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

Episode Date: September 9, 2025

In this episode, Dr Louise Newson is joined by US-based orthopedic surgeon and bone and hormone specialist Dr Doug Lucas for an important conversation about bone health and why it matters more than most people realise.Together they unpack the reality of osteoporosis, a condition that is often underestimated yet has life-changing consequences for those affected. They explore how hormones play a crucial role in keeping bones strong, why vitamin D and nutrition are vital and the limitations of relying solely on bone density scans or conventional drug treatments.Dr Louise and Dr Doug highlight why osteoporosis should be seen as an imbalance of bone metabolism rather than just a number on a test result, and they discuss how lifestyle, hormones and medical treatments can all contribute to protecting bones and preventing fractures.This episode is essential listening for anyone interested in understanding the true risk of osteoporosis and how to take practical steps to safeguard bone health at every stage of life.LET'S CONNECT  Website 👉 https://www.drlouisenewson.co.uk/Instagram 👉   / @drlouisenewsonpodcast  LinkedIn 👉    /https://www.linkedin.com/in/drlouisenewson/ TikTok 👉   / https://www.tiktok.com/@drlouisenewson Spotify 👉 https://open.spotify.com/show/7dCctfyI9bODGDaFnjfKhg LEARN MORE Take my online education course, Hormones Unlocked 👉 https://www.learningwithexperts.com/products/hormones-unlocked-dr-louise-newson Sign up for my Confidence in Menopause Course 👉 https://www.drlouisenewson.co.uk/education---confidence-in-menopause

On my podcast today, I'm with Dr. Doug Lucas, who's from the US. He's an orthopedic surgeon and a bone and hormone specialist. And we really talk a lot about osteoporosis. What it is, what it means to have it, the risks of having it and how we can prevent it. We talk about hormones, we talk about exercise. It's so important because osteoporosis really is common as we age. So have a listen and hope you learn. So Doug, we're here to talk about bones mainly and I've been quite vocal in the past saying that one of the reasons that I take hormones is because I'm really scared of osteoporosis. But lots of people don't even know what osteoporosis is and I'm actually, I'm less scared of having a fractured hip but I'm more scared about osteoporosis of my spine and I've doctored hundreds of women in the past with osteoporosis of their spine and they've been very disabled. they've been deformed in their shape, but they've also been in a lot of pain. They're on morphine. They're on laxatives. They're on antisickness.

Every time they cough and sneeze, it could be another little micro fracture. So osteoporosis is a real condition, but it's, I think, quite a scary diagnosis that people just, like, are brushing under the carpet. They're not, it's not sensationalised enough, really. So you are a bone expert. I'm really keen just to really unpick and go back to the basics. Like our bones are more than just a skeleton that hold up our body, aren't they? Oh my gosh, absolutely. Yeah.

So my journey as an orthopedic surgeon really taught me a lot about bones, what they are, how they heal. I mean, literally how they feel, right? But as I exited out of orthopedics, I got into the space of prevention, integrative medicine, hormone optimization. And then I really realized that we're looking at osteoprocess in totally the wrong way. We get so wrapped up in this idea of the Dexsa, the T score, the diagnosis of osteoprocess. And you're absolutely right. It is an anxiety-provoking diagnosis for a lot of people.

And unfortunately, a lot of times unnecessarily. But it comes down to me from a definition perspective, we need to look at it absolutely another way. We need to look at it as an imbalance of bone metabolism. We're all taught in medical school that there's cells that break down bone and there's cells that build up bone. And we can talk about how hormones have an impact on those. But if you think about it in the simplest way, which is your bones are always turning over.

You have a new skeleton every 10 years. The dynamic nature of that, of that organ system is remarkable. And you're right. Nobody talks about it. So I like to look at osteoporosis now as not just a T score, not bone density, or even fracture risk. it's really just an imbalance of bone metabolism over time. Depending on where you start and how fast you break down,

eventually you will develop osteoporosis. It's just a math equation. So the cool thing about looking at it like that, though, is that if you think it's an imbalance of bone metabolism, then all we have to do to improve it to reverse osteoprocess is change the imbalance of bone metabolism, do more buildup, do less breakdown. And there's a ton of tools we can use to do that.

Yeah. And that is so important looking at how these sounds, the osteoclasts, the osteoblasts work, because we've got to look after our bones, our bodies, all our tissues and organs, because we want to keep them healthy. And like you say, the bones are so dynamic. They're repairing their building.

We're getting new cells all the time, new bone, but we want them to be as good as possible. But we also, there's this thing, isn't there, I think, that people think if it's really stiff and hard, then it's very strong. But we want a bit of flexibility in our bones as well, don't we? Yeah, so it's really interesting thing in the space of orthopedics. You know, I think we all think of our structure as this just rigid thing.

But actually bones are pretty flexible. And the way that they are actually, you know, laying down the new bone, laying down the actual like spiculals of bone on the inside, it's all based off of load. Your bones are always responding to your load. And your femur, that big thigh bone, you can actually bend it. If you grab onto each side of it, you can actually bend it and see it flex.

So every time we walk, everything we do, your bones are bending and flexing and they're responding to that stress. And, you know, there's so many factors that we can talk about that affect our bones, but even very basic, lots of people think about calcium and their bones. But vitamin D, the sunlight vitamin, people sort of know it probably has an effect on bones, but it's really important, isn't it? Yes, it's one of the strongest associations. When you look at the literature, it's interesting. We talk a lot about calcium, but it's not, I mean,

calcium deficiency is pretty rare in the Western world. And you see it in children who are malnourished. We don't see this in adults. And in children, it's a different disease, right? Like this is rickets. This is vitamin D deficiency, right? This is bone metabolism dysfunction disorder. In adults, it's not a calcium deficiency for the vast majority of people.

but it can be a vitamin D deficiency. Because without vitamin D, your body can't utilize the minerals. And it's not just calcium either. It's the calcium. It's the magnesium. It's the vitamin K. It's the boron. I mean, it's all of it, right?

Vitamin D is the gateway to a lot of that. So if you're vitamin D deficient, yeah, you're going to have a really hard time building bone. Yeah. And that's really important because, you know, I'm very interested in preventing diseases. I know you are. And I'm very interested in inflammation in the body. And I know you are as well.

And there's a lot of talk about osteoporosis being associated with all these other disorders and diseases. And of course they are, but the root cause is often increased inflammation in the body. But also a lot of the root cause can be vitamin D deficiency. And I was taught many years ago by a hospital doctor, Louise, people with chronic disease, it's an association not a cause. It's like a marker of poor health is low vitamin D. and I'm like, well, hang on, maybe it's more than an association. Maybe there is, it is related. I spoke to my husband recently and I said,

do you ever measure vitamin D levels in hospital? He said, no, because it's always low. What's the point? What? But it's so cheap and it's so easy. Like, we should all be thinking about vitamin D as an anti-inflammatory hormone, really, which is what it is. It's a hormone, yeah, yeah.

Yeah, it's funny. So then did you ask him the follow-up question, which is, well, if you know that it's universal, low, are you universally treating it? Of course I did, and you can guess the answer. Yes, no. But that's because in medicine, you become very rigid in the way you think, because he's not a orthopedic surgeon.

He's not a general physician. He's a, you know, a urologist. So it's like, oh, that's not my area of medicine. Of course it is, Paul. Like, we should be looking very holistically, and it's very easy to do. But as a GP, we weren't allowed to prescribe vitamin D for our patients. and I worked in quite a deprived area, so people would prioritize the food for their kids

rather than vitamin D. And I get that, but I think we should be looking at ways to keeping our bones really healthy. So I did a little research on this recently because I remember back in orthopedic residency, some of my mentors were studying vitamin D deficiency. And it was clear as day.

If you're vitamin D deficient, you're not going to heal your bones very well, if at all. But yet, there's the guidelines, the recommendations, I just read this yesterday, the Indocrine Society here in the U.S. still says the benefit of testing vitamin D does not outweigh the, you know, the financial burden of doing so. It's a $5 test. I mean, it's wild. It seems bad because how much is a hip fracture to be repaired? You know, it's more than $5, isn't it? Yeah. Oh, it's $100,000. You know, and, you mentioned at the start, you know, you're worried about spine more than hip. Having treated both spine and hip fractures,

I know you see it clinically, the burden that comes with spine fractures, that's very real. But if you break a hip, you have a 30% mortality rate in the next 12 months. You have a 60% chance of losing your independence. Oh, that's a big deal. That 10% that's sort of sitting there that I didn't talk about. That 10%'s not the same either. I remember one patient of all the hip fractures that I treated in. We're talking thousands.

One patient that seemed to bounce back. One. Yeah. I said this to someone recently. If I was choosing the different diagnosis, you know, I'd sometimes play in my mind, how would I feel if I had X or Y condition? And if I had breast cancer or if I had osteoporosis

with a hip fracture due to osteoporosis, my prognosis would be worse with the osteopotic hip fracture. But if I said to my friends, oh, I've just been diagnosed, I've just had a hip fracture, oh, what a shame, hope you get better. if I say I've had breast cancer, this is just catastrophic. And I'm not belittling either, but I just think the sort of word on the street is, oh, never mind, it's fixable.

But it affects all our bones in different ways. It loses independence. And like you say, there's a high mortality from an osteopartic hip fracture. Absolutely. So there's not just vitamin D. We've said vitamin D is a hormone, which it is. But there are other hormones in men and women that are really important. for our bones, aren't there?

Absolutely. Yes. Let's get into this. So I'm very interested in the history of medicine and the history of hormones, and I was reading a book recently, and it was describing Professor Albright in 1941, who there's a great picture of this spine that just you can see through it, basically. I'm sure you've seen the same picture. And he wrote about, it was a very eminent doctor, and he wrote about osteoproval.

and estrogen. And they knew that there was an association with menopause or women, not having estrogen, having osteoporosis. And not long after they realized that women who took HRT had stronger bones. And now, H.R.T is licensed as a preventative treatment for osteoporosis, isn't it? Right. Yeah. I mean, this is such an interesting space when you read the literature.

And this is one of the reasons why when I left the conventional model and I started my own practice, very quickly niche down into bone health. And I very quickly started talking a lot about HRT because when you read the literature, what we do in practice does not follow the literature, at least over the last 20 years. And so I hear all these stories because I have a clinical practice. I've got a community, an international community of people improving their bones. And then I have a YouTube channel that is global. We get thousands of comments every month. So I have a pretty good pulse on what's happening in the bone health community. And I heard over and over again out of the gate, you know, my doctor won't prescribe this for me.

I'm worried about my bones. They say we don't use it for bones. But as you said, in Europe, in the UK, in the U.S., it is FDA approved, licensed for use to prevent osteoprocess because we know that it very clearly has a powerful impact not only on slowing down breakdown, which is what people talk about, but also on the buildup side. It's one of the rare things that works on both sides of that equation in a positive way. It is extremely powerful. And if you look at it compared to the bone drugs, the pharmaceuticals, right?

When you compare estrogen to the pharmaceuticals, it is night and day the potential benefit that estrogen, specifically estradiol can have for the bones. And yet, we don't use it for treatment. And most women who go to their doctors and say, I'm interested in this because I have osteoprosis, are told that we don't use it for that. Yeah, and I can't work that out in some ways. because as a GP for many years, I was encouraged to prescribe blood pressure lowering treatment because if we reduce blood pressure, it reduces risk of a heart attack and stroke.

That's great. I was encouraged to prescribe statins if people had a higher risk of developing heart disease. So, but often the cutoff, it varied on the guidelines, but usually if someone's got about a 20% risk of a heart attack, then you look at their blood pressure, you look at their glucose, you look at their cholesterol, you look at their cholesterol. In women, primary prevention with statins is very scanty data because the studies haven't really been done, but we would still do it. So on average, people say one in two women who are menopausea will develop osteoporosis. So that's 50% isn't it? So we've got a drug.

You can see where I'm going here, can you? And it's cheap, but then, like, people have been scared for the wrong reasons. Now, the WHO study that's scared the whole world. world of HRT and still is the Women's Health Initiative study. Actually, one of the good things it showed was that women who took hormones, even when they started them in their 60s, guess what? You know, it showed that they had a lower incidence of osteoporosis, didn't it? Yeah, I mean, it actually showed fracture reduction. I mean, this is actually hard to do in studies because it was large enough. Yes. And they followed them long enough. The oral, you know,

conjugated equine estrogen, perembrane used in the women's health initiative showed a four 31% reduction in risk of hip fracture specifically, which is a big drop. So say that again, 41%. 41%. And this is with Premarin, which is conjugated equine estrogen, which has very little estradial and it is losing market share because it's not a great product. But yet even that not so great form of estrogen had a tremendous impact on hip fracture risk. And that I think is really, really important.

And, you know, a lot of my work is about choice and education. But if I knew there was a medicine I could take that had a 41% risk reduction of a disease, I've got one in two chance of getting and one in three chance of an osteoporotic hip fracture. Like surely as a patient, we don't need to know anything else about hormones. You know? And it's basic physiology because we've already said these hormones work in our bones. We're just replacing them, aren't they? Yeah.

Let me play doubles advocate because this is what the doctors who treat, you know, the fracture liaison doctors and the doctors that you, use the bisphosphonates and the prillia. This is their counter to that. If you look at even like let's call the newest, the newest, the greatest drug for bone health of entity in the U.S. I don't know what it's called in the UK if it's the same. But romosomab is the generic. And this drug is has a, I think it's 70, like a 74% reduction in fracture, right? So you could say, oh, well, it's better. But the thing about the drugs compared to using estrogen specifically is that estradiol, you can continue to take, I mean, potentially indefinitely, we can talk about what

happens if you ever stop it, but potentially for the rest of your life, whereas the drugs that are having an impact on bone metabolism, you can only take evinity for one year. You can take the bisphosphonates for three to five years. And pro lea, we have safety data to 10 years. But even then, those drugs do not work with bone metabolism. They don't work with your dietary changes, your exercise changes, you know, any of the things that you're doing that are good for your bones, they work against it because they're shutting down bone metabolism. Estradial actually enhances bone metabolism. And I think this is really important because I was reading the history of the bisphosphonates and these drugs, because I'm very interested in how do you decide, how do you make these drugs? And they were drain cleaners,

actually, weren't they? And like, I don't know how someone decided. Initially, it was the foam from soap, wasn't it? They realized that and then they made them as drain cleaners and then they converted them into a drug. But it's, they hang around in the bone and the blood, don't they? Even when you've stopped using them. But I was looking at the risks of them because there are risks of medication, especially when it's a synthetic chemical that's not designed for our body. And there is risks of heart failure, those risks of atrial fibrillation, it's irregular heartbreak, there's risks of stroke. but that seems to be ignored. And those risks are greater than any risks of even the synthetic hormones, aren't they?

Right. Yeah. I mean, we always, if we're going to use the benchmark of the WHA, which is, you know, like we could talk about all the negatives of the study, right? But the medical community seemed to accept that an incidence or a risk, an increased risk of eight out of 10,000 patient years seems to be important enough for women, right? So if we're going to use that as the benchmark, then yeah, everything that you just said is wildly higher than that in these studies. And you didn't even mention the two that I really

worry about, which is the atypical femur fractures and the osteoanacrosis of the jaw. Because those are around 1% of users, depending on the study you look at. If you combine it with steroids, like corticosteroids, prednisone, it goes up by 10x. I mean, these are real risks, right? These are absolutely frightening risks. And if you have osteoenacrosis of the jaw and you can't heal, you know, a fracture of your jaw, talk about a life changer, right? You can't eat. So, yeah, I mean, there are real risks to the drugs, but I'm not anti-drug either. There is a time and a place for these drugs, but my perspective is, wow, if we can have a conversation about hormones and about lifestyle and prevent fracture that way, why aren't we

having that conversation? I totally agree. I mean, the drugs in general are quite expensive as well, whereas hormones are cheap. So that, in my mind, as a patient, is good. But the other thing is I often say to patients, I don't know whether you agree, but I hope you do, is that when people are taking HRT to protect their bones and they have a fall, the bones are like a plastic tumbler. They'll probably bounce on the floor and then they'll, you know, shouldn't flatter.

But when they're taking often the bisphosphonates, if they have a fall, it's a bit like a champagne glass. It just shatters because the bone becomes very hard and rigid. And that is a real problem. If you're trying to operate on that broken, stiff bone, I mean, you know more than me. It's a very different, yeah. Yeah, so this is the way I look at bisphosphonase. Because you know, you mentioned that they stick around in the blood and in the bone, and they do.

These drugs go into the bone. They poison osteoclast, the cells that break down bone and they prevent them from working. But they bind to that material. So then in order to get them out, you have to turn over that bone. But I already said this about the anti-resorptive drugs. They shut down bone metabolism. So when we use bone turnover markers to look, you know, how quickly are we breaking down and building up,

they're both very suppressed. You have very little bone turnover. So what happens over time is all of the collagen that was laid down before you started the drug does go through the calcification and mineralization process. It becomes bone. But just like, you know, clearing out an old road before you put in a new road, you have to do the work to clear. That's what the osteoclasts do before you can build. So then you end up just building, building, building, not clearing.

And that becomes a dense, so it looks better on Dexa, a dense but fragile bone. And that's why we see these weird fractures like atypical femur fractures, these other fractures that normally wouldn't happen in places where they wouldn't happen. And then surgically, yeah, this is a big deal because you go in there and it feels like chalk. I mean, literally like just scraping it, drilling in it, it has a totally different feel to it for people that have been on bisphosphonates for too long. And that is a real problem because it's not going to be good when you're thinking about recovery as well. you know if you've fractured your wrist you want to be getting back home if you've fractured your hip you want to be

be able to walk independently and a lot of people men and women it can really be the end of like you say their independence and it will take longer to heal if you have these fractures won't it yeah that's right so when we talk about HRT a lot of people think about estrogen estradiol really important progesterone the natural progesterone. We're very different to the synthetic progesterogen, like modoxy progesterone acetate that was used in the WHOHI study, because progesterone has really positive effects on the bone as well. So we see a lot of women who've had a hysterectomy and their gynecologist say you don't need progesterone because you've had a hysterectomy, you don't have a womb to protect. But I sort of say, well, you've got bones and brain and cardiovascular system.

Yeah, and nerves. Yeah, precisely. So progesterone is important for our. up musculoscretal system, isn't it? Yeah, this is a toughie because I run up against the same wall, right? So many women come in, they've had a hysterectomy for whatever reason, and they're not offered progesterone or any type of progesterone. And I agree, same thing. I'm actually setting up, my small practice was acquired by a bigger practice,

and I'm setting up all these new protocols. We're setting up the women's health protocols. And I just passed by the board. I said, look, we are going to have a discussion and recommend micronized progesterone for all women going on HRT because of the benefits to the brain, to the bones, to the nerves, right, to the arteries, because that literature is pretty clear. Now, unfortunately, progesterone is rarely studied alone, right? It's always the co-captain to estradiol in studies. There are some, but there's not a lot. So I can't say, you know, for a woman, let's say a woman off label using progesterone without estrogen

for bone health, because I see this frequently because I talk about it a lot. I can't say how much that's going to help. I don't know. It's never been studied alone. It makes sense. Physiologically, we know that progesterone or osteoblast, the building cells, have receptors for progesterone. It should have a positive effect. And we see it clinically, but I can't attribute, you know, how much is coming from the progesterone versus anything else that we're doing. So I think progesterone is really important for a lot of things, again, sleep, brain, nerves. But I can't put a number on it. I can't say, oh, yeah, 10% improvement. Yeah. And but we know we've got progesterone.

receptors in the bones and the osteoclast, osteoblast, there's a reason that they're there. So it makes sense, really, doesn't it? But also the other hormone that is often forgotten about, especially in women, but I think also in men, is testosterone. But you don't have an FDA-approved for women, testosterone preparation. But even so, testosterone is branded as a hormone that will help with libido. But yes, it will help with libido for many women, but it really can help with the bone strength. And again, we've known this for a long time. But that data seems to just be ignored

the whole time, doesn't it? Yeah, this has been really frustrating for me because I practice all through telehealth at this point. After I left orthopedics at beginning of the pandemic, we started the practice. We didn't need a brick and mortar location. So we got licensed in all 50 states in the U.S. And then once you do that, like a brick and mortar does you know good. So we've maintained telehealth. the company that bought my company, LifeMD, is all telehealth. But we're restricted in the United States because testosterone is as a controlled substance. So it is controlled just like you would control benzodiazepines, narcotics, you know, all of the things that should be controlled.

Testosterone is the same way. So we can only prescribe in about 30 out of 50 states through telehealth. And even then, we're probably pushing pretty hard. It's really unfortunate because when you look at the data around testosterone and there was a study that was just published last. month. When you look at the data around testosterone, it does so much more than improve sexual function in libido and women. But we run into the same issue because it's only, it's actually not even FDA approved, but it's recommended for use only with the diagnosis of HSDD,

hypoactive sexual desire disorder, right? That's the only thing that doctors are allowed to write down in the chart. If we say we're concerned about your muscle mass, we're concerned about your brain fog, your sleep, your energy, we're concerned about your vitality and we want to consider off-labeled testosterone use, they get crucified. And so it has really put up like a big shadow over testosterone use, but fortunately you've got some big, big voices that are coming out talking about the use of testosterone, what it's good for. I don't know if you listen to the FDA panel in the US, the expert panel. Oh, it was great. Oh my gosh, so many great comments around the use of testosterone and how ridiculous some of these restrictions are. When it comes to bone,

you know, there are studies in men. There's two studies I can talk about in women, but there are studies in men that show that it increases bone mineral density. It doesn't, this is the, again, devil's advocate side is they say, oh, well, the studies didn't show a reduction in fracture risk, but they weren't big enough to show a reduction and fracture risk, right? They weren't big enough studies. And whenever researchers use testosterone in studies, they always use these tiny, like, not,

they're just trying to go take a guy who's hypogonadol, so total testosterone under 300, and then push them up to like, yeah, not like 350, 400, you know, but this is not you go natal. This is not optimized testosterone. So you get these tiny little doses and they say, oh, well, the effect wasn't that great. It's like, well, the testosterone wasn't that great either, you know, so like we're, we're not doing great studies, but even then they do show increased bone mineral density. In women, there's only one study that I've found where they use testosterone, and this was a pellet

study. So it was estradiol pellets and micronized progesterone with and without testosterone. testosterone. The testosterone group had better bone density at the end of the study, but it was small. It was a pellet study. And so, you know, okay, this is helpful, but we need better data. The study that I mentioned that was just published last month was a big retrospective view. So it actually looked at an older population, looked at the rate of fracture and who was on testosterone, which is actually kind of hard to do. It's not a lot of women of that age group are on testosterone. But they were able to show that if you were on testosterone, there was a significant reduction in hip fracture risk. So it's very real. And we have to get around the stigma of testosterone is bad. It's dangerous. It needs to be controlled. No, just like any drug, if it's used appropriately, we can expect it to have the benefit

that it should have, which is improved bone health, reduced fracture risk, improve muscle mass, you know, improve cognitive function, likely, improved vitality overall. We see this in men. Like all of the symptoms of aging get better with testosterone. And it's true in women as well. And then, oh, yeah, also, it might have an impact on your libido and your sexual function. And that's a great side effect, right? But that's not the big picture.

We need to be using it for what it is known for, which is really like the lifeblood of energy, the lifeblood of vitality. Absolutely. And I think also, you know, you're the same as a doctor as me. You often try medication in people and you give them options. And if it doesn't work or doesn't help, then they can have something else. but there's no reason why people can't have H.R.T. testosterone and a bisphosphonate or another bone drug if they need it. So, you know, there's always options for people. And I feel it's sad when people are just given the bone drugs without thinking about hormones. Yeah, I make comment on that real quickly because I hear a lot of doctors who are prescribing the bisphosphonate drugs, again, the fracture liaison clinics, which have value, but they're not hormone experts.

And so I hear this a lot, which is, well, we can't use HRT and bisphosphonates because the HRT will make the bisphosphonates less effective. And I know where they're getting it from. I do. Because if you look at studies where they have combined the two, the bisphosphonate doesn't seem to do as well. But they're taking the data the way that they want to, which is, oh, well, I want to use the drugs so I shouldn't use HRT. But what they're missing is that, no, actually the HRT made the osteoclast function better. therefore they had better bone turnover. Therefore, the bisphosphonate didn't do what you expected it to do

because their bone function is better. And their outcomes ultimately are better too. So yes, you can absolutely use them together. But there are a lot of doctors saying, no, no, no, no, it makes the bisphosphonates less effective. So at the end of the day, it comes down to patient choice as well. But I just sit here feeling really frustrated. I'm really grateful for your time.

But, you know, it's 2025. It was 1941, Professor Albright. talked about hormones. So I'm just keen, I always ask for three take-home tips. I'm just keen for three things, Doug, that you think are going to make a difference for women and men thinking about hormones and bones so that in another 80 years, we're not having this still ridiculous conversation. Yeah, let's not make it to a century from that, right? Let's not make it to 2041 before this is resolved. Yeah, so I'm on a mission to go around the globe talking about bone health in a different way. We need to look at bone health as a biomarker of health span. So I'll try to make this into three

points. So one would be if you are a perimenopause or postmenopausal woman and you are considering some kind of hormone optimization replacement and you don't know what your bone density and quality is, you have to get that information before you have that discussion with your provider because you are missing a massive piece of the puzzle. So I'd say that's number one. one. Number two would be if you are, oh, let's do this one for number two. So we need to image our bones. Dexa is available. It's around. There are other new devices that you can measure with as well. There's an ultrasound device called REMs that measures both density and quality. I would actually encourage you to get both. So what I would say here for number two is get all the data that you

need. Get both at Dexa, get our REMs. This is more available in the UK than it is in the US. But get both so that you can have as much information about your bones and then follow it over time. If you're losing bone, something's wrong. And that's what I mean by saying bone health is a biomarker of health span. If you're losing bone, something's off. I can't tell you what it is. Could be hormones. Could be diet.

Could be a lot of things. But if you're losing bones, something's wrong. So that's number two. And then number three is don't lose sight of this. If you're measuring, if you're imaging, if you're optimizing, you can use these things called bone turnover markers, which I know are available in the UK. but not broadly. P1 and P and CTX are out there.

Those are the bone turnover markers that we can use to understand what's happening with bone metabolism as we're doing the things in between our imaging modalities which are going to be every six months for REMs, every 12 months for DEXA. We can use the bone turnover markers in between

to make sure we're headed in the right direction. So lots to think about that the most important thing is getting the message out that hormones have a role on bones. So thank you so much for your time, Doug. It's been great. Yeah, thank you, Louis.

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