Connection Between the Sex Hormones and Bone Density

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Good night.

Today's episode is everything.

It is a great review, but don't go away if you think, well, I know so much about osteopenia, osteoporosis, and bone health. Don't leave yet because this is not just a basic review. You can think of it as a refresher course, or you can think of it as your introduction if you're new to being 50, if you're not quite sure You can make the connection between your sex hormones and your bone density. Consider this a perfect episode to share with your younger friends and daughters so that they become aware of the early, the more than seen and felt symptoms of perimenopause that are going on under the hood. You don't see it. It is one of those silent diseases. We're in a moment in time where women aren't made aware of the options available to them and why you might want to choose them, all the pros and cons of using or not using these options. The more we know, the more we can make our own informed decisions. It's no secret that bone density declines dramatically at menopause, and postmenopausal women are at greater risk of fractures. But do you know the importance of estrogen and testosterone and progesterone in your health? Stay tuned to review the relationship between those sex hormones and your bone density. My guest and I, I'm going to call him a co-host almost because he did such an amazing job with this topic. Our two goals for this episode is that you, listener, could describe the role of your sex hormones in bone health and that we decrease your fear around osteoporosis and osteopenia. And we get to that almost right away. Here we go.

My guest is Dr. Doug Lucas.

He's a double board certified physician specializing in osteoporosis reversal, hormone replacement, and in healthspan. After completing his training at Stanford University and practicing for nearly a decade in the field of orthopedic surgery, Dr. Doug left his practice to pursue an additional fellowship and board certification in anti-aging and regenerative medicine. He went on to achieve the status of fellow in anti-aging and metabolic medicine. This functional and hormone training gave him the breadth and the depth of knowledge to support his deeply held philosophy that patient care and start optimal human health. MD, he is nationwide telehealth practice. So listen, that means just wherever you are, stay tuned, pay attention, you have access to great health no matter where you are. Dr. Doug has gone on to build a team of experts, each with unique skill set to help optimize his patients' health and help them live better, longer. The OHH team now focuses exclusively on bone health through the lens of optimization, with a dual mission to educate the world that osteoporosis is reversible and to provide an unparalleled patient experience. Dr. Doug spends much of his professional time exploring, researching, and uncovering truths behind controversies in bone health. His mission to educate the world plays out on his YouTube channel, The Dr. Doug Show, Bones, Hormones, and Healthspan, within his membership community, Healthspan Nation, and on stages across the globe. His patients experience the direct benefit of his efforts and his dissemination of groundbreaking and paradigm-shifting research.

To his team.

Dr. Doug also enjoys helping physicians find their own path to escape the traditional medical model and serve their patients in unique—

I'm Debra Atkinson. You're listening to Flipping 50. I started this podcast over a decade ago to answer questions about fitness in menopause and beyond before you knew to ask them. The goal to help accelerate your results with science and the practical application of proven protocols while living your best life. There's no more powerful health influencer in the world than a midlife woman. And it's not just about you, but the 3 generations that you influence. My unique 40-year career, including being a university senior lecturer in kinesiology, an industry subject matter expert, and an international speaker, to founder of the first and the only exclusively made-for-menopause and beyond fitness membership in the world. Every week I interview experts behind the scenes and the science of optimal hormone balancing, fitness, and longevity, and share answers to our community's questions so you can have the vitality and the energy that you want, need, and deserve.

Dr. Doug Lucas, thank you for joining us.

Thank you for having me, Debra.

Well, and we should just give a shout out and a nod to your lovely wife. It's, you know, it's a little unusual, but, you know, the amount of talent in one household over there is pretty great.

So thank you. I'm very lucky to share this household with her, so I appreciate that.

Well, this is a topic we need to revisit again and again and again, and I think really for good reasons right now, because we're kind of in an era where it's changed so much since, you know, 1995 when I first started talking about it, educating people about it. I had to describe what osteoporosis was. What is osteopenia? Define it. I remember drawing pictures on the board like, this is not having it, this is having it, and using the imagery of Swiss cheese and pancakes to kind of get the message across. So We've come so far that it's a household word. They're both household terms. And, you know, yet there's some things and connections that we probably don't quite understand as well. And what I'd love, my objection for the end of this episode is that everybody listening can walk away, turn around, and explain it to somebody you love who needs to know this about either your bones or their own in a way that makes complete sense. So there's our challenge and our task.

That's great.

What I would love to know about you is why bones and why hormones for you? How did you get to, you know, be doing what you're doing right now?

Yeah, thanks for that. And actually, I'd love to add one more objective in here, which is to let's reduce the fear around osteoporosis because it is a diagnosis that grips people in fear, and I see it every day in our patients. Yeah. So it can be scary, but there's a lot of things. If you know enough information, you can really kind of work your way through the weeds and figure out what your real risk is. There's just so many unknowns. So I think we can reduce a lot of fear. So that's, would be a great objective too. To answer your question. So my background is in orthopedics. So I'm an orthopedic surgeon by training. I'm still a board-certified orthopedic surgeon, but I don't practice anymore in that space. I left around beginning of 2020 for a number of reasons, but the biggest one was I just wasn't happy with what I was doing because I felt like I was just cleaning up the ends of metabolic dysfunction. Basically operating on people, foot and ankle is my subspecialty. So I was operating on people that had a lot of metabolic dysfunction, diabetes. We're doing amputations. We're doing a lot of reconstructive work on feet that just could have been saved if they had good information a long time ago. And so while we did a lot of great work, I love being in the OR. I wasn't happy clinically because I wanted to spend more time talking to patients about the things that could prevent them from needing my services rather than actually providing the surgery. So you mentioned my wife, and she runs a weight loss program, and I was blown away by the benefit that she was able to provide for people as far as reducing medications, you know, basically reversing diabetes, like all of these things that I thought in my training were not possible. So it sent me on this journey to really learn more, and I went down another, an entire fellowship in functional medicine and anti-aging medicine and learned a lot about hormones in the process. And then when I came out on the other end of that, I wanted to start a practice that allowed me to see patients in a way that I felt like they needed to be seen. And that includes spending a lot more time. It includes getting more labs, more than just what your insurance will pay for, and getting as much information as we can so that we can really get to the root of the problem, which is a little bit cliché, but we have to understand why something is occurring before we can really figure out what to do about it, or we just end up using drugs or surgery to fix it, which is what the traditional system does. So I went on that journey initially, started working on building a program for patients that were coming out of my wife's program because hormones were dysfunctional, thyroid was dysfunctional, they needed some gut help. And so we really wanted to help people to maintain weight loss. But then after we opened, because of my orthopedic background, people with osteoporosis kept coming to us and saying, hey, would your approach work for this? And early on, I was like, no, you just need the bone health drugs. This isn't a thing because that's what I was trained. And so then I have an open mind. So I started doing some research and realized, wow, there's actually a lot of things that we potentially could do. And it seems like this approach would actually be pretty effective. So we started working with patients. We're helping them to improve bone health and doing all the things that we thought. And in the meantime, I'm just, like, you know, voraciously reading, learning, looking at research studies, and then realizing that osteoporosis is really, from my perspective now, it's a disease that if we know about it early enough, if we know about bone health early enough, it's a disease that really shouldn't exist. Except for in some rare circumstances when people have to take chronic steroids for something else or whatever.

Yeah.

But for most people, this problem should not exist if we can manage bone health properly.

I am so glad you said that.

And you said something really juicy in there that I don't want anybody to skim over, and I'm gonna embellish it just a little bit. You said you should take the drugs because that's what I knew, that's how I was trained. And I want to point that out to everybody listening. And I just posted a video on YouTube. I was educating about some, I think, some non-exercise ways to boost fat burning, but there was something in there that led to a short discussion or mention of bone health and osteoporosis. And someone very defensively piped in. I mean, comments are not always nice on YouTube. They're mean, but Somebody said, you know, no, my brother and sister-in-law are both doctors, and they said, absolutely not, you cannot gain bone after age 30, it's just over. And I, I was just like, oh, oh my God, it's 2024, we, we have to stop.

Yeah, yeah, yeah. Well, I'm here to tell you that's absolutely not true. And I still, I still catch my forward-thinking partners— not actual partners, business partners— but my forward-thinking colleagues in the bone health space who I like what they're saying, but I catch them and they'll say our goal is to slow down bone loss. We're not going to rebuild bone. And I say, that's not true at all. Yeah, you're seeing, you know, 5-10% improvement, BMD, 12, 18, 24 months, year after year after year. You can absolutely build bone in your 50s, 60s, 70s. We have patients in our 80s that are turning around their bone health. So it's absolutely possible.

Yep, I love it. And what I also find interesting is that some of my colleagues who happen to be very niche in the bone density field, and I am not, you know, I'm less so. We're niched in exercise fitness for muscle and bone and brain health, but we have to deal with this significantly. And she said, you know, we can't say that we can reverse bone loss. I said, I can say it because we did it. Why can't we say that?

Why not?

I know I, I have to say no, that's a lie. What do you mean?

Yeah. Well, and I, I mean, I look at it like this where, like, if we're gonna use the definition of osteoporosis, which your audience probably knows is based off of DEXA, it's a T-score thing. If we're gonna use that as the definition, then clearly we can reverse it. Just improve your bone density to above that T-score and you're done. Now, realistically, clinically, like, there's, it's a bigger picture, but why can't we say that we can reverse a chronic disease? Because we do, and we do it all the time.

Yeah.

Yeah. It's very interesting. Everybody's so afraid of litigation and claims. It is like, but don't forget, you can tell the truth. Let's remember we can do that.

All right.

This is, again, this is such a great time to review for some of you who are listening, who know this, and probably, you know, some of it because you've been in the trenches, ladies. I know that you're listening and you've gone through this and you've learned it because you had to learn it. But my hope again is that we catch this earlier in, in the people that we influence, and those younger people, or those of you who haven't yet gotten there and don't know where you are, what your status is, which is another problem. I'd be interested to get your opinion, but I'm about to be a mother-in-law, and I really desperately want to give a bone density test to my 30-something, you know, daughter-in-law, but Talk about sex hormones, and let's link those sex hormones— just refer to what are they, how did they tie into our bone status, so that obviously as they're going through a roller coaster and trending down, how are we impacting bone?

Yeah, so sex hormones play a big role here, and this is one of the areas where I really struggled early on because it's one thing to say, oh, I'm trained in hormone replacement therapy, it's another thing to actually do it. And so for me to walk from an orthopedic surgery office into my own clinical practice where I'm actually doing hormone replacement therapy, there's a lot of anxiety around that. And so I really wanted to get deep. I learned from every different subspecialty that I could in the hormone space. And what I really learned about the hormone space is that it is an absolute mess. And there's, you know, there's what the literature shows and then there's what the recommendations are. And then there's like the dogma from 25 years ago that just makes absolutely no sense. And so we had to get you know, we had to be like what feels like very bold in our approach, but it's not. It's very supported by the literature. But we, we are able to do this in our practice because bones are very sensitive to hormones and bones leave biomarkers. So we're able to look at our patients and, you know, especially our postmenopausal patients, we see this rapid decline and I'll get to why that happens, but we can see rapid improvement when you start HRT for women and testosterone for men if they need it. And you see this rapid improvement because each of those primary sex hormones is related to bone. So progesterone has an impact, estrogen has an impact, and testosterone has an impact. And so we had to start getting more creative as to how can we work with women, especially if they're over 10 years out from menopause. They're the quote unquote at-risk population, right? What are our protocols here? How can we help keep women safe while also potentially offering them HRT? But before I get to that, let's talk about those hormones from the get-go. So for women that are naturally cycling, so premenopausal woman, having what's hoped is a normal cycle, 28-day cycle with, you know, hopefully an uneventful menstrual flow, she's going to go through this rise and fall of estradiol, rise and fall of progesterone. That push-pull throughout the menstrual cycle, we know based off the literature, is critical for maintaining bone health. And it goes back to the fundamentals of each of those hormones. So estradiol in particular is the most, most potent of the estrogens for women. Estradiol have an impact on both the osteoclasts, the cells that break down bone, and osteoblasts, the cells that build bone. As estradiol rises and then falls, it's going to make way for bone growth that progesterone is going to help with. It's also going to help progesterone by increasing the receptor density for progesterone. So estrogen falls and then progesterone rises. Progesterone is going to have more of an impact on the osteoblasts, but the bone that was resorbed by the estradiol and osteoclasts now makes room for the bone for the osteoblasts. And so it's this push-pull every month that that helps to maintain or build bone depending on the situation and the age. We know that if women have dysfunctional cycles or if they stop actually having ovulation, then they don't protect their bone. And this is why birth control is related to birth control that stops ovulation related to bone loss. Progesterone is related to bone loss, but amenorrhea also related to bone loss. And so there's actually a threshold of 5 cycles. If you don't have 5 natural cycles per year, women will start losing bone. And that clearly happens for a lot of women because I just described 3 groups of women. There's a lot of women in those groups. So it's actually really common. We see it more than you would expect for women in their 20s, 30s, and 40s to have osteoporosis.

Yeah. No, no surprises there. But I also wanna grab something that is like a, a minute detail that you said that I think listeners, you wanna pay attention to. Like you said, everything that you're doing was supported by literature. And yet I think really important to realize that sometimes that literature takes like 20 years to make it to mainstream peer-reviewed journals. And yet, you know, I mean, we would trust eating orange-colored Cheetos before we would trust something that was in a peer-reviewed journal simply because it's new.

Yeah, well, and I just did a post on this. The patient who was talking to me about hormones, and, you know, she said that she went to her doctor with a diagnosis of osteoporosis, went to her OB-GYN and said, I want to consider hormone replacement therapy. And the doctor said, we don't do HRT for bones, which it's— estradiol is actually FDA approved for bone health, but okay, we don't do it for bones, and you don't have symptoms of menopause, and the risk of breast cancer is too high. She has no history of breast cancer and no family history of breast cancer. So this doctor actually stated, well, the WHI from the 2002 showed there's an increased risk of breast cancer. And I almost stopped my patient visit. I was like, I got to put that on Instagram because I hear it so often that dogma dies hard. And yet study after study has demonstrated that that wasn't true at all. In fact, that wasn't even true in the original publication. And so it's just like the dogma that physicians are trained in, unless they're continuing to educate themselves, they will not change their minds. And physicians have to be hardheaded, and I never slight physicians for this. It's a hard job.

Yeah.

But if we're going to treat people with hormones, we really have to understand what the literature shows as it's changed over the last 25 years.

So good. Talk to me more about progesterone. So I think, you know, estrogen, and for those women who are really paying attention, you know, the realization that testosterone also plays a part, not as new, but to hear that progesterone plays a part in bone density. I think that's a real key insight we need.

Yeah. So progesterone, I feel, has been relegated to this like copilot seat behind estrogen. Yeah. You know, and it's interesting, and I can think of a few ways how it got there, but if you think about the current recommendations, even coming from NAMS, and this is like the, you know, the most up-to-date recommendations, which is unless a woman has a uterus, she doesn't need progesterone. As if the only tissue in the body that had progesterone receptors was the endometrial lining of the uterus. You have progesterone receptors everywhere in your body. Same with estrogen, same with testosterone. Sex hormones do a lot of different things. And so when I started looking into the research on this progesterone, unfortunately, there's not a lot of studies using it independently because it's just not protocol. Very rarely would we use progesterone. Well, I might, but most doctors would very rarely use progesterone without estrogen. So most of the studies then have study protocols where they're using both. But you can see in some of the studies where there's clear benefit from progesterone perspective for bones. I'll talk more about that, but also for the vascular system, the endothelium of the vascular system, the heart, the brain nerves. So it has a lot of potential benefits. There are some people who are using it for some really interesting things, but from my perspective, from a bone health perspective, Again, go back to those studies looking at, you know, quote unquote normal cycling women. If they didn't have an appropriate luteal phase, then they would not maintain their bone. We have to have that push-pull. And when we look at women who are, you know, on estradiol without progesterone, can they maintain bone? Probably. But what I think we find is that you lose the benefit of estrogen over time, especially with lower doses, if you don't have both. But then it also brings up this really interesting point, which I actually just recently uncovered as I was digging into some of the older studies on bone health and hormones, which is that most of the protocols for hormone replacement therapy prior to the mid-2000s were on rhythmic approaches. So they were cycling progesterone in postmenopausal women, and they had estrogen that it was either stable throughout the month or had a 7-day window of no estrogen or actually went up and down, actually trying to be more physiologic. So every study was different, but in those studies that used a rhythmic approach, the improvement in bone mineral density was 50% to 100% better than those that use static approaches. So I really think there is evidence to support the idea that using a cyclic progesterone, that giving that push-pull even in a postmenopausal woman is gonna have better impact on bone. But the question I have is, well, what about other tissues? What is the threshold for the heart? What is the threshold for the endothelium and the arteries? What is the threshold for the brain? We just don't know because they don't leave good biomarkers, but the bone leaves great biomarkers. So I can at least say what it is for the bone.

I have a question on something that is a little bit of a detour, but talking about progesterone and endothelium lining. So with a lot of women, and I don't think enough people talk about it, I, I think it gets kind of passed off as just umbrella of signs and symptoms that are mysterious that we don't know what it is. But there are a number of women that potentially I'm a little bit more aware of because it's so related to exercise that, that have what I discovered is called exercise intolerance that can be caused from changes in hormones in menopause, has to do with the endothelial lining and makes them feel like I can't handle it, or I get almost asthmatic when I try to exercise hard. It would progesterone be helpful in this case, and does that also apply to long-haul COVID?

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Yeah. Interesting questions. So again, progesterone is so rarely studied on its own. It's hard to give a solid answer. But if you think about the physiology of how it works, if it can improve the function of endothelium, especially it's tied into the nitric oxide pathway. So for those who don't know what I'm talking about, nitric oxide is something that the blood vessels actually make on the endothelium, that lining. It makes this nitric oxide, which will then allow the muscles to relax, and it allows your vessels to expand and contract. Without nitric oxide, your vessels are not as compliant, meaning you have blood pressure issues, can lead to basically any vascular problem that you can imagine. So progesterone is tied to that. So would that have an impact on exercise tolerance? I would assume so. I've never seen a study on it, Same thing with long COVID. I think that COVID was such an interesting virus in a lot of ways because it really just amplified sort of whatever was wrong with someone. You could just see, like, if they had an issue with this, like, that was their problem with COVID It's such an interesting virus. And so for women that have dysfunctional hormones, you know, could restoring hormone balance have an impact on somebody who is still symptomatic and from the long term from a COVID infection? Again, I haven't seen a study on that. It would make sense that it's something worth trying. Because in those patients, I've had a few of them in those patients, we basically just look to say like, well, what was wrong in the first place? What can we optimize? And then, you know, sort of rebuild the system from the way it was broken down.

So good. Thank you. Thanks for taking that little detour with me.

Okay.

Talk to me about testosterone.

Yeah, testosterone. Boy, I've been on like a full circle with testosterone where when I was trained, I wasn't really trained to use it. And then based off of my own experience, my own research, and even my personal experience of recognizing how powerful it can be, I sort of fell in love with it and I started using it in a lot of my patients. And we have good results with it, and I'll talk about why and how. But what I found, especially in an older population, and by older, I mean, don't take this the wrong way, anybody, but older is generally defined as over the age of 60 or 70. In an older population of women, I don't find that they tolerate adding exogenous testosterone as well. And this is my population with osteoporosis. And so we were using very low doses. We were really restricted by symptoms, mostly of hair loss or potentially of hair growth. And so we were kind of struggling getting people to a physiologic level with testosterone, which was our goal. So we've looked at alternatives. And what I think is really interesting about testosterone, and I write about this in our book that's coming out soon, is that if you think about the physiology of androgens, so just a little background there. So testosterone is an androgen. Other androgens include DHEA, pregnenolone. Those are things that are going to be in that, like, testosterone category. If you think about androgens in general, women are unique to men in a lot of ways. But with androgens specifically, men make most of their testosterone in their testicles. Women make only about 50%, or some people would even say 25%, in their ovaries. So there is the potential to make testosterone from adrenal function and peripheral conversion of the testosterone precursors, DHEA and pregnenolone upstream. And so it is possible that a woman that has good adrenal function can have reasonable levels of testosterone. So now we've really gone to focusing on optimizing estradiol, optimizing progesterone, and then seeing what they need from an adrenal perspective, maybe supporting them with DHEA. And then if they need testosterone, fine, we can then add that later. But optimizing the other two sex hormones first. And what we're finding is that most women that we do that for don't end up needing testosterone because they feel great. They've got good energy, they're building muscle mass, they're building bone. So then why add another one that they already have reasonable levels of? So it's been an interesting full circle where I was a huge advocate for a while. I even had to rewrite the majority of my book because I was so like pro-testosterone in it. And then with my clinical experience, just kind of pulled back. I think it's definitely a tool. I think it's overutilized because a lot of physicians, you know, they're kind of— it's out there now that, you know, women need testosterone and women have more testosterone than estrogen naturally. All those things are true, but we shouldn't use it as a tool because we're afraid of one of the other sex hormones. And that's what I see is guys where doctors are going to overuse testosterone. Because they're afraid of giving estrogen. And I don't think that we can hide from the risk of estradiol because testosterone converts to estradiol in the body. So just because you're giving it another form to give the same level systemically doesn't mean you're going to avoid the risk. So I think they're kind of just sticking their head in the sand and riding the wave of testosterone for women, which is important, but I don't think it's potentially as important as some people think.

Great points.

And, you know, I also think and would love your opinion on this and what you've seen clinically, but postmenopausal women still generally produce a fair amount of testosterone, especially if they have good habits, right? I mean, right, can't be overdoing alcohol, got to be doing the protein, don't want to— don't overdo sugar. But if you were exercising correctly, doing the things you should be doing anyway for the body and the health that you want, you're prioritizing your strength training, your staying away from endurance exercise and you're doing high-intensity interval training, those things will help you boost your testosterone.

Absolutely. And we see it. We see women that are— they're optimizing their lifestyle. That's part of our program for bone health. It's a lot of lifestyle, you know. So they're, they're doing resistance training, they're not doing as much cardio if that's what they were doing, you know, but optimizing sleep, getting adequate nutrition, getting adequate protein. And these are things, especially in the bone health population, that these women and men have not been doing for a long time, for decades. That's why they have osteoporosis. But when you do those things, you're right, testosterone rebounds. It's amazing.

Almost every woman here listening influences a woman in her 20s or her 30s. And some of you also, I know you may have kindergartners. It's 2024. But, you know, we influence younger generations in so many ways. What would you like to see a 20 to 30-something be doing to secure a strong future for her bones?

Yeah, boy. So I'm actually going to take it a step further. I'm going to talk about that population.

Yeah.

But for those of us that are listening that have children— so I have a 12, 10, and a 5-year-old— bone metabolism is so interesting that even that childhood adolescent experience is really critical as well. So we need to develop our bone. In order to do that, we need to get kind of what we just said. We need to get adequate nutrition. It's not a calcium problem. Most kids are getting just a finite amount of calcium. They don't need to mainline milk or take calcium supplements. They just need to eat real food, whole foods, avoid highly processed foods, and then they need to actually move their bodies. And this is a huge problem I see right now. And I fight this pull of video games and TVs and all this stuff with my kids. It's hard to get them to go out and actually do some activity and see impact. And so the, you know, the rough and tumble— I have two boys— the rough and tumble boys of the past have really been relegated to boys sitting on a couch playing a video game. Hmm.

And we won't—

I won't do it in my house. I won't let it happen. But it's still hard to get them out and get them to, you know, to like wrestle and, you know, fall on their knees and do all the things because we need impact to build bone. Yeah. This is even worse with young women who are especially going through adolescence who are not involved in some kind of activity that's gonna drive that. And what makes it so much worse for women over the men and the, you know, the older boys is what's happening from an eating perspective. So continuing to eat less and less, worried about being lean. I love this, you know, this push on social media, you know, be strong, don't worry about being too muscular. Yeah. But I still see this in young women who eat nothing. They eat under 1,000 calories a day. They're eating no protein. And it's it's terrible for their bones. And so what's going to happen is that when they reach early adulthood in their 20s and early 30s, they're going to not have achieved good peak bone mass. And that's a big problem. And so a lot of people ask me in our program, like, why did I develop osteoporosis? And my question is, well, do you have a DEXA from when you were 30?

Because I need that.

I need that to really be able to answer this question. And because we need to know what your peak bone mass was. So what I would tell every young adult is if you have any risk factors whatsoever. And actually, I'll just take it even a step further. Every young adult should know what their bone mineral density is one way or another. There's two main modalities. We can talk about how to image it, but you need to know. Like, I have osteopenia. I had osteopenia when I was a 22-year-old male, 22-year-old, 200-pound muscular athlete guy with osteopenia. So you really don't know because I didn't have any risk factors. You really don't know until you scan.. And so I think it's important that everybody knows and then identifying what risk factors there are. There are so many, I could kinda hit a few of them, but if you have any risk factors, then making sure you're continuing to monitor that over time, because what you don't want to have happen is to have a low starting point and then just continue to lose bone every year. And then you have severe osteoporosis in your 50s. Yeah. It's so important that we understand as a young adult, the things to do.

Yeah.

And the things to do as a young adult are the same things you would do as an adolescent. You, you need to do resistance training. You need to move your body. You need to eat adequate food, adequate protein. You know, don't worry as much about being lean as being strong. And then impact has to be in there somewhere or simulated somehow.

Yeah. It's, you know, I love, you know, when we're getting kids involved in lots of sports, not overcommitted and overextended, but, you know, we are giving them, we're giving them soccer. So they're moving laterally and in all different directions. Giving them jump ropes as gifts or, you know, encouraging things like gymnastics. And swimming and biking are wonderful, but they're not weighted. That's going to help muscle and cardio, but it doesn't help bone. So you want to look at exposure to so many things. Plus, we want them to fall in love with activity.

Yeah, I love that.

Yeah, love that. And you were going to come back to talking about different ways to test and measure.

Yeah.

And I think, yeah, this is very insightful because I think everybody thinks, well, I just go and I get my DEXA numbers and, and that's as conclusive as it's gonna be.

Yeah. So DEXA is what everybody knows, and it's globally available, and insurance will pay for it under the right circumstances. And so we have to use DEXA because we have it. It is what it is, right? That's fine. DEXA is the gold standard. DEXA is what the definition is based off of. Everybody should have a DEXA at some point, but DEXA is not great. In fact, I would argue DEXA is pretty terrible because DEXA is an X-ray. It's very low radiation, but it's still radiation, and it is really inconsistent from scan to scan. There's a lot of variation in the scans, and this could be based off of the person doing it, the software, the positioning, the actual scanners will differ from one to another. And so really, if you want to have the most accurate DEXA possible, you need to recreate all of the same circumstances, same machine, same operator, you know, same time of day, like everything. And that's really hard to do for most people unless they happen to like have one. And so DEXA is not great because you can get up to, and I've seen variation, like wild variation, but they say the literature like 6%, but 6% in bone is a lot. It's a lot, right? So when people say, oh, I reversed my osteoporosis, I, you know, I gained 2%, I'm like, actually, you don't know that. If you're talking about DEXA, that's, that could all be just by chance. And so DEXA is not great, but we use it because we have it. It also only tells you about bone density. It doesn't tell you about bone quality. And bone density and bone quality are the two things that go into bone strength. Bone strength is what matters when it comes to fracture risk. So really you only have half the equation with DEXA anyway. There's an add-on to DEXA called TBS, Trabecular Bone Score, that some machines have that gives you some sense of quality, but it's not great because there aren't doesn't break it down into very many different sections. It's basically like a 3x3 grid. And so, it's something that can be helpful for some people, but usually it doesn't help us. So then, there's a new modality that's come out that's an ultrasound-based device. It's from a company called Ecolight and the product is called REMS. It's an acronym, but I won't spell it out. But a REMS machine, again, is an ultrasound, so there's no radiation. You could do it on a pregnant woman, you could do it on a, you know, a a child, and it would give you information about both the bone density as well as the bone quality. And what's really cool about that is that now we get the T-score just like you would on a DEXA, but you also get this thing called a fragility score. And the fragility score is now, because they've done— they have so many of these now, you know, you can imagine hundreds of thousands or maybe millions at this point scans of data looking at bone quality according to the ultrasound and people that ultimately fracture. So they can now sort of relate, like, this led to a fracture, this didn't lead to a fracture. So they're always updating this over time. And it's really helpful for women and men that have low T-scores, meaning like -3, -4, but they have really good fragility scores. So you can imagine somebody who is so afraid to do anything. I don't want to lift weights. I don't want to, you know, I don't want to put anything over my head. I can't travel because I can't put my bag in the in the, in the, you know, the luggage band. People that are in that situation that have not had a fracture that have a really good fragility score, we can say, look, yes, you have low bone density, but you have good bone quality. We need to get you lifting more, doing more impact. We can be a little bit more aggressive. You still don't know, like, what is the actual threshold of a fracture? There's no way to know. But it gives you more information. What's interesting too about those two modalities is that sometimes they are wildly different. Meaning I've seen patients that had— I had a patient that had a negative 4, which is a negative 4.5 in her spine on DEXA and a negative 1.5 T-score in her spine on REMS. And so, you know, of course she's super excited. Oh my gosh, I don't have osteoporosis. And I'm like, whoa, whoa, whoa, whoa. We don't know which one's right. You know? And so there are different technologies. Sometimes they have wildly different scores, but the problem is that you can't say that REMS is more accurate when there isn't a third test to compare it to because it's the gold standard. So how could something be different from the gold standard and be right? Now we know there's variation in DEXA, but we can't prove that REMS is better until we start using some of the newer modalities that are not going to actually be used for screening, but we can use them as a tiebreaker. So you can use now both CT and MRI. You can do a quantitative CT and MRI. The software is new. It's not available. Really most places, but it's out there. And I think it's going to become more available because we're going to see more and more people that have these weird discrepancies between imaging modalities. And it really makes a difference. You can be recommended to be on a drug for the rest of your life or not based off of this test. You really need to know. And so I think we're going to eventually show that quantitative CT is a much better test because it can tell you about the architecture, it can tell you about the density, and it can do it in a really, really clear, objective way. So we're gonna be able to say your QCT says this for people that have discrepancy between REMS and DEXA. I don't think it'll take over because it's, there's too much radiation. You wouldn't wanna do that on an annual basis, but I think we can use it as a tiebreaker.

So to a listener, how accessible is this?

Where do we get this? And you've already hinted, of course, DEXA is covered by insurance. My guess is Yeah, the rest is not.

Of course not. Well, you can imagine, I mean, there's a lot of history between insurance companies and the companies that make DEXA machines, and it's a whole system, you know, not a conspiracy theorist, but these businesses are aligned to work together. So to bring in a new imaging modality that isn't connected to that system, it's going to be a really hard push to either supplant that DEXA or to even just get insurance coverage for it. So The company's fighting for it, but honestly, I think it would almost be a disservice at this point because the, the people that are buying the machine, it's an inexpensive ultrasound. It's a $50,000 investment for the people that are buying it. So for the people that are buying it, they're setting up cash pay businesses in order to cover it. If insurance were to actually start covering it, I bet they would reimburse not very much because right now I don't know what they reimburse for DEXA, but it ain't much. That's why DEXA screening is going down too. So I think it would actually probably prevent that. Technology from advancing because nobody could afford one except a hospital system and they have no reason to buy one. So what's happening is that the, some entrepreneurial individuals in the bone health space are buying these machines, making them available. And right now in the US, you know, I see probably 1 or 2 spots across the country a month pop up. So, and because it's portable, you can take it with you. Some of these companies are actually saying, well, let's go to, you know, these franchises that will support bone health or a gym that does, you know, osteoporosis-specific work. And just be there for a day and let people sign up. Like, we have an in-person event in February next year. We're going to have, I think, 3 REM scanners there, and we're just going to sign people up. We're just going to do scans all day long. So it's becoming more and more available. We have an updated list always in our community, and it, it's worth traveling to if you are concerned about bone health for sure. But it's going to, I think, be available hopefully in the next couple of years from driving distance for most people.

Fantastic.

So good. So for those of you who stayed to the end, smart decision, right? Okay, so you just got a lot of intel. Dr. Doug, tell everybody where they can find you, follow you, learn more about you. I know you've mentioned you're on Instagram, but there are other places, and where would that be?

Yeah, gosh, I feel like I'm all over the place right now. So if you want to hear bone health-specific information, our YouTube channel is really the source So I spend probably over 50% of my professional time right now researching and creating content for the YouTube channel. It's called the Dr. Doug Show. It's all about bones, hormones, and healthspan. So that's number one. If you're interested in figuring out how we reverse osteoporosis, our website for that is called optimalhumanhealth.com. And then I'll just mention one more. If you are in need of hormone replacement therapy from a team of providers who are looking at the newest literature, offering alternatives to traditional methods. That company is called Pema Bioidentical.

That's PemaBioidentical.com.

That we just launched that this month. It's a really cool opportunity for people to get access to hormones that don't have access to it now.

Thank you so much for being here and diving into all of this. Such great insight. And if there was a question that I didn't ask you and should have, what would that be?

Oh, well, I think that the thing I like to leave people with on recordings is just to remember that our healthcare system is not a healthcare system. It's a sick care system, right? So if you don't have a complaint, if you don't have a symptom, it really doesn't have a solution for you. And osteoporosis and hormone dysfunction often can be quote unquote silent. Hormone dysfunction cannot be silent too. But those two things are so underserved in our system that you have to be an advocate for yourself. You have to say, hey, this thing's going on, or hey, I want a DEXA scan or REMS. And you really have to almost demand it. I hate saying that because, you know, I like doctors, but doctors are a victim of the system too. And so they have to stick to their rules. They have to stick to their system. And so you guys have to work together to get the care that you need. So definitely be an advocate for yourself.

Amen. Thank you so much for being here.

Yeah, thanks, Debra. It's fun.

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