bones compared to, say, bisphosphonates. And when hormones build bones, they still make the bones a bit more fluid. You can still sort of, if you fall, they’re not brittle in the same way the bisphosphonates tend to build the bone. I always sort of compare it to a champagne glass. So if you fall when you’ve got a bone that’s been made stronger with a bisphosphonate, some of these treatments for osteoporosis, it is more likely to fracture. And we know that people can get these atypical fractures when they’ve had bisphosphonates, which then can be quite hard to heal, whereas the bones are sort of just softer and more likely to bounce almost. So you’re almost less likely to fracture even if your bone density is very similar, if you’re on hormones as opposed to bisphosphonates. And that’s a generalisation. Of course, not everyone is the same, but I think it’s very important to think about the differences as well. And actually, also we know that with a lot of bisphosphonates now, certainly in the UK, we’re recommending only to use them for three or five years and we don’t know the long-term effects, whereas hormones have been around for a long time. We do know the long-term effects and benefits of being on HRT for more than just the bones. And like you say, even starting HRT in older women is a lot safer than it used to be. And we certainly start a lot of women, even in their 70s, we’ve got a few in their 80s who start HRT, but we’re giving transdermal estradiol so it’s got no risk of clot. We can often start very low doses, but we know from some studies, even low doses can help still protect the bone. So, you know, there are still benefits out there even just from low doses of estrogen.
Dr Kristi DeSapri: [00:25:17] Absolutely. I mean, I think comparing like we’ve talked about over bisphosphonates for the right patient or estrogen, again, looking at the contraindications and we know that estrogen, we talked about muscle and skeletal muscle and connective tissue, we know that estrogen increases the collagen content of bone, we know it decreases the stiffness, we know it most likely has an effect in increasing skeletal muscle and different situations. So again, in women in the Women’s Health Initiative study, have less joint pain. So we have to think about it as muscle, bone joined all together. And I think, again, like you said, we know from many of these clinical studies we have such an armamentarium of different doses of estrogen, oral estrogen, transdermal estrogen and vaginal estrogen at systemic or local doses. Same with progestogens. So we have so many of these different options, and we do know that the very low dose patches once a week do offset bone loss in women with low bone density, low bone mass like osteopenia, and not at elevated risk for fractures. And so sometimes I would say you can use that with other products, though there is some research looking at some of the anabolic agents with estrogen because again, we know that there are different mechanisms of action of how they’re going to stimulate the bone. And so it’s not an all or none phenomenon. And we know from what you know, and I think one of the best done studies, which was the PEPI trial looking at estrogen and progesterone, and the most interesting was that when women were between 45 and 55 and they were not given estrogen, they lost more bone density than women who were older and not given estrogen. And the same reverse is true and women at 45 to 55 were given estrogen plus progesterone they lost less than the women who were just given placebo. So again, we know that we probably need more standard doses of estrogen closer to the time of menopause. So we don’t want to be giving just like a little bit of estrogen and let’s hope it helps your bones. I mean sometimes we start that way and I certainly do with my patients because some people have some intolerances to estrogen or they couldn’t tolerate the birth control pill or they just are concerned or breast tenderness. I mean these are all very real situations, but using it for bones, really we want to be using it at a standard transdermal doses that were used in studies in the Women’s Health Initiative study or similar. So 0.25 milligrams of conjugated equine estrogen, a transdermal estradiol patch of at least 50 micrograms. And these might be a little different in terms of the equivalent, you know, in the UK, but same with oral estradiol from 1- 2 milligrams a day. So to really make an effect and a change and oftentimes again those are going to help other symptoms like GSM (genitourinary syndrome of the menopause), night sweats, mood, hair, skin, nail changes, all of these things. So I think we know that younger women, like you’re saying, in the perimenopause or early menopause, really, if we’re going to use hormones for their bone treatment for either treatment or osteoporosis prevention. But we need to think about the dose, think about the formulation and have that evaluated.
Dr Louise Newson: [00:28:11] Absolutely. And I always say to women, let’s try and balance your hormones properly, get the right dose that’s right for you and try and achieve a physiological response. And so people absorb at different amounts, or even with time, they might need different doses, but then you can optimise their symptoms clearly, but also you know that you’re going to optimise their bone health as well, which is so crucially important going forward. And certainly there’s a lot more work and education that we need to do going forwards. But just starting this conversation, allowing people to think about the menopause as a time where our bone health is affected is really important. So I’m very grateful for your time today. Before we finish, I would like their three take home tips. So three things that people could do if they’re worried actually about their bone health, they might have listened and think, right I might have an increased risk of osteoporosis. Well, the three things that you would recommend them to do?
Dr Kristi DeSapri: [00:29:11] Yeah, I mean, I think the first would be just what we’ve kind of talked about, awareness. So understand your risk of a fracture or understand your bone mineral density. So obtain a DEXA, do the free FRAX assessment for yourself and bring that to your clinician. Find a clinician like a women’s health clinician through many different organisations ACOG, NAMS and the UK, I’m sure you have very similar databases to find someone to do that assessment with, Bone Health and Osteoporosis Foundation, we also reference a lot here in the United States. And I also think another take home is really what we’ve talked about with the timing hypothesis. I think that should really resonate, expand beyond just cardiovascular benefit and cognitive benefit, which we know with starting hormones earlier and even more research points to that. But think about the bone health benefit, because in the United States, unlike in the UK, hormones are not indicated in any of our clinical guidelines for treatment of osteoporosis, and some of them do recommend prevention. But we absolutely know from the data that they are. So if that is your main symptom or complaint, but I always know that there’s other things behind that, then really in your, within the years that we’ve discussed, the menopause transition and even beyond really considering hormone therapy for bone health, if you have no contraindications, I think is really important. And I think just what we’ve talked about as well, understanding that it’s more than just bones is more than just hormones. We know that there’s such a cardiometabolic effect. You know, this affects the joints we know affects skeletal muscle and women are living longer, right? So women are living into their 80s. 40% of our lifespan is now spent in menopause. So for many women, I would say we’ve been mothers and teachers, we’ve been workers, we’ve been supporters, we have contributed to society in our communities. And so most of them want to live independently and would rather die than go into a nursing home. So I always say, like really, you know, again, advocate for yourself. Find someone who you can educate yourself. And I think a lot of these forums, what you’re sharing and some of the evidence-based research and finding those providers can be very helpful.
Dr Louise Newson: [00:31:13] Excellent. So make sure that you’ve got the right knowledge to make the right decisions. And if you don’t get help the first time, be your own advocate and see somebody else. So really great advice. Thank you so much for your time today and look forward going forward, how you can educate over there and we can educate over here to really improve bone health for women and also for men as well. So thanks ever so much, Kristi, it’s been great. Thank you.
Dr Kristi DeSapri: [00:31:40] Thank you, Dr. Newson. Appreciate your time too.
Dr Louise Newson: [00:31:46] For more information about the perimenopause and menopause, please visit my website www.balance-menopause.com. Or you can download the free balance app, which is available to download from the App Store or from Google Play.