Amanda Wilde (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. This episode is part of our menopause and perimenopause series focused on. Helping women understand what's happening in their bodies and how to take charge of their health. Today, we're looking at how menopause affects your bones with orthopedic physician assistant Ben Diffenderfer. Ben leads the Bone Health Program and Bone Health Clinic at the University of Maryland Upper Chesapeake Health. I'm Amanda Wilde, your host. And Ben, thank you so much for being here to help us understand bone health in menopause. Something that affects so, so many women.

Ben Diffenderfer: I appreciate the opportunity. We look forward to speaking with you.

Host: Well, let's start with this. What actually changes in the body during menopause and how is that connected to bone health?

Ben Diffenderfer: So, the big connection that we see with menopause and your bone health is estrogen. I'm sure most people know, most women certainly going through this know, that as you go through menopause, your estrogen levels significantly drop. This directly affect your bones, because of the effect that estrogen has on your bones in helping to regulate your normal bone metabolism or the way your bone functions normally in the body, because you're constantly creating new bone and absorbing old bone and estrogen plays a large role in that.

Host: Why does bone loss often speed up during menopause and perimenopause even in women who feel otherwise healthy?

Ben Diffenderfer: Well, certainly, estrogen is the main reason for this. When estrogen production starts to decline and through menopause decline significantly, it affects the bone cells that actually absorbs bone. Bone normally has a nice ebb and flow. Over time, you're creating new bone, you're replacing bone in its place. When you go through menopause and that estrogen drops significantly, the effect on those bone-absorbing cells is rather profound. What we see is when estrogen goes away, those bone-absorbing cells no longer have that break holding them down. Their activity increases, so you end up having a significantly larger amount of bone absorption over time, leading to significant losses where the bone-building cells can't play catch up and account for that loss where normally there was that nice ebb and flow, like I said, and it just leads to more loss over time.

The estrogen loss also does affect other hormones in that kind of cascade, including progesterone and testosterone. Those hormones affect the bone-building cells, which also affects their ability to replicate so you end up with less, and it affects their ability to form new bone. So essentially, though, the activity of new bone formation actually decreases a little bit. But the bone absorption on the other side does significantly increase leading to that net loss over time.

Host: With bone loss, it's often called a silent condition. We don't know it's happening. Are there early warning signs that we can look for?

Ben Diffenderfer: I wish there was something I could tell you that would ring that bell or set off a light in your head that you could recognize at a certain point. But there really is not, and that's why it is referred to as kind of like a silent disease. You're never going to have pain, you're never going to have like symptoms. It simply makes you more likely to fracture.

The thing to really look out for would be family history, certain medications, the presence of a fracture, or certainly reaching that point in life where you are perimenopausal or actually menopausal once you hit that point. Those would be the important times to maybe reach out to your primary care or reach out to your OB-GYN providers to, at that time, kind of more proactively seek a screening through a bone density scan.

Host: And that's the DEXA scan?

Ben Diffenderfer: Yeah, bone density and DEXA—kind of potato, potahto. They're referred to either way. But that is the main tool that we use to identify and diagnose osteoporosis. There are other certain screening measures, using like ultrasound that can give an idea about bone density. You may find those at some like community fairs. I know Upper Chesapeake, we have a tool like that that sometimes we will have out at community events. But there are also even like screening tools such as the FRAX, F-R-A-X, which is like a 10-year probability of fracture risk, which is simply just a list of 11 different factors that might put you at risk.

A more accurate way to use that tool is to include what's called the T score from your femoral neck of your hip, which does make it a little more accurate, but you can still get an idea about fracture risk just based on this FRAX questionnaire, which incorporates age, height, weight, sex, certain things like smoking status; the use of glucocorticoids or oral steroids like prednisone, because those medications really have a very negative effect on the bone; other medications; certainly, the presence of a fracture or a history of a fracture in your adult years puts you at a higher risk; even the risk of mom or dad maybe having a hip or a spine fracture, something we would consider a fragility fracture, which includes hip and spine, as well as certain fractures of the proximal humerus or the shoulder. The diagnosis or the terminology that we've been using more recently for these fragility fractures has been expanding to include even some wrist fractures and, in some cases, some really more complicated ankle fractures.

Host: You've mentioned the risk factors that should make some people be especially proactive in seeking out screening and bone density testing. When should women at large start thinking about getting this screening? Maybe we don't know what our risk factors are, but normally when should we start looking at these screenings?

Ben Diffenderfer: Traditionally, you will find the recommendation is, once you hit 65, you should get a bone density scan. Now, a lot of organizations nowadays that have a strong focus on osteoporosis, like the Bone Health Osteoporosis Foundation, BHOF, as well as the American Academy Clinical Endocrinologists, American College of Endocrinology. They have guidelines and recommendations that are much more comprehensive than the standard recommendations. And I tend to fall in line with most of their guidelines. I use those for my clinical practice, working in an orthopedic office, certainly I see a lot of fractures.

So, we make sure any patient 50 and older with any type of fracture other than basically fingers, toes, or head from a low-impact trauma, which is falling from a standing height, anyone that falls in that category should get a screening. I recommend to anyone who is perimenopausal, postmenopausal, like at that time of menopause, I feel like a baseline screen would be important. And then, certainly, if you are on certain medications like oral steroids, chronic inhaled corticosteroid use for treatments for like COPD or chronic asthma, certain cancer treatments, particularly in women breast cancer treatments, medications like anastrozole, some of these medications that block estrogen put you at higher risk; men with prostate cancer that have testosterone-blocking agents are also at higher risk. And there's a whole multitude of medications that do have a connection and risk for early bone loss.

Something very common like acid reflux medications, the PPIs, like omeprazole or Prilosec, Protonix or pantoprazole. These medications also carry risk factors. Certainly, family risk as well. I mentioned that FRAX tool—they look at did mom or dad have a hip or spine fracture? You could take it a step further and say, you know, even if siblings have a diagnosis of osteoporosis, you all share similar genetics. Similar disease processes carry on through families So, it is an argument to get that screening DEXA, and I recommend it early and often.

Host: And on the preventive side, what can we do to protect or strengthen our bones during or after menopause?

Ben Diffenderfer: Sure. The key is certainly making sure you're maintaining a good healthy diet is you want to have good sources of calcium, good sources of vitamin D. We can certainly talk about other supplements that are important, making sure you're getting them through your diet often is good enough. But things like vitamin K and K2, magnesium and zinc and phosphorus, all of these components that make up that kind of mineral matrix that bone is made out of, having deficiencies in those can lead to additional problems. With a good healthy diet, most people are getting those things. But certainly, supplementing a small amount usually is safe and certainly something you could discuss with your primary care or if you talk with a bone health specialist, certainly having that conversation would be appropriate.

Most people do have to supplement vitamin D3, unless you're eating salmon, three meals a day, you know, you're just getting it in the atypical American diet. Good sources of calcium, the ideal forms are food sources. Your body's going to absorb it better. It's going to be able to utilize it better. And it's not going to get deposited in other areas of the body as frequently if you're getting it through these food sources. But certainly, if you're not getting your daily value, which is around 1000 to 1200 milligrams a day, whatever you're not getting, you should be taking as a supplement. But I don't ever recommend taking any more than the 1200 a day, because you don't want it depositing in your blood vessels or in your kidneys and giving you kidney stones or in your joints or just other areas of the body.

So, diet is certainly important. But then, the other thing that's extremely important is exercise. Your bones respond to stress. They will get stronger and stay stronger the same way muscles do. Keeping your muscles strong around your bones, provide them with good blood supply and nutrients and all the things. And that's one of the things we see as we age. We lose bone mass, but we also lose muscle mass. So, the idea of muscle wasting that's associated with aging, something we call sarcopenia, goes hand in hand with bone loss and is often very closely associated with it. So early on in your life, getting those good habits of a good diet, of good exercise, maintaining good skeletal muscle is essential for maintaining bone health later on in life.

You know, I talk to every single one of my patients about diet and nutrition. I talk to every single one of them about the importance of exercise. They all get a physical therapy referral to go over fall risk reduction and then recommendations for exercises that they can pursue safely, because everybody's going to have different ability levels. So, meeting with a specialist, like a physical therapist, other trainers that have a mindset focused on bone health and osteoporosis is important. You know, your trainer down at the local gym is going to be good to get you stronger. They may not have the same type of training or mindset to allow you to do that safely and make those safe recommendations for you. But ultimately, weight-bearing exercise, progressive resistance exercises all are going to be super important. Your bones have these little receptors inside of them that measure stress. And they will respond to that stress so they become more resilient, less likely to fracture, if, God forbid, you do have a fall, and it will slow down that bone loss over time.

Host: Ben, this has been really helpful. Thank you for this vital information to help us support bone health.

Ben Diffenderfer: Sure. It's been my pleasure. I'm always happy to get the word out, because it's so under-recognized and undertreated. The more people that hear about it, the better.

Host: Ben Diffenderfer leads the Bone Health Program and Bone Health Clinic at University of Maryland Upper Chesapeake Health. He is a doctoral candidate at University of Maryland, Baltimore for Doctor of Medical Sciences. Listen to more at umms.org/podcast, YouTube, or your favorite podcast platform.

Thank you for listening to Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.