The Dr Louise Newson Podcast - 107 - Osteoporosis: What is it and how to prevent it, with Prof James Simon

Episode Date: July 13, 2021

In this episode, Dr Louise Newson is joined by Professor James Simon as they take a deeper look at our bones and discuss osteoporosis: what happens to your bone strength during the menopause, what are the risk factors for developing osteoporosis and what we can all do to try and prevent it.     Professor Simon's 3 top tips for keeping your bones strong and healthy are:  Have adequate calcium from your diet and if you're lactose intolerant (or vegan) you may need to take calcium supplements spread throughout the day.  Take good care of your skin by using sun block and a hat, but try and get the vitamin D you need through time in the sun and from fortified foods.  Do regular weight-bearing exercise that impacts through your bones as you hold your own body weight during the activity. 

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I'm also the founder of the Menopause charity. In addition, I run the Newsome Health Menopause and Well-Being Clinic here in Stratford-upon-Avon. So I'm very honoured today to have with me, Professor James Simon, who some of you hopefully have heard our podcast before, but I've in time. heist him back into the studio to talk again. So thanks ever so much for giving us your time today. My pleasure. So I spend a lot of time trying to demystify the menopause to debunk some myths about HRT. And you like me are hardworking and work out of the evidence because we've got really good

evidence. And so that's what we work out of as doctors. But there is lots of good evidence showing how Slave HRT is at reducing risk of diseases. And today I really wanted to focus on bones because osteoporosis is a almost hidden killer, really, isn't it? And a lot of people don't even know what it is and what the risk factors are and what can be done about it, especially for women. So I would just love it if you could help over the next half an hour. Let us know first the basics and risk factors and how we can manage it.

So let's talk very broadly about osteoporosis. Recognize that calcium metabolism is one of, if not the most important mechanisms in the human body. The amount of calcium in your blood, your mind everybody's, is critical. If it's too high, your heart stops. If it's too low, your heart stops. So it has to be maintained within a very, very narrow band. And so literally everything in a human being's body is meant to maintain calcium at its proper level. And the skeleton, your bones, which I like to say in my office, is about this beyond what we have here in the U.S.

is a skeleton that comes out only on Halloween to dance around and then leaves. The skeleton is actually a very active tissue in the human body. Even though it's on the inside of us, we don't get to see it, but it's very metabolically active. And it forms the reservoir for calcium when we don't get enough in our diet, or we lose too much through either urination, through the kidneys, or through our fecal material. If our balance is out of whack, the skeleton kicks in, and we always maintain that calcium balance in our bloodstream because keeping the heart pumping is very, very important. Now, to that end, when women are breastfeeding, and I know we're talking about menopause

in breastfeeding the same sentence here, which doesn't make a lot of sense. But when women are breastfeeding, their estrogen levels are extremely low, just like they are when that same woman is menopausal. The blood level of estrogen is the same. And during breastfeeding, that mother needs extra calcium from her bones to go into the breast milk. She still needs to maintain the same calcium in her blood, but she needs extra to go into the breast milk for her baby. And so she takes it from her bones, and that becomes an important reservoir.

Well, the same exact thing happens when she's menopausal, except there's no breast milk. Calcium comes out of the bones, and then is lost out of the kidney because too much calcium would actually stop her heart. So the calcium's lost out of the kidney. And if it's lost for long enough, the bones get very brittle and weak and they break. And then we see this older woman all hunched over, could be an older man also, all hunched over. and he or she, as we're speaking about today, has what we call osteoporosis.

And worse yet is when she's lost enough calcium that her hips become weak, she may actually fracture a hip just walking down the street or stepping off a curb or with a small trip where she loses her balance. and break a hip. And this is a very common phenomenon in both US and in the UK where we don't have very strong bones. And it's not easy to know you've got osteoporosis until often a fracture, like you say, a low impact, a fragility fracture. It's different if you're, you know, fall over when you're running or cycling or whatever. But if it's like you say, just stepping off a curb and you break, this is called a fragility.

fracture or low-impact fracture. But we don't want to be knowing when we've had a fracture, do we? So there's no easy blood test, for example, is there? How do you diagnose the thinning of the bones? So there are a number of devices that are approved, both in the UK and in the US, to measure bone density. It can be measured typically with x-ray, or it can be measured with ultrasound. as a surrogate for bone density, but density itself is about 60% of the entire bones' strength. So when we measure density, we're not measuring about 40% of what could contribute to strength, but we're measuring the majority of what is considered bone strength. and bone density using x-ray or a dexas scan, dual energy x-ray-absorbtiometry,

dexa, is very, very accurate, it predicting bone density. But you don't even need that because we have very good data from the UK, actually, for the entire world on one's risk of fracture, and we can use a woman's weight and height as a surrogate for bone density using that frax score, which I know you know lots about, but maybe your listeners could learn a little bit more

about the frax score from Sheffield is where they keep that, actually. Indeed, yeah. So you can actually just Google, FRAX, F-R-A-X, and it will come up and you put in, don't you, some parameters, and it will give you a likelihood of what your score is, but also it can help indicate whether you need a sex scan or not. Correct. And the FRAX score was designed to be specific for your race, your ethnicity, and your country. So let's imagine that you as a practitioner in Shakespeare's hometown, that you are seeing a patient that's visiting you from the U.S., you can put her into the frack

score as if she's a U.S. citizen. And I do this all the time because we have an ethnically diverse group of patients we care for, and you need to put her in as French or Spanish or from Africa or maybe she's from Asia. We have Asian patients and black patients. and people from all over the world. But you can use that frack score for determining whether a patient needs specific treatment for her skeleton because she's at elevated risk of a fracture. Now, there are some problems with the fracks. And the biggest one, in my opinion, is that the fracks score is the risk of a major

osteoporotic fracture, but particularly focused on the hip. Now, why is that good and why is that bad? Well, it's good because that's what really causes the greatest morbidity and mortality, a hip fracture. It's bad because most women fracture their spine first. And it's the weakest link, if you will, but the frax score was purposefully developed for the hip, not for the spine. So I like to say to patients and other doctors, frax is a very good tool, but it's spineless. Remember, the frax is spineless. So we need to always think outside the box in taking care of a particular woman

as it relates to her spine. Yeah, which is really good advice. But when you Google or look at osteoporosis incident, some websites tell us that one in two women over the age of 50 will develop osteoporosis and one in three will have an osteoporic hip fracture. So this is women over the age of 50, as you know, are postmenopausal. You've said the importance of estrogen. So does that mean, just to spell it out really, that postmenopause women are a higher risk than women who've got their hormones of osteoporosis? Absolutely. So the risk factors, number one, would be a low estrogen environment like menopause. The other is being of light skin. So someone who is Caucasian or Asian typically would have a greater risk than a woman who is African American or African of African descent.

So it's very close to Scandinavia in England, very far from me. But we have lots of Caucasians here, but we also have a lot of black people in the U.S. And there's a great difference based on race. But that's not the whole story. So we have her hormonal balance, her race, but you can never escape your relatives. So if your parents had osteoporosis, or if your parents, your mother or father had a hip fracture, these are very important risks for you as an individual. And medications that we use commonly in just general medicine can be major risks for

osteoporosis. For example, those medications that are used to treat inflammatory diseases like cortisone and its relatives, the glucocorticoids, in both the U.S. and in the UK, depression is actually a big problem for women and for postmenopausal women and women as they age, and many of the antidepressants at a yet another risk factor for osteoporosis and fracture. So there's lots of reasons why, I mean, I'm sure, there's, well, there will be, won't there? So many men and women walking around with osteoporosis,

but don't know it. And then I said it's a silent killer. I wasn't being overdramatic, actually, because if you look at what happens after even just having an osteoporotic hip fracture, the mortality, so the instance of people dying in the first year after a hip fracture, are staggeringly high, aren't they? Yes, and it's particularly high in men. Now, in men that have a hip fracture. It's a little bit difficult to understand why so many men would die from a hip fracture until you realize, at least in the U.S., that the average age of a hip fracture in a man is about 88 years. So he is rather old when he has a hip fracture, but in women, it's much younger, and I don't know what it is in the U.K. what the average age of hip fracture is. But

regardless, that woman typically would live much longer without her hip fracture, and most importantly, most fractures, whether they're the hip or a spine type fracture, most fractures are preventable. So if it's going to kill you early and it's preventable, why wouldn't you do it? Absolutely. And it's not just mortality. I mean, some figures say 25% of people after a fracture will die. And that's all sorts of things. You know, people even in hospital can have an infection.

They can have a chest infection. They can be another reason. Or it could be that they've had a problem maybe with a heart that's led to the fall. But it's usually the consequence actually of the fracture. And then there's reduced mobility, reduced dependence as well. So people often become dependent on others. and often can't live at home, they end up with sheltered accommodation or nursing accommodation. And it's a real decline, actually, for a lot of people.

I've seen it a lot over the years as a GP. People are just about managing at home. They have a four, just usually tripping up over a carpet or a step, as you say. And that's it, really. It's a really quite sudden decline. But we don't see that when we're young, do they? We don't realize what our bones are. And I'm actually personally very scared of osteoporosis.

And like you say, the osteoporosis of the spine really scares me because a lot of people find they can't digest food properly, they get recurrent infections. And actually it's really painful. Having lots of fractures in your spine is really painful. So it's not a nice disease, is it? No, and the problem is that it's largely silent until you break something when it tells you with pain,

that you've got this disorder. And once you have it, while it can be arrested, the damage to the entire skeleton is somewhat done. Well, I would argue that partially osteoporosis is reversible with modern medication. Partially, it is not reversible. And there's just so much benefit you can get once you've developed osteoporosis and fractures.

And it's not something that is new. We've known about osteoporosis for decades, and we know how to prevent it, and we know how to treat it, and we have better treatments than ever, as long as they're initiated early in the course of the disease. Absolutely. So obviously, all we're talking about really is the perimenopause and menopause.

So for me, as a menopausal woman, tell me what I need to do to reduce osteoporosis. This is not very complicated. You need to know what your bone mass or your bone density is. Just like knowing how fat you are or how thin you are, you get on a scale, we can get a bone density and know where you are. And we can follow that bone density with good preventive measures and try. treatments to make sure that you stay at your density or hopefully increase if you've already lost some bone. You need to get a certain amount of calcium and vitamin D. These are the building blocks of good skeleton, as I alluded to when we talked about breastfeeding and menopause and the

correlation there. So you need adequate calcium, which you can get in your diet in the UK of wonderful dairy products, probably better than we have over here, quite frankly. And dairy products are the principal source, not the only source, but the principal source of calcium in the diet. But also, there are other sources of calcium. Green leafy vegetables have some calcium in them, as do small fish, kippers and herring and sardines and canned salmon. We eat them because they have the skeletons of those fish actually in them. By consuming the fish's skeleton, we can also get some extra calcium in our diet. And vitamin D is obtained from sunshine.

Now, I can make a joke and say, you don't have any sunshine in the UK. That would be just an exaggeration, not necessarily a lie. but you can get vitamin D out of tablets or supplements equally used by the body as if you get it from the sunshine. And we want you to protect your skin from too much sun. So it's always a battle between the sunblock and getting some sunshine and calcium from your diet or supplements. You want to make sure you don't get too much a dietary or supplemental calcium

all at once, but spread out across the day is a good way to do it. And then we want you to get adequate exercise to include some kind of weight-bearing exercise. Now, riding a bike doesn't count. Swimming doesn't count as weight-bearing. Great exercise both. But the skeletons like to be abused. They like pounding. They like stress in order to.

to grow and be strong. So we want lots of strength building, weightlifting, running, et cetera, as long as it's not going to hurt your joints. Those are the basic tenets of skeletal health. And then if you're a woman or a menopausal woman, we want you to have adequate estrogen in your body to prevent bone loss. Remember that estrogen, just like the story I gave you about breastfeeding. When a woman's menstruating, she doesn't lose bone unless she has some kind of unusual bone disease because her estrogen in her menstrual cycle prevents her from losing any bone, unlike when she's breastfeeding and unlike when she's menopausal, when she may need estrogen in the case of the menopausal woman. So estrogen can be used to prevent or to reduce the

incidence of osteoporosis. And it also does. can be used as a treatment for osteoporosis, can't it? Yes, it can, although many critics of estrogen for the treatment of osteoporosis might find there are better treatments or more rapid treatments that increase bone density. And that's largely because scientifically we've used hormones primarily to prevent osteoporosis and less often to treat it. And so the amount of scientific information that we have on its use in treatment is much less than what we have for its use in prevention. But either way, yes, hormones can be used to either arrest bone loss while increasing bone density somewhat or as an excellent, really natural way to prevent bone loss.

Which is really important. So we have a dexas scan in my clinic. I bought one at great expense because of my sort of, I suppose, fear about osteoporosis, but also I strongly feel that women should be offered the opportunity to have a bone density scan around the time of their menopause. And it's very hard actually over here in the NHS to get a bone density scan. But when I speak to rheumatologists, I spoke to one recently actually who I was thinking might be able to report for us to do spectres when our professor who reports for us is on holiday.

And she said, yeah, that's fine. And then I said, what's your feeling about menopause and HRT? And she said, oh my goodness, I would never prescribe HRT. Never prescribe it because of the breast cancer risk. And I would never prescribe it for bones. So I thought, well, you're never going to report on my scan. But that's a real shame. And I think when you look at some of the osteoporosis management guidelines,

HART is almost in the small print, isn't it? It's been totally taken off the agenda because of this unfounded scare from the WHO study. And I always think of medicine, if I'm not sure about something, I go back to the physiology and the basic pathology and look at the science. And you explain it so eloquently, when you're used to do levels drop, your bone density reduces. So therefore it would make sense, that giving estrogen back would reverse that and help.

Yeah, in fact, the Women's Health Initiative, where your rheumatology colleague, and many of mine as well, are still stuck. Remember those studies came out in 2002. That's almost 20 years ago. But it doesn't matter. Doctors can get stuck with group think and get stuck in their thinking like everyone else.

But the real answer is that that same study is one of the best references for showing that hormone therapy can both prevent bone loss and actually prevent fractures and including hip fractures. And it is the only study, the only study in the entire world's literature. And I'm not kidding. It doesn't matter the entire body of the world's literature that shows that hormone therapy can prevent hip fractures in women who didn't have osteoporosis when they were first assessed. Now, that's an unusual kind of study for the same reason that we usually don't grab for estrogen in much older women who might be at risk for that hip fracture. from the get-go. It was the kind of strange way the study was done that gave us both good and bad

information. I would say bad as it relates to breast cancer. We're looking critically at the data on hormones and breast cancer, I think the data actually are extremely reassuring that hormones in the WHOI did not cause breast cancer, number one, and also looking very carefully at osteoporosis and fracture prevention, it showed that it did prevent osteoporosis and did prevent fracture. So it's strange, but it does offer reassurance about our topic for today, which is bone loss and osteoproduct fracture. Which I think is really reassuring. And, you know, there are other treatments. We're not here just to say HRT is the only treatment to help bones. And there are bisphosphonation. which are drugs that can help.

And certainly when I was doing hospital medicine, we used to prescribe them a lot all the time. And then they were started to be concerned because people can get these atypical fractures. And in a very simplistic way, you want your bones to be a bit bendy, don't you, because they can cushion that forward. And bisphosphonates theme for some people

to make the bone too hard, a bit like a wine glass, and it will just shatter too quickly, whereas you want a bit of give in a bone. And so estrogen works in a different way to sort of build that bone, but keep it a bit flexible. And there are real problems, actually, with some of these. So now the modern thinking, if you like,

is to take them for three or five years and then have a drug holiday. And some of you listening might know they can be quite difficult to take because you have to take them on an empty stomach, you have to stay sitting upright. And the compliance is quite hard. I've been to lots of home visits and opened the cupboard

and seeing them full of bisphosphonates for people with osteoporosis. And I said, well, you're not taking them? No, doctor. I keep anywhere of people's pictures delivered, but I'm never taking those. So they're not without problems, are they, these other medications? So there are a couple things. First, the bisphosphonates do work, and they are very good studies that document that they work. Since in both the UK and the US, there are tremendous pressures.

on cost. Just like estrogens, the bisphosphonates are very inexpensive now. They didn't use to be, but they certainly are now. And there are some of those bisphosphonates that can be taken once a week or once a month, where a patient can commit to the more elaborate way they need to be taken if it's once a week or once a month. And I actually actually, recommend if bisphosphonates are for her, that she actually sets her smartphone to remind her to do it and to do it on time. Now, there also is one other medication. I'm pretty sure you have it in the UK, although it's very expensive and it's not used as much. And it's called prolia or denosumab, which is a twice-yearly injection that's extremely convenient. It's a very little teeny

injection for twice a year. And the reason I bring it up is not to give it more credit than is due, but it works in the skeleton the same way that estrogen does. And so if one is to say that estrogen is really good for bones, but you're worried about the risks, then one should also say that this medication is also really good in the bones and evaluate them side by side for the benefits in the bones. And I think that in doing that, many of the specialists, whether they're over there or over here can be reassured about the benefits of estrogen or prolia in the bone, and then you settle looking at the risks which most GPs here and there overestimate based on the Women's Health Initiative and which we, you and I and other individuals who are knowledgeable,

should be able to reassure both patients and practitioner about those risks, because quite frankly, a careful look at them shows that they're very small or even non-existent. Which is so important. And also, obviously, women who take HRT not only have a lower risk of osteoporosis, but other conditions, as we know, such as heart-sleeves, type two diabetes, dementia, and actually early death as well. So there's a lot more going for HRT than me. the eye. But I think this has been just a really revealing conversation to try and help people think

more about the bones. And as you say, we take them for granted. We don't know what's going on deep down until either we have a fracture or we have a dexascan. And so I think just being aware of our bones is really important. So thank you ever so much. May I just say one more thing? women have a very strong fear of breast cancer. And most women these days, in both of our countries, fortunately, find out about their breast cancer because they've gotten a mammogram. They don't find it when it's a big tumor or hopefully they don't. And so you can't know what's going on in your breast without doing a test. And we frequently do those tests as younger women and take the test as a baseline and stick it in a drawer, a cabinet, or an electronic file somewhere until the woman is of an age

when she's much more likely to have osteoporosis in the case of a bone density or have breast cancer in the case of breast cancer. And this should be the way we use bone density. And this should be the way we use bone densitometry, to get a good baseline to find out where Dr. Newsom is or where Mrs. Simon is at around the time of menopause, and to find out, is she at high risk for osteoporosis, average risk, or low risk, and then put that scan away for a good long period of time to see how she's doing, but resurrect it before she gets a fracture, and make it. sure that she's getting proper care before she gets at too high a risk for that fracture because she's lost so much bone in the interim.

Such good advice. And it's all about prevention is better than cure, isn't it? And it's so important with osteoporosis, and especially as it's so common. So before we end, I'd just like to ask you three take-home tips, actually, for people who may think, right, what am I going to do? One of the three things that us and women and men actually can do to just three things that can help our bones. Yeah, so get adequate calcium in your diet. If you happen to be lactose intolerant, it's very difficult to do without getting supplements. Take those supplements spread out across your three meals a day, so you're not getting too much at one time.

take good care of your skin, use your sunblock when you go out in the sun or wear a good hat. But if you're doing that, make sure you get adequate vitamin D either in your diet. Many dietary foods, including calcium-rich foods like dairy, are supplemented with vitamin D. And good doctors can check your vitamin D if it's low or if you have intolerance or cannot take those supplements. Weight-bearing exercise with good punishment of your bones, not so much your joints, if you can do it. And as we age, both women and men, women pass menopause, men past age 65, should have a good understanding of what their hormone balance is as it relates to their skeleton because bone loss can be prevented with

adequate estrogen in women, testosterone in men, and we can prevent osteoporosis and bone loss and the resulting fractures that can kill you. And if they don't kill you, it may actually be worse because you end up being cared for by the health system or your younger family members and become dependent upon them where you could be living independently. Really important. So scary, but it's true and we need to really think about this. So thank you ever so much for your time today. I really appreciate it. So thank you.

It's my pleasure. It's always good to be with you. For more information about the perimenopause and menopause, you can go to my website, menopause.com. Or you can download our free app called Balance, available through the App Store and Google Play.