Optimizing Women’s Bone Health

Nearly eight million women have osteoporosis, but most are unaware that they have it until they experience a break – making screening, prevention and treatment critical. Dr. Kristi Tough DeSapri is the director of the Northwestern Medicine Program for Women's bone health and is joining us today to share the latest strategies to protect women's bone health.
Optimizing Women’s Bone Health
Featured Speaker:
Kristi Tough DeSapri, MD
Kristi Tough DeSapri, MD, is the director of the Northwestern Medicine Program for Women’s Bone Health and assistant professor of Obstetrics and Gynecology and Medicine (General Internal Medicine and Geriatrics). Dr. Tough DeSapri specializes in women’s bone health, osteopenia and the prevention and treatment of osteoporosis in the Center for Sexual Medicine and Menopause. She earned her medical degree from University of Texas Health Sciences Center at San Antonio and complete her residency at Lenox Hill Hospital and fellowship at Cleveland Clinic in women’s health. She is a member of and active contributor to the National Osteoporosis Foundation and the Association of Bone Mineral Research. She is also a certified menopause practitioner of the North American Menopause Society and a certified clinical densitometrist with the International Society of Clinical Densitometry.

Learn more about Kristi Tough DeSapri, MD 
Optimizing Women’s Bone Health

Melanie Cole, MS (Host): Nearly eight million women have osteoporosis, but most are unaware that they have it until they experience a break or a fracture making screening and prevention and treatment critical. My guest today is Dr. Kristi Tough DeSapri. She’s the director of the Northwestern Medicine program for women’s bone health. Dr. Tough DeSapri, I'm so glad to have you with today. What a great topic. As we mentioned, nearly eight million women have osteoporosis. Why is this disease more common in women?

Kristi Tough DeSapri MD (Guest): Yes. I'd like you to know that October 20th is world osteoporosis day, and a majority of women are effected by osteoporosis. In the United States, eight million women have osteoporosis. What's more important is that 34 million also have low bone mass, or what is referred to as osteopenia. So it’s important to recognize that you do not have to have osteoporosis on a bone density or a DEXA to have a fracture. When we look at the problem worldwide, more than 8.9 million fractures occur per year. That equates to a fracture every three seconds. So when we’re thinking about osteoporosis, osteopenia, and these diagnoses we have to remember what we’re trying to prevent and that is a fracture.

Host:    So important that we know that in women and men too. Why is osteoporosis more common in menopausal or post-menopausal women? I mean I, myself, am in menopause right now. So is this because of the decline in estrogen? Tell us what’s going on in our bodies while this is happening.

Dr. Tough DeSapri:  So women are more effected than men for a variety of reasons, and particularly post-menopausal women. So women’s bones are generally smaller, and we acquire bone density until age 20 or 30 years old, which is considered our peak bone mass. Then what happens at menopause with the sharp declines in sex hormones—particularly estrogen, but also testosterone—is that we lose a dramatic amount of bone density starting around the menopause transition, which doesn’t have to be right at age 51.5 which is the average age. But even a little bit prior to that. With those significant drops we can lose a lot of bone density in the most common bones, the two bones that we have in the body—which are both the trabecular bone or the cancellous bone or the cortical bone, which make up our long bone.

So we see a dramatic drop due to sex hormones, but we also have to remember that women have a lower peak bone mass than men just because men have more testosterone which stimulate more bone building and just have denser bone. So when we look at what's happening around menopause we’re taking a snapshot of what’s happening in the bone, but we need to remember that the bone we have is—I liken it to a bone bank. So in our early years—our teens, our adolescent years, our young adult years—we sort of build that bone density. This is why we talk to our teens about getting off of the couch and not just doing video games. We want them exercising. We want them eating nutritious foods with calcium and vitamin D because that’s all going to help their bone bank and their bone building until we hit the 20s and 30s when we have a plateau. Then we start to lose bone density in our 40s and beyond.

The transition around menopause, again, is the most significant for many women, but we do need to make sure that we’re looking at bone density as women age. Even into their 50s, 60s, 70s, 80. The lifespan of women now is 81.3 is the average lifespan of women. So we’re seeing a lot of this osteoporosis and bone loss happen as we naturally age. If we don’t diagnose and understand what's happening around the menopause transition, we can really end up with a lot of bone density loss later that goes undiagnosed.

Host:    So then tell us about the program for women’s bone health at the Northwestern Medicine Center for Sexual Medicine and Menopause. Tell us a little bit about your team and what other providers that are referring to this program can expect.

Dr. Tough DeSapri:  So we are starting the Northwestern Women’s Bone Health program through the Department of OBGYN. What's exciting about our program is that we’re collaborating with not only Northwestern physicians but also physicians in the community, general internists, primary care physicians, gynecologists, endocrinologists to really make patients have better access to bone density screening, evaluation, and treatment. So our program is really focused on women, and, again, the high risk areas. Menopause, talking about your peak bone mass, making sure that we’re doing a timely preventative bone density or DEXA screening, which can help evaluate what your risk for future fractures or your risk for osteoporosis. So we really can think about optimizing bone health. I am an internist by training and then did some specialty training in the Cleveland Clinic. I practiced in general medicine and gynecology for many years. Now with a specialty in menopause and osteoporosis, I know how important it is for women to get this information.

Sometimes at the general level with our general internists and general gynecologists, they don’t have the time to spend with patients to talk about bone health. But as I've mentioned, its’s so, so important. So we have a lot of time and a lot of resources at our Northwestern Women’s Bone Health program to focus on not only bone density but evaluation for risk factors, and then an educated discussion about the therapies that are available. So we really individualize our approach, both for sexual medicine as well as for menopausal medicine. We do the same for bone health. So things like hormone therapy, exercise, the appropriate supplements, lifestyle modifications. Those are all part of our discussion and part of your treatment plan. Then in addition to the [inaudible] of FDA approved therapies for osteoporosis or if patients are at a high risk for a fracture, we have a very educated discussion on treatment options to really make sure that we’re optimizing bone health and preventing those fractures.

Host:    Wow. That’s great information. Are there any new advances in the field of bone health or new research that you're working on that you’d like other providers to know about?

Dr. Tough DeSapri:  Yes. There have been done advances in the bone density screening world, which is for the software that’s added to a DEXA machine, which is called TBS—trabecular bone software. Which is a 2D grayscale image of the spine or vertebrae that we scan when we do a bone density test to help better evaluate bone quality, not just bone density. So bone quality has been discussed in more recent years as equally important to bone density. We do a DEXA scan, which really helps us look at the bone’s mineral calcium, and that is defined as the bone density. The report that you get shows a T score or a V score which compares your bones to those of a peak bone mass.

The TBS—or trabecular bone software—really helps us guide some diagnosis in those patients who are maybe more in the range of osteopenia who might be at high risk for osteoporosis because of low bone quality. We particularly feel this is important, again, around menopause. So patients who are menopausal who might have very low bone quality who need to be alerted of that as well as there are so many patients that we see on medications that effect bone density. So these are early menopausal women or even premenopausal women who have breast cancer who are on aromatase inhibitors like Femara or letrozole, etcetera. Those can really effect bone density and they're on those medications to prevent the recurrence of breast cancer, but they can also effect bone density. Other medications like steroid, even proton pump inhibitors like Pepcid can effect bones. So the trabecular bone score helps us determine who is at higher maybe because of those secondary risk factors that are often more silent.

Then the second advance is because there's so many women with osteoporosis, the therapies are keeping up with the demands for better options and more options. So there is a new class of osteoporosis medications, which both build bone density as well as prevent bone resorption or bone breakdown. So it does both. It is called Romosozumab and it is a humanized monoclonal antibody against a protein called sclerostin in our body. So this is a very exciting advance in our field with new therapies to really reinvigorate the discussion about osteoporosis. Lastly there is a patch technology. So most of our osteoporosis therapies come in oral pills, such as bisphosphonates or intravenous bisphosphonates or subcutaneous injections. So this is an exciting trial that is ongoing looking at using a patch—a transdermal or on the skin patch—to treat high risk patients for osteoporosis.

Host:    Wow. Really a lot of exciting information. What a time to be in this field Dr. Tough DeSapri. So as we wrap up, what would you like other providers to know about screening and prevention when they're discussing with their patients whether it’s about things that can leach that calcium from their bones and make their bone density more porotic. What would you like them to know about things that they can discuss as far as smoking and nutrition and how you'd like them to go about it and when you feel it’s important that they refer?

Dr. Tough DeSapri:  Yes. As I've mentioned, primary care physicians and family physicians, internists, obstetric gynecologists are really the gatekeeper to specialty care for women. We see this time and time again and patients do trust your judgement and do follow up on the recommendations that you give them. So it’s really important that you are ordering a screening bone density for those patients, those women particularly aged 65 and older, or those post-menopausal women who are over 50 who have risk factors, or if you have a premenopausal woman who, for instance, has endometriosis or is a breast cancer survivor. You want to make sure that you're ordering those screening bone densities because we know looking at data that women are not getting screened enough, even the women over aged 65.

So let’s order screening bone densities and then follow up on those bone densities or follow up on those bone densities or follow up on those patients who’ve had a fracture or had a call and make sure that they're getting referred to specialists in your community, bone health specialists. I'm happy to see your patients and provide them that resource so that we can educate them and make them aware and even talk to them about treatment options and the gamut of treatment options that we have. Because they do deserve optimal bone health to have their life a good longevity.

Host:    Wow. What great information and such an informative segment. Thank you so much Dr. Tough DeSapri for joining us today and telling us about all the exciting advancements in screening and prevention for osteoporosis. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. For more information on the latest advances in medicine, check out sexmedmenopause.nm.org to get connected with one of our providers. If you found this podcast as informative as I did, please share with other providers, share on your social media, and be sure not to miss all the other fascinating podcasts in our library. Until next time, I'm Melanie Cole.