Bone health starts now

Bones don’t complain until they break—so we went straight to the source to decode how to measure, protect, and strengthen them before trouble starts. Dr. Thacker sits down with Dr. Kristi Tough-DeSapri, a leading women’s bone health specialist, to break down what DEXA really tells us, how trabecular bone score adds vital nuance about bone quality, and where newer ultrasound-based REMS fits when access is limited.

Strong bones start with fundamentals—calcium, vitamin D, protein, resistance and impact training, and fall prevention—but often need targeted therapy to truly cut fracture risk. We cover where hormone therapy can help near menopause, how SERMs and antiresorptives reduce fractures, and when bone-building agents are warranted.

Transcript

Why Midlife Bone Health Matters

SPEAKER_01 0:06

Welcome to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Packer, and I am back in the Sunflower House for a new edition of this podcast with one of our favorite guests, Dr. Christy Tuff DeSapri. And this is her third appearance. And today we're going to dive into a really important topic, one that I've gotten a lot of questions on, and my nurses have. And our lead nurse said, you have to have Dr. Tuff DeSapri back on the podcast and ask her about traditional bone density scans, some of the newer technology called REMS or radio frequency echographic multi-spectrometry. Dr. Tuff DeSapri, as many of you know, uh, is an expert in bone health and women's health. And today she's going to help us understand when and why these tests matter and how they impact your care or the care of a loved one. And as I mentioned, this is her third time on our podcast. We're in season four. Um joining me, she's joined us in season one and two. And uh all of May is osteoporosis awareness month, but we really focus on women's bone health year-round. But before we dive into the interview, I want to share a little bit about Dr. Tuft DeSapri. She is the founder of Bone and Body Women's Health in Chicago, Illinois. She graduated cum laud from Tufts University. She attended medical school at the University of Health Science Center in San Antonio, Texas. She then completed some training and internship in OBGYN at NYU and a residency at Lennox Hill Hospital. And she is board certified in internal medicine. She is a super achiever, one of my top fellows. I've run this fellowship for now 29 years. And she completed her fellowship in specialized women's health at our Center for Specialized Women's Health at Cleveland Clinic. And it feels like it was just yesterday, but I guess you started about what, 16 years ago was when my oldest son, Stenson, who's now a PhD, he was a senior in high school. And he was in the office when I was talking with you about starting the fellowship and some things, and he thought I was exceedingly hard on you. He's like, I can't believe, mother, you were that hard on that nice doctor. And I said, Well, she's so super smart, and I know she's gonna have an incredible career. And so I want her to do the best that she can. And you have certainly done that. And you're the married and the mother of three sons. And we were talking before we started podcasting that doing women's health all day long, it's kind of nice to have a little difference when raising your family, dealing with boys.

SPEAKER_00 3:12

Yes, it is. It's a nice, it's a nice yin and yang.

SPEAKER_01 3:15

So welcome to our podcast again, uh, Dr. DeSapri. And um, you want to just tell us a little bit about bone densitometry? I know you do that in your practice, and you're an expert, you're ISCD certified. Uh, why should women at midlife think about getting a bone density?

SPEAKER_00 3:35

Great. Well, thank you. Thank you for that introduction. I feel like you um give back so much to our community in this podcast and all of the education that we had as fellows. I cannot believe you have been doing the fellowship for that long. And we were just saying how there's many of us, you know, women I would say doing, you know, boots on the ground, really great work and research and clinical care and um for you know all midlife women. So I I thank you. You are inspiration to me daily. If you email or text Dr. Thacker, she will get back to you in a minute because she is so dedicated to all of us as well. So we are um so thankful for you. So um, you know, to answer your question about bone density, I think this is such a you know a great topic. Obviously, my practice is bone and body women's health, and used to get questions like, why bone? And now I don't get those questions anymore because people know that menopause is a revolution, and menopause is more than just loss of our sex hormones from our ovaries and changes like hot flashes and vaginal dryness, those are the outward symptoms that we can see in signs, but then there's so many changes at menopause. So bone health being one of them. So when you ask me why do we need to get a bone density or care about our fracture risk, um, it's because so many women this changes a lot during the menopause transition. And then in the postmenopause years, right? We're gonna live in menopause. A lot of women will live a third or close to a half of their lives in the post-menopausal years, and our bones need to carry us through that time, right? Our bones and our muscles, so our skeleton. Um, and then we know that the conditions of osteoporosis or weakening of the bones can lead to fractures, and that's where that impact happens. So, you know, we've always, you know, from the fellowship and from learning about menopause in midlife back before it was cool. Um I always say, back before I was reading the menopause journal on airplanes, and I used to hide it behind something else because um people would look at me strange with menopause. Now I, you know, we're we're singing menopause from the hills, but we've known that you know, all of these changes, whether we can see or feel them, will impact our life at menopause and beyond. And and I think that when I look at my practice and I look at the patients we used to see at the at the Cleveland Clinic, you know, I have women as young as 37 in their 30s and actually even 20s, if I included the athletes that I see, you know, who have low bone mass or fractures, and as old as you know, 98 to 100, where we're trying to prevent them from having a fracture and keep them living independently. So this is a huge age range. So it really impacts all women, not just at menopause before, after, and then uh and during.

SPEAKER_01 6:11

Yes, I you know, I was seeing two patients today. One was a lady who had a sacral fracture just sitting, no trauma, just sitting, and in incredible pain. And another lady who hasn't fractured yet, but has severe osteoporosis and is too fearful of side effects of treatment. Um, and so it is really a serious condition that doesn't get enough attention. And like now, menopause is so hot and everybody's talking about it, and people are even blaming things that aren't hormonal on perimenopause and menopause. I I hope we get to that point with bone health that people really start thinking about their bone health and being proactive and not waiting until they have that painful fracture. So you were a really early adopter of trabecular bone scoring, and I was the first at the clinic to do TBS. Now, all everybody else, all the other machines, the radiology department and endocrine and rheumatology have kind of caught up. So it was nice to do that positive uh peer pressure, but I found it exceedingly, exceedingly helpful. And I don't know if you want to talk a little bit about that.

DEXA Basics And What It Measures

SPEAKER_00 7:21

I think just like you know, we were gonna chat about imaging first, and obviously the importance of osteoporosis is you know can't be underscored, but you're you're right, like the imaging that we have for bone density, I think that's one of the reasons why it's not as popular. You know, we everyone talks about mammograms and getting their breast ultrasounds and MRIs. And in the you know, in the bone density world, how we diagnose or how we you know do a risk assessment for bone health is really you know either a screening bone mineral density, which is like essentially like a glorified x-ray of looking at your spine and your hips and sometimes your forearm. And it tells us again, it estimates it's about a you know 60% of our bone mineral density estimates our bone strength. And so it's one of the best variables. And of course, we ask you all those questions about falls and fractures and dizziness in your medical history before, because that also helps us determine you know what what else is going on that might impact your bone density or your fracture risk. But that is good, but maybe we need other you know techniques, just like a mammogram, we add on an ultrasound. So the other techniques that can help us assess bone strength, you know, with maybe more uh certainty or um you know, sort of more diagnostics, or could be something like a trabecular bone score, which is essentially looking at um, you know, it's a 2D grayscale image of the spine, um, and it helps us evaluate you know, not just the the number the bones that are there, but maybe how the quality of the bones with mic with a microarchitecture, sort of that intangible quality of the bone might be. And it's helpful in women who have scoliosis and who have arthritis because a lot of that that density can be um impacted or can be skewed when we look at a bone density. So this can sort of help that, you know, our determination of your bone density a little bit better if you have those conditions, and also underlying conditions like autoimmune conditions or diabetes or rheumatologic conditions, also. So it it can be very um in addition, you know, helpful to kind of give us an overall picture, um, just like other technologies, and and this is where again you mentioned the radiographic, you know, echographic multi-spectrometry. I always need to like re-revisit what they why why they can't make that easier, but it's called REMS technology, which is essentially just an ultrasound way of looking at your bones instead of an X-ray that is uh with the DEXA scan, essentially. So it's just a different technology. You know, it's also helpful. The issue is it's still not you know validated as a scientific way to check the bone mineral density. The gold standard is still a DEXA, which is still very easy to obtain and very low amount of radiation. Um, but again, there's other techniques that are out there that are growing in interest, potentially due to just being able to be more available, uh, maybe more affordable, um, and also you know, hit a population that you know of women who we're missing. So it's interesting technology. I think we always need to be open to things, but also check them, you know, against our gold standards and our scientifically validated ways that we assess bone density.

TBS And Bone Quality Explained

SPEAKER_01 10:30

I think that's very important. And you know, you talked about mammogram and all the different uh breast imaging that we have. I really think that in terms of bone health and postmenopausal women, that bone densitometry is a lot more precise and accurate, and much less prone to over-diagnosis, which mammography can be, um, and underdiagnosis, especially with doing the clinical risk assessment and now being able to actually look at the bone microarchitecture for structure. Um, now a lot of women are concerned about radiation, that's why there's a lot of women, uh, especially in the age of three-dimensional tomo mammography, which is more radiation, very concerned about um having bone densitometry. So, do you want to address that fear?

SPEAKER_00 11:21

Yeah, for sure. I mean, I think we all need to be stewards of our own health. And I and I know that there are, you know, we're just coming into you know flu, cold and flu season, so people might be getting an X-ray. So if we put that into you know context, you know, the uh radiation in a DEXA is about one one hundredth of an X-ray. So it's a really low amount of radiation. Um, you know, if we look at like the you know, technical, it's you know, 0.1 micro sieverts. So it's really um really low. Um, a dentist I go to has a great like um chart in her office about x-rays, and she has like you know, what eating a banana is the radiation, which is essentially just living, you know, during a day. We get exposed to some radiation, talk about our phones and our devices and all of those things. So it's a very low amount of radiation. And if we think about a screening bone density that's essentially, you know, the ideally, you know, done, you know, around the menopause transition. So for some women that might be in their 40s, for some women that might be around their you know mid to 50s when we know that 95% of women are through the menopause transition between 45 and 55. So again, during that time we should be doing a screening bone mineral density. And if it's normal, great. You know, most people say we don't need to repeat that for a couple years. Maybe that's an interval of three to five years. If there's some changes that we need to alert ourselves and make a, you know, sort of I call that osteopenia or low-bone Netsia stop and think diagnosis and intervene, then we might want to recheck that in a couple years, the same way we would if there would be an abnormal PEP smear finding or something on a mammogram. So again, women's health, where we need to, you know, think of it beyond just like bikini medicine that we're checking our cervix and our, you know, our mammograms, but we're also including this other screening that's just as actually as equally important, especially when we get in the post-menopause years where you know women are living longer.

Radiation Concerns Put In Context

SPEAKER_01 13:12

So uh one of the issues that I've I've dealt with with trabecular bone scoring is it's not completely validated in all groups in terms of like long-term outcomes and knowing fracture risk, but ISCD wants us to evaluate um and and use it basically in virtually all patients, um, although there are uh body mass index uh limits to that. Do you have any idea when we're gonna get that skin thickness correction? Because certainly if someone is very heavy just centrally, that kind of degrades the ability to take a look at the microarchitecture.

When To Scan And How Often

SPEAKER_00 13:49

Yeah, so um, you know, just having my own machine and like you said, being ISCD certified, which is again just, you know, as we talk, doctors speak, I think it's just helpful for people, you know, listening. And you know, anytime you get a scan, uh either a mammogram, a DEXA, whatever, you know, obviously you want the person who's doing that or reading that to like understand what they're looking at. And and it sounds silly, but you know, some of the radiologists and some people just kind of, you know, they they just do this, but they're not really trained in understanding like how do we make sure we're looking at the spine correctly, or removing vertebrae, or understanding if you're on treatment, what sort of scores we need to give, or your age, or where you are in the time of menopause. So um, I just sort of go back to making sure that, like, yes, you're getting a scan done in a place that's reputable, asking them about their certifications, getting that report, asking the doctor who's looking at it if you really are seeing someone for bone health, that they're not just looking at a report, they're looking at the images. I'm such a stickler on that. Ask my staff or chasing down images and pictures and DEXs, and I thankfully I have my own DEX and picture because you know, I when I sit down to read that, I am taking the whole story in, both the clinical story and the radiographic story. So it's really important so we get good information in equals good information out. And so when you mention like the trabecular bone score, that can BMI ethnicity, there's some variable, um, and even you know, uh this is validated to help us predict fracture risk. So for some of those, you know, variables, ethnicity or BMI, those might, it might be harder to read this exam with those people, or we haven't had the science to show us the direct correlation between low trabecular bone score and quote unquote fracture risk. And I do think that they have now changed. There is a skin tissue thickness um upgrade on the on the DEXAs that can be done, just like any technology that could be updated through time. Um, the biggest issue, and again, this is more technical than maybe our audience, is that it doesn't the prior tubecular bone score cannot just be transposed or transfixed onto the new uh software. So you essentially get a new number. You get a new number. Yeah, that's a very good point.

SPEAKER_01 16:06

And also having w women who maybe this isn't their area, this isn't their field, they're not technically necessarily oriented about about bone imaging. But if you have the ability to go to a place that just focuses on bone densitometry, as opposed to a place that maybe the technologist and the person reading is a jack of all trades. You know, they're doing ultrasounds, CAT scans, you know, MRIs, plain films, um, and the and the technologist isn't ICD, uh ICD certified. Because when you're comparing, it is very important to uh have that precision and know what your error rate is because that can make big differences in treatment. Like I'm confident when I see a patient back to say you're the same, you're better, or your test is worse, and this implies, you know, a higher risk, meaning we might need to escalate therapy.

Precision, Certification, And Comparing Scans

SPEAKER_00 17:00

Absolutely. I mean, and I think this is where you know bone density, it is it is specific, right? So it's not just a like, oh, what's your T-score? I think people are like, you know, sometimes, you know, well, I'll see a woman and she'll say, Oh, great, my T-score is minus 2.3. Phew! I have osteopenia, not osteoporosis. And I say, Well, that you're right, you know, and and I that's great. We don't see you know severe bone loss, which is osteoporosis, which is, you know, again, the definition of micro architecture and density changes that predispose you to a fracture. But actually, you know, more women have osteopenia. We think in the United States, about 34 million women have osteopenia. That number is probably larger. And more women with osteopenia or low bone mass is really the correct term, have fractures because there's just more of them. So you can still have a fracture or a clinical fracture, like a wrist fracture or a hip fracture, a vertebral fracture, a forearm, a pelvis, sacral fracture, as you mentioned, your patient, if you have low bone mass. Because bone density is one variable in our whole you know fracture risk uh discussion. So if someone has osteopenia, they're still at higher risk for fracture. And guess what? They're only maybe three, five, three percent sometimes away from having actually osteoporosis and a BMD change. And we know that menopause, let's say, if someone comes to menopause with a bone density of that's already in osteopenia and they will lose anywhere from in their spine on average, you know, seven to ten percent, if that's based on the our data that we know from the SWAN study, a study of women across nations that looks at women who go from perimenopause to menopause, that is that's an extreme amount of bone loss, and it can be even higher in the spine than the hip. So actually, if we're starting at minus 2.3 and we think you're gonna lose that three to anywhere from three to ten percent of bone loss, you will end up with osteoporosis if we don't do something. So very important when we rescan or when we scan that we're doing that either on the same machine or reliable machines that can be, you know, what we call cross-calibrated or uh looked across time. So again, I think you it's where we are starting from and where we're ending. And you're absolutely right. It's the the devil is really in the details, is what I say with the DEXA.

SPEAKER_01 19:11

Quite a bit. And also how long you live, like the the lady I was uh talking to today who didn't want treatment and was worried about some rare possible side effect with osteonecrosis of the jaw, which we don't even know if that's even a legitimate risk in the average risk post-menopausal woman without cancer or radiation. I said, well, if we have some big natural disaster and we both die in the next year, then you probably were fine and didn't need your bones treated. And and I sometimes make a dramatic description like that because I'm trying to point out when we're seeing you today, we're not just thinking about your immediate risk for fracture in the next couple of days or a year or so. We're talking about assuming we can expand your lifespan and your health span so much that you're enjoying yourself and you want to be independent and functional and um not having major orthopedic surgery or in some rehab or nursing home because you've outlived your skeleton.

Osteopenia Risk And Menopause Bone Loss

SPEAKER_00 20:11

Yeah. And I think you're right. And that's what I think is so important, right? For what you've taught us at our fellowship and also just, you know, women learning or listening, even clinicians that are learning and listening is that women's health really is something there. I think it's different than like endocrinology or rheumatology or other subspecialties, we really have to look at women across the decades, right? So, you know, I saw a woman as young as 22 today, who's a patient of a, you know, daughter of a patient who um I see was pe polycystic ovaries, and then I saw, you know, women in their 40s and women in their 60s, and you know, women in their 70s, and every decade is different, right? And so you're right, like there are if someone who has osteoporosis and they're 50 and they're on their first EXA, actually to me that is more sometimes concerning than someone who has a T-score of minus 2.5 and they're 75 and haven't had a fracture because they're being treated that woman who's 75 might be being treated or knows she has osteoporosis at 50, you're coming to menopause with low bone density. If we do nothing and you live long enough, you we can promise you you will have osteoporosis and most likely a fracture because one in two or 50% of women have an osteoporosis-related fracture. So I think again, it's decades of life. Where are you at your T-score? How is that changing? Um, you know, we know that there's some age-related bone loss in addition to the menopause transition. So, again, we're so clinical, and I, you know, saw a woman the other day who'd see me in 2022. I moved my practice, she you know, sort of has moved and then found my practice again, and we did repetit repeated her DEXA from you know four years ago, and she had had you know six percent of bone loss in her spine and two to three percent in her hip. And she's in the postmenopause, but that's because she's had just some age related loss. She wasn't on her calcium, she actually someone she didn't continue her. The hormone therapy because someone told her to stop despite that was helping her gender urinary syndrome of menopause and helping her bones. So guess what? We re-evaluated her, and she is a good candidate to continue hormones and resume hormone therapy. So we are going to do that for her. And she's 61, right? That's again, everyone's an individual, but this is an example of what happens. We see time and time again when women again just get treated for menopause and not think about their bone density long term.

SPEAKER_01 22:30

And you have been listening to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Thacker and the Sunflower House, with a recurrent and favorite guest, Dr. Christy Tuff DeSapri, an osteoporosis and women's health expert. And we are talking about bone imaging and osteoporosis and uh the whole clinical and aging uh perspective to improve people's health span. Can you tell us, uh, Dr. DeSapri, when might a woman prefer a REMS test compared to a traditional bone density uh DEXA test?

SPEAKER_00 23:08

Sure. So you know, we kind of define both of them, and and essentially, you know, they are similar in what we're trying to look at, the bone mineral density, but just by a different technology, an ultrasound technology for the REMs and a sort of an X-ray type technology for the DEXA. So I'm, you know, again, I'm I'm spoiled slash like have preferentially chosen to have a bone mineral density or DEXA scan in my office because it's the gold standard.

SPEAKER_01 23:33

Yes.

Lifespan, Health Span, And Treating Early

SPEAKER_00 23:33

Someone who might, you know, but I do know that patients come to me with their REMs testing and they've had that done at potentially like a health center or a health clinic or a gym or a uh you know integrative medicine office that is caring, thankfully, about women's bone density. So I'm happy that they've done that test. Um, and so a lot of women who might be, you know, again, pregnant and have low bone density, we do know there's a small subset of women with pregnancy and lactation-induced osteoporosis, someone who um has maybe a significant amount of degenerative spine changes, things like that. Again, this could be is discussed more maybe in like a rural setting or a setting where there's less tertiary care. You know, I was I'm here in the North Shore of Chicago, so we have plenty of that, but I know that when I go do my lectures in Indiana and in other places, Iowa and Wisconsin and Michigan, sometimes around here, there are less, there's less access, you know, to just you know, to imaging and and physicians and clinicians in general. Um so those are really the the areas that I see. And I I think again, there's there are some studies, and we we both have read them about, you know, validation of how how much you know you know how you know how much uh sim similar overlap there is between DEXA and REMs. And some studies say yes and some studies say no. I think it is very much dependent on you know the operator or the you know radiologist or the clin the person who's doing the scan to make sure that they're scanning the right area, they're doing it correctly, they're obtaining the right information. Um and again, the REMs I think tends to say that you know there's a sort of a fracture score. And if women are on the younger side, again, closer to the menopause transition, the fracture or the fragility rate is going to be lower. And naturally we know that because the balance and posture and fall risk is much lower generally when we're you know in our you know less than 65 or less than 70. And a lot of you know, men and women we look over all the the data over time. But it still doesn't mean that the bone that your risk of osteoporosis for lifetime or your chance of developing a fracture later in life is not high. It just says that your risk of fracture right now is low. And so that is one thing that when I look at the reports and I compare when I've done a DEXA and someone brings me a REMS, the difference, you know, in terms of, and that's probably what you see, but I'd be curious.

SPEAKER_01 25:55

Uh yes, and um I I just see that in this field that we in women we really do have a lot of good research, we really do have so many options, non-hormonal, hormonal. Um, there's lots of choices, and we can really individualize it. It just seems like there's this intrinsic um gut reaction that women don't uh want the imaging or they don't want to pay attention to it if it's particularly bad, or they don't want to take therapy, or they just say, I'll just go exercise, and and they're always looking for something else than maybe what we know works and can evaluate and and treat women and really reduce a lot of problems. Uh, you know, a lot of women are coming to me and they're saying, Oh, what about that prune study? I can just eat prunes instead of taking my osteoporosis medicine. Um and there's just a lot of um looking into other things, which I'm all about being holistic and boosting the vitamin D3 and K2, making sure there's not other secondary causes. Like I pick up so many secondary causes from low vitamin D to celiac to um uh hypercalciuria, you know, from a genetic um leak in the kidneys. So there's a lot of things that we can do besides standard hormone therapy and osteoporosis medicines. But I just wish that that the general public and women in general had a little bit more urgency because if they haven't seen women through the lifestyle or they're still looking at themselves through the lens of being a healthy 20 or 30-year-old, and they thought that their mother's hip fracture was, oh, just because mother was old, or because father was climbing up on a ladder and he fell. Um, that there just still seems to be so much poo-pooing of the seriousness and the fact that we can get ahead of this, we can prevent, we can treat. We've got so many excellent options. Right. Um, and I I just wonder, is that your experience?

REMS Vs DEXA: Access And Limits

Underestimation Of Risk And Long View

SPEAKER_00 28:00

Yeah, I think you're I mean, I think the the issue with the the the REMs, particularly when we look at the DEXA, is that right, it it does tend to sometimes underestimate like the fracture risk or the again the definitions are like you're of a lower fracture, or you're you you know your your fragility score is low. But for for many women, particularly again, I'm seeing primarily women 40 to 60 getting these tests who do haven't had a who haven't had established osteoporosis or who are you know just trying to understand or do a comparison, again, that underestimates your fracture risk for lifetime. Sure, you might be low risk now, but today today, but and that's where like again, how can we, you know, how can we quantify some of this? So this is where we, you know, using like a T-score diagnosis, which means again, you're you're if you're osteoporosis, your two and a half, you know, T-scores or your two and a half standard deviations from a normal strong bone density, which of course there's some age-related losses. Remember, there's some genetics that determine our peak bone mass. And so some of that we can't, you know, we can't handle, but we can we know that those are regardless of those, those are risk factors for fractures and for future osteoporosis. So sure, we can blame our parents and our genetics all we want, but like you said, it still might catch up with us, and then what, right? And I I think we hear that a lot more in cardiac testing now that we're checking LP lilae and apOB and doing advanced lipid screening where people say, I eat a Mediterranean diet, yet I still have an LP lelae of 300. Well, that's there's only so much salmon and omega-3s that are gonna change that, you know. So and but oral hormones do reduce LP lele by 20 20 percent, and we finally have some cardiologists, you know, talking about that. Yeah, so so again, and so it's putting what we have in front of us and then making some decisions, and that's where like the fracture risk assessment or the fract score can come in. So it tells us what is your percent, you know, over the next 10 years that you will have a major osteoporosis-related fracture or a hip fracture. But again, women in their 50s and maybe even 60s might that may be low. But again, if you add 10 more years, we know that that then will double. And so that risk is actually when we think about the risk of a hip fracture or a major osteoporosis-related fracture that's over 10%, that's actually equal to the risk of getting breast cancer through the lifetime, which is a 12% risk if women again live until 90 to get developed breast cancer. And if your risk of a hip fract or a major osteoporosis-related fracture is over 10%, we recommend to treat you because we can actually lower that risk. And oftentimes by 50% or more, regardless of the treatment we use, hormones, bisphosphonates, and then if you're very high risk, of course, we're using the bone-building agents and talking to you more in depth about those. But so that's what I mean. We we we have to look at the numbers and the percent of that you have for your risk, and then say, well, we can actually have that, you know, or we can significantly reduce that. I I kind of kind of call it a lot of like bone health insurance of what we do, right? We're ensuring you're getting, you know, your vitamin D and your calcium so that we can mineralize and strengthen your bones, so that you know the medicines that we use work, or the the jumping and the resistance training you're doing are adding on to those things, right? And I'm sure you use a lot of those same analogies because I don't think it's just medicine, and that's I don't think it's just the exercising more. We know that, right? We know those things don't work in silo well. Absolutely.

SPEAKER_01 31:27

And you mentioned breast health, and that's one advantage about seeing an osteoporosis and women's health expert like yourself, and like many um physicians I've trained over the years, and as well as uh many of our APPs that are interested in the field, is that we have bone agents that also can reduce breast cancer risk, like hysterectomized women on oral conjugated estrogens have reduced risk of breast cancer. Women without hot flashes who don't want hormones. We have relaxifin, uhsta, which has been shown to reduce estrogen-positive breast cancer. Um, and so we can really kind of tweak that and look at the woman's stage in hormonal life. And it's not that we want to over-treat women, that one of the big benefits is that I've always seen very healthy, very thin, petite women who've never broken a bone, who have great dentition, a nice straight back, but they had osteoporosis based on their two standard deviations below the average 30-year-old woman. And when you get that normal trabecular bone score, um, which I think gives us so much more information and power uh than maybe just looking at an ultrasound, you know, test, then when you have normal bone markers and maybe the woman's on hormone therapy for longevity and anti-aging and plus minus menopausal symptoms, you can be confident that you don't have to jump to another therapy, another traditional therapy.

Treatment Options And Individualization

SPEAKER_00 32:56

Yes. Yeah, exactly. I mean, again, it comes down to like what you're saying, individualizing and also just looking at the woman's age and stage, right? Of like where where we're at. And but you know, and I and you and I have both seen that woman you just described, but then also that woman you've just described who maybe is in their 50s and has had a fracture or is higher risk. And you know, I saw a woman today with a minus 4.1 P score in her spine who, you know, is in her 50s. Of course, you mentioned it quickly, but it is so important that we do, you know, look for other causes. You know, the the statistics are pretty high. I mean, they say 30% of women with osteoporosis might have a an underlying condition. I think that is higher than I usually see, but it always is important to, you know, rule out malabsorption and like you're saying, the 24 iron calcium. I see a lot of people sometimes just uh have a great case. I mean, unfortunate case, but thankfully she found her way to us, is that she had osteoporosis and she went to you know a spspecialist and they just said, Yep, you know, thin Caucasian female, we're just gonna give you a laundronate. And yet she had high calcium on her blood testing, and they said, Stop your calcium supplements. And she said, I'm not taking any calcium supplements. And then they called her back and they said, We're check it. And they said, Stop your calcium, and she said, I'm not taking any calcium. And thankfully she had the no wherewithal to say, This is probably not someone who's listening. And right, you know, turns out she, of course, has you know hyper hyper parathyroidism and a large thyroid adenoma, high calcium in her urine, and other symptoms. So this isn't just garden variety osteoporosis, right? This is something else. We're gonna take that paratyroid hormone, that parathyroid gland out, and we're also gonna treat her osteoporosis. So um, you know, again, important to always be looking for those, you know, secondary causes and you know, again, evaluating. And if someone is high risk, right? We my point was that we use hormones, but sometimes we also you need to use hormones and something else. So sometimes we need to also augment the therapy and give a bone-building agent or something in addition, so that we're not just saying, well, let's cross our fingers and hope the hormones are doing it. We'll maybe need to think about something else in addition. So I think that's where, you know, again, medicine isn't like longevity medicine and women's health medicine. We're we're we're working together, you know, we're thinking about the long game as well.

SPEAKER_01 35:20

Well, as we wrap up this terrific interview, tell us a little bit about your practice and how listeners can learn more about you and maybe potentially um see you in your practice.

Secondary Causes And Smarter Workups

SPEAKER_00 35:30

Yeah. So I I always say that I started my practice and I try and, you know, really um have how can I say, sort of fashioned it after like the care that we used to give at the Cleveland Clinic because I I do feel that, you know, this day and age we all know how medicine is fragmented and women's health is sometimes rushed. And you know, we are complex, we were saying we are complex beings. So, you know, especially at menopause, all the factors that come in from head to toe are hot flashes, our brain fog, cardiac health, breast health, GYN, urogynecology, muscoskeletal syndrome of menopause, osteoporosis, libido, sexual health, so many things that we address. So I I am very lucky and honored that I get to spend a lot of time with patients to talk about these things and then see them back. So I have a direct care practice in on the North Shore of Chicago. So most of my patients see me in person, but we obviously have a ton of snowbirds. So I think today I saw two people from Arizona who were um here after the holidays. So um that is our practice. I have lucky I have a DEXA scanner in my practice, and we do you know routine gynecologic care. I do a lot of coordination of care with subspecialists if it's something we like urogynecology or women's psychiatry, where I feel like you know what, someone could also help us in this way and make our, you know, your health better. So that has been a really fun part of what I've done and learned a lot from those subspecialists. Um, and then I do see some patients virtually mostly just obviously for bone health or try and connect them with someone. We have a great network of women's health providers across the country, so um try and connect them there. But I do see women with maybe more complicated osteoporosis who want to see me, you know, virtually um send me their DEXA images and really get into it, or if they need a second or third opinion there.

SPEAKER_01 37:14

And tell us what's your uh social media and your website. I know you've got a great Instagram.

SPEAKER_00 37:19

I do. I was one of my New Year's resolutions to work on that a little bit more. I love the science and writing and things like that. So I'm working on that, but um it's so important. Um, so I do some Instagram on just my boneembody WH, and um I have my website which is boneembodywh.com, and we have a newsletter there. I pour some information into, so that's really where I um you know get the writing and um and just be able to share you know some updates in women's health and and uh translate the science.

SPEAKER_01 37:50

Well, that is terrific. Thank you so much, uh Dr. DeSapri for joining us and giving us the insights on bone density. And thanks to our listeners. Uh, if you haven't already, please share the podcast with friends and family and encourage them to subscribe or follow. And if you enjoyed this podcast, give us a five star rating. We'll be back with another episode. Until then, remember to be strong, be healthy, and be in charge.