The Dr Louise Newson Podcast - 200 - Osteoporosis: how to protect your bones during menopause and beyond

Episode Date: April 18, 2023

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: 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 Increasing evidence suggests HRT can help protect bone health, so consider this treatment option to keep your bones strong 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. You can follow Dr DeSapri on Instagram @boneandbodywh. Her website is www.boneandbodywh.com

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-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 interest or shared interest and she's called Christy de Sappre and

she works in Chicago and has a special interest in bone health and women's health and was initially trained as a gynecologist. So welcome to the podcast. Hi, thanks for having me. 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, Christy, 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, changed 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. Absolutely. Yeah. So I'm a board certified internist. So just like you started in a pretty traditional path. I always thought I would be an OBGYN and really take care of women just at that time. And then in doing that for my first intern year, I realized two things. One, I do still love women's health.

And I think it's very exciting field. It has a lot of innovation. And we obviously get to care for women at, you know, a very vulnerable time. And also a time where we can, you know, 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, you know, women that, during the lifespan, you know, from the adolescence to, you know, I have some patients as old as, you know, 99 and 100, which I love seeing. So I absolutely, so I started in gynecology and I sort of morphed my way through in medicine to internal medicine. And then I did, I really focused and I knew that I

always 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, you know, diverse. Really, there's only about six fellowships from the country and it really focused on multidisciplinary women's health care. So sort of those health care centers that we think are, which the universities are trying to create today, where it's a mixture of urogynocologists, gynecologists, breast surgeons, women like ourselves, focused on menopause, metabolic changes, hormonal changes. And that's really where my passion for bone health started. I really loved seeing those patients. As we talked before, I enjoyed the science of DECSA, which is dual energy x-ray absorbiometry, and how we can translate those results through

talk 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 Osteoprocess Foundation, in private practice and then an 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, you know, concerns, hormonal, metabolic, and particularly with a focus on bone health. So it'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 it men and falls a 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 realize 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 risk fractures when they're young, but they bounce back within weeks.

They're fine. It doesn't happen like that when we're older, does it, when we have fractures? No, absolutely. I mean, you've touched on so many things. I think the reason why, again, osteos, 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 sort of the subset of low bone mass, are undiagnosed or largely undiagnosed.

You know, we know from, at least in the United States in the Medicare beneficiary is less than 25% of women would get a 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, what we're trying to prevent is fractures, which most people don't understand what a fracture really is. They think of like, yes, being pulled out of a tree by their brother when they were younger and they broke their wrist. But we know the fractures of the hip, the spine, the wrist, pelvis. These are all fractures with very significant consequences, particularly hip fractures, which is the fracture I always trying to prevent the most. And we know that, you know, those are affecting women who are, you know, getting on in years.

a woman in their 70s and 80s. And these can be very preventable by the diagnosis of osteoporosis, the evaluation and the treatment. 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. They do a lot more than people realize, don't they? 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, you know, delicate balance. And so, you know, absolutely. I think when we think about what you mentioned, a dynamic process, I always share this, you know, cocktails, party facts with my patients, but 10% of your skeleton remodels every year, which means every 10 years your whole body is remodeling. And I say, I do not like to decorate. So I always liken that to, you know, like house decorating. Think about if you just like your whole, you know, house was redone every 10 years. That's significant. So we know that our bones are always remodeling, which is the process of removing old bone, modeling, 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. 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 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. 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 skeletal bone mass,

loss of bone quality, increasing your risk for fractures. How we, you know, capture that as looking at bone density, but, you know, again, fractures. When 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. You know, worldwide, we know that 9 million women fracture annually, which is a fracture every three seconds. So a lot.

And I always share the statistic, too, with women, before we go into the clinical risk factors, we all, you know, when we get our next patch smears, basically that is very popular in the United States since the guidelines are always shifting. You know, when do we get our next mammogram? People, you know, want to do those things yearly. However, they don't, you know, know their bone density, but more women have hip fractures than, breast cancer, uterine and ovarian cancer combined. So when you think about midlife women's cancers,

and we put that in perspective, we need to think about osteoprocese 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 our women with premature ovarian sufficiency, early menopause, due to whatever, you know, cause, whether that's just genetic, whether that is smoking, whether that is cancer-related treatment. 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's 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 some of 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 brought with some issues, but, you know, can help a family history of fracture, particularly a maternal history or paternal history of a hip fracture before age 70, certain use of medications like steroids or glucocorticoids and bone metal density at the hip is evaluated, as well as other factors. There's such a host of past medical history, surgical history, medicines, lifestyle factors that contribute to bone density. So, you know, 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 recommended that at age 50 or a menopause that someone does a bone health assessment, which is basically just talking, thinking up through things about that could

affect your bone growth as well as your bone loss over time. And it's so important, as many of you know, when I opened my clinic, I was very adamant that I wanted a dexas scan in the clinic and everyone said, Louise, you're mad. You know, you're refirming this clinic. You've spent every single penny and you've got a bank loan and now you're talking about a dexter scan. And I said, but I'm doing it not because I want to make money from the dexter scan and I don't think I ever will because it's 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 dexascan around the age of, you know, 45 to 55 to see where we are.

And, you know, it can be very common that people have their cholesterol measured. But as you know, a cholesterol level doesn't always predict heart disease. there's so many other factors as well. But actually having a dexas 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? 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 dexascan when you've had a fracture, isn't it? Right. And I think we're talking about both of our countries through the UK and the United States and worldwide and the fact that prevention, you know, 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, you know, studies 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 whole net of risk factors, look at them, you know, as a sort of totality. And I always find that, you know, in the 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 the spine. Oh, yeah, you know, my mom, she did like start to lose height. Oh, yeah, then she did fall, you know, things like this. And also, we forget about bone growth years.

You know, the cruel of bone mass, really, we know we achieve peak bone mass between 25 and 35. But at puberty, we're having a very dramatic, you know, bone growth. And so a lot of times what's happening, you know, with our use at that time in terms of calcium, soda intake, nutrients, exercise, although those things are very important. know, I asked all my patients about that or were you a healthy child. You know, it's amazing what you'll hear. And so I think, right, calcium, vitamin D. I mean, these things are all, they all have an interplay, right? So I agree with you that we, in my clinic, the same thing. We evaluate it anytime someone is postmenopausal. And we know that there's a large set of women who undergo premature

ovarian insubiciency, surgical menopause now that we're diagnosing more hereditary breast and ovarian cancers and we're recommending prophylactic, you know, BSO. 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 genetic predisposition. Their mothers had osteoporosis, but no one really checked it and things. 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 your Asian ethnicity. These 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, you know, in 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, you know, is important. And a dexas 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 reation, low cost, very simple 10 minutes. I have people take off your bra so we don't see the wire and things like that.

But it's pretty simple test as far as test go to gain a lot of information. Absolutely. And so tell us about hormones. We know, like you say, if women have an early menopause, they have longer without their 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 very an important fact on the way our bone stays strong, doesn't it? So tell us a bit more about that. Yeah, all the hormones. In fact, you know, there's evidence with estrogen, progesterone, testosterone,

I mean, all of these are cortisol, you know, effect. I mean, it's just, you know, again, it leads to this interplate. But, you know, 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 a menopause, right? And so they have a slower bone loss trajectory over their lifetime and a lower fracture risk

for that reason. And because women have this menopause is loss of estrogen, like we talked about a little bit loss of testosterone, but that's 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 Cancelis bone, which is more dominant in the spine and the femoral neck area, and then the cortical bone or the periosteal bone, which is more dominant in the total hip or the femur or the long bone. So at menopause, with that decrease of estradial and the increase of fs, we know that sort of that, sort of

lovely balance of bone being formed and bone being broken down that I alluded to, which is called remodeling, is thrown off. It's totally thrown off the kilter. If you have young children or if everyone knows the analogy of a sort of a teeter-totter. And so what's happening is basically, if we think about two sides, you know, the estrogen declining is really throwing off the balance and breaking down more bone, both in the trabecular bone and the cortical bone. We see a more precipitous drop in the bone density lost in the canceles 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.

We can lose up to 20 percent of a trabecular bone loss and close to five to seven percent in the cortical or the hip bone 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, particularly of a family history. be, again, that might be another area when we're going to see more a drop in bone density. And again, I would say another area that we could intervene. Interestingly, you know, we know the dominant effect of the loss of esteradile is to throw off the imbalance of increase the antoresorptive 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 then some bone biopsy, which is basically studies looking, you know, more deeply how estrogen is working at the physiologic level. Yeah, and it's very interesting. I mean, there has scanty research because obviously good quality women's health research never exists, as it, 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 postmenopause or symptoms, but not for perimenopause. Yet we prescribe HRT for the perimenopause because studies show that the earlier 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 HART. And certainly many osteoporosis guidelines don't mention HART. And if they do, there's always there 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 HART. 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 menopause of women, had osteoporosis, I would really much prefer to take HART 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 our symptoms the same way as HART is. Would you agree? Absolutely. I mean, I think, you know, we talked before that the women's health initiative of the WHOI, you know, didn't do us any favors in terms of, you know, 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, you know, when adjudicated really non-significant.

But what it did show is it did show that these women, again, on average, in their age 60, you know, more than 20,000 women, that there was a reduction in both hip fracture and non-vertebral fracture as well vertebral fractures. So we know that it works, right? We know what it works actually for the demographic of women that sometimes we sort of say like, ooh, I think in the United States, you know, when women are, we think particularly the North American menopause society and some of these other guidelines where we say, you know, when women are less than age 60 or within 10 years of menopause, you know, we know that there's something called the timing hypothesis, particularly from a cardiovascular standpoint that it is, you know, more favorable to start hormones during that window of time, potentially less favorable

later, but we know from a bone health perspective that really both starting within the ages of, you know, right at menopause or perimenopause to menopause, as well as women from the WHI, the largest randomized control study that we have, that estrogen in that demographic also reduced the risk of fractures. And I would, I always say that those women, again, because they're older, and we know that for every loss in T score, or 10% loss in T score, it increases your risk of hip fracture by 2.5 fold, which is significant. So those women, it being old, older, higher risk for fall, still had a prevention benefit of reduction of fractures using hormones. So really women from their 50s, you know, we should even extend that a little bit

beyond until their 70s can still show a vertebral and nonvertebral 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, you know, or evaluate your osteoporosis. And I really think that we need to move, you know, beyond our sort of class system in terms of a patient. And sees that one doctor and they get one answer, another doctor, they get another answer. And 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 risks. 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 remodeling system. What I said before, preventing bone resorption. They're both working on those active resorption cavities and trying to fill those spaces in. And they do it pretty equally. So we need to sometimes reconsider the options we're recommending.

I totally agree. And I think also we need as patients, so as menopausal or 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 glove. 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's 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 bisphosphonate. And that's a generalisation, of course, not everyone's 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 and 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 transdermalistradial 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 aren't there even just from low doses of estrogen? Absolutely.

I mean, I think comparing, like we've talked about the bisphosphonates for the right patient or estrogen, again, looking at the contradications. 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 at increasing skeletal muscle in different situations. So, again, and women in the women's health initiative study, again, had less joint. pain. So we have to think about it as muscles, bone, you know, and joint altogether. 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, vaginal estrogen at systemic or local doses, same with progestogens. So we have so many of these different options in it. We do know that the very low dose patches once a week do offset bone loss and women with low bone density, low bone mass, like osteopenia, not at elevated risk for fractures. And so sometimes I would say you can use that with other products. So there is some research looking at some of the anabolic agents with estrogen. Because, again, we know that there's their 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, you know, I think one of the best, you know, done studies, which is the peppy trial looking at, you know, estrogen or progesterone. And the most interesting was that when women were, you know, 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 when women at 4550 were given estrogen plus progestion,

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, though we don't want to be giving, we say someone, oh, just like a little bit of estrogen and like, 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 breast tenderness. I mean, these are all very real situations.

But for using it for bone, really like we want us to be using it at a standard transdermal doses that were studies in the Women's Health Initiative study or similar. So 0.25 milligrams of conjugated equine estrogen, a transdermal patch of at least 50 micrograms. And these might be a little different in terms of the equivalent, you know, in the UK. But, you know, same with oral astrodial, sometimes we need one to two milligrams a day. So to really, you know, make an effect and a change. And oftentimes, again, those are going to help other symptoms like GSM, genitone, urinary, syndrome, menopause, night sweats, mood, hair, skin, nail changes.

So all of these things. So I think, again, we know that younger women, like you're saying, in the perimenopause, early menopause, really, if we're going to use hormones for their bone treatment, for either treatment of osteoporosis prevention of autism, we need to think about the dose, think about the formulation, and have that evaluated. 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 different amounts or even with time they might need different doses. But then you can optimize their symptoms clearly, but also you know that you're going to optimize their bone health as well, which is so crucially important going forward. And certainly there's a lot more work in education that. we need to do going forward. 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 just 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. What are the three things that

you would recommend them to do? Yeah, I mean, I think the first would be just what we've kind of talked about, awareness. So understand your risk of, you know, 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, you know, through many different organizations, 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. the United States. And I also think, you know, another take home is really what we've talked about with the timing hypothesis. I think that should really resonate, you know, expand beyond just cardiovascular, you know, 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, and you're within the years that we've discussed, the menopause transition and even beyond really, you know, 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, you know, it's more than just, you know, bones and more than just hormones. We know that there's such a cardio-metabolic effect. You know this affects the joints.

We know it affects skeletal muscle. And women are little, longer, right? So women are living into their 80s. 40% of our lifespan is now spent in menopause. So for many women, I always say we've been mothers, even teachers, we've been workers, we've been, you know, supporters. We have contributed to society in our communities. And so most of them want to live independently and would rather, you know, dive and, you know, go into a nursing home. So I always say, like, really, you know, again, advocate for yourself, find someone who 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.

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 ever 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, Chris. It's been great. Thank you. Thank you, Dr. Newsom. Appreciate your time, too.

For more information about the perimenopause and menopause, please visit my website, balance, menopause.com or you can download the free balance app which is available to download from the app store or from Google Play.