Osteoporosis Prevention & Hormone Replacement Therapy I Dr. Doug Lucas

Speaker A: 00:00:00

Our bones are these amazing organs that are living and breathing and doing a lot of things all day long. Every day. There is constant bone building, constant bone breakdown occurring every day in every bone in our body, some faster than others.

If the metabolism of the bone gets wonky and you have more breakdown than building for a long enough period of time, you're going to develop osteoporosis. So it's this imbalance in bone metabolism that ultimately ends up in osteoporosis.

Assuming that you had not osteoporosis at some point in your peak, bone mass was higher than that.

So that allows us then to look at this differently because when we talk about treatment, the T score doesn't really tell me much other than I have low bone density, what do I do about it? Versus the bone metabolism question becomes, well, why am I losing bone faster than I'm building it?

Let's fix that problem first so it gives you something to aim for when you decide that you want to do something about it.

Speaker B: 00:00:57

Welcome to the Optimized Woman, the podcast for high performing women ready to take back their health.

Speaker C: 00:01:02

Hi, I'm Orshi McNaughton, a board certified holistic health practitioner and functional nutritionist. If you're tired of feeling stuck, you can't lose the weight.

No matter what you do, your energy is in the toilet, your metabolism feels like it's at a standstill, and you lost the spark you once had, then.

Speaker B: 00:01:18

You'Re in the right place.

Speaker C: 00:01:20

We are here to unleash the unstoppable force you're meant to be and give you the tools to fix what's holding you back. So if you're ready to own it.

Speaker B: 00:01:28

Start thriving again and live the life you deserve. And let's get to it.

Speaker C: 00:01:36

Welcome, friends. Today we are diving into a conversation that could transform how you think about bone health and aging.

Did you know that over 10 million adults in the US most of them women, are living with osteoporosis? But here's the good news. In most cases, it can be reversed through natural and holistic therapies. Joining me is Dr.

Doug Lucas, a double board certified physician who transitioned from orthopedic surgery to focus on reversing osteoporosis, optimizing hormone health, and helping women extend their vitality through functional medicine. While many think this issue only affect older people, poor bone health often begins much earlier, sometimes as early as your 20s.

As a matter of fact, we discussed how Dr. Doug learned he had osteopenia in his 20s. Additionally, when it comes to Women's health.

The most rapid bone loss occurs during the first five years after menopause, which is a critical window where timely intervention can make all the difference.

So in this conversation, we'll explore the key considerations for hormone replacement therapy for women of different ages and how optimizing hormones can transform your bone density and muscle mass. We'll also tackle the essential role of nutrition and lifestyle in reclaiming your health and vitality.

So let's dive right into this important topic that all women should know more about.

Speaker A: 00:03:02

I started getting the sense that I was in the wrong place pretty early on in practice. So through training, traditional medical training, medical school, residency, fellowship, all of that made sense.

And I was just very mission driven, wanted to be the best surgeon I could be.

But as soon as I got into practice and I was actually taking care of patients and following them long term, which is the biggest change when you actually get into your own practice, I realized that while we were doing great things in the operating room and the surgeries were going really well, and I really do like operating. Actually. What I was noticing, though, is that we were making people very different, but oftentimes not making them very much better.

So I was a foot and ankle subspecialist. So foot and ankle is a really interesting subspecialty. Lots of chronic disease, diabetes, lots of stuff that's really hard to treat.

We would do surgeries in those when we had to for those patients. And again, different, not really better, hopefully trying to keep them mobile, but feel like we really weren't doing very much.

The fracture work that we did was a little bit different. Obviously, if somebody breaks their leg and we fix it, they're going to get better faster. So that part was different.

But I felt very quickly and early on that there was more to my exposure to patients than I was actively getting. So I went through a couple of years of really challenging discrepancies in what I wanted to do versus what I was doing.

And I would start to talk to patients about nutrition and lifestyle, and they just looked at me like, this is not what I'm here for, Doc. Just fix me. So I was exposed at the same time to my wife's experience.

She has a PhD in nutrition, she has a clinical practice, and she was helping people to reverse diabetes and let go of medications and drop weight. And I was watching all of the things that cause people to need me go away. And. And I thought, wow, that's impressive.

So fast forward about seven years, couple of different practices, different scenarios where I was trying to make it work. And I realized that I really needed to make a change, not only so that I could do what I wanted to do for patients, but also for my own lifestyle.

Because being a surgeon in some of the trauma heavy areas where you have to take call, you're up all night. In my household, with three young kids and a wife who also has businesses and lots of time demand, it just wasn't working anymore.

So I was forced to make a shift to not only do what I wanted to do for my patients, but then also for my family. So I jumped ship, did additional training, started the practice, and it's been a totally different road since then.

Speaker B: 00:05:22

Well, we are really glad you're here because not a lot of traditional and trained doctors are in this space. So you're doing some amazing work and that's what we're going to dive into today.

And interestingly, when I was getting ready to do this interview, I listened to the interview with your wife and, and in that interview, you guys both mentioned that you had osteoporosis or osteopenia at around 20 or 30, at a really young age. And to be honest with you, this is one aspect of osteoporosis that I did not know about, is that people can get it at such a young age.

And that this idea of peak bone density and developing that when you're younger, when you have the highest level of hormones and all that in your body. Can you talk about that a little bit? Because this is a disease that's really hit home to you. Were you 20 or 30 or what age were you in?

Speaker A: 00:06:19

My. I was in my early 20s. So this story is.

I don't know how much of it we told in that interview, but the story is my wife was getting her PhD in Virginia Tech, where I was going to medical school, and her thesis involved doing DEXA scan, which is the modality we use for imaging for Bono. She was using it for body composition, but we got a T score, which is the diagnostic criteria for osteoporosis.

So we were getting T scores on all of the participants in her study, and I was one of the participants in her study. And so we got a T score and I had osteopenia and I was in my early 20s. And I didn't even, didn't even know what that meant at the time.

I didn't really realize it until I went back later because I remember I was like, gosh, I had a dexa in my 20s. I wonder what it looked like? And I went and looked and I was oh, negative one, two, which, weird. So it's not terrible.

But still, for a 6 foot tall, relatively athletic guy, you wouldn't expect that. My wife, similarly, we both were professional ballet dancers before we started our second or third career, whatever you want to call it.

So there's a lot of reasons why we potentially have osteopenia. But same for her where she had low bone density as well.

And something that we've both been working on, not extensively, but something that's been on our mind, which is really important when you think about it.

If everybody knew that they had good or, or not so good bone density, it would change the way that they train or eat or the activities that they do throughout their entire adult life. So it's really important that we do screen early. And I think that's something that's really missing in our recommendations.

Speaker B: 00:07:47

I think most people think of osteoporosis as an old people's disease, something that you get when you get really old. I don't have to worry about that right now. So many other things to worry about. Let's not worry about that right now.

But you have especially maybe as we go into this topic a little bit more and you can talk about hitting that bone structure and development when you're younger, how important that is with all your knowledge. Now, what caused that for you to have that and for your wife too, at such a young age, being in ballet?

I, I would assume that's a lot of exercise, a lot of jumping, very athletic. Was that malnutrition? We can dive into that later. But before we even go there, I would really love to just define what osteoporosis is.

So let's start with that.

Speaker A: 00:08:33

There's two ways to look at that. There is the traditional definition, which is that T score thing that I mentioned.

So when you get a DEXA scan, they're going to look at the bone density of specifically your spine and some areas around your hip. And they're going to measure the density through the X ray that goes through it.

That density is then compared to a sex and ethnicity matched person with peak bone mass in their early adult life. And you're going to basically grade that from a standard deviation or number of standard deviations below that average.

And that's going to give you a T score.

The T score then could be negative one to negative 2.5, which is osteopenia, and that's one to two and a half standard deviations below or below negative 2.5 or less than negative 2.5 is osteoporosis.

And those are the definitions based on the World Health Organization and the National Bone Osteoporosis foundation and all these different organizations. But that doesn't really tell the whole picture. So that is the diagnostic criteria.

However, I look at osteoporosis as more of a bone metabolism problem. Our bones are these amazing organs that are living and breathing and doing a lot of things all day long.

Every day there is constant bone building, constant bone breakdown occurring every day in every bone in our body, some faster than others.

If the metabolism of the bone gets wonky and you have more breakdown the building for a long enough period of time, you're going to develop osteoporosis. So it's this imbalance in bone metabolism that ultimately ends up in osteoporosis.

Assuming that you had not osteoporosis at some point, your peak bone mass was higher than that.

So that allows us then to look at this differently, because when we talk about treatment, the T score doesn't really tell me much other than I have low bone density, what do I do about it? Versus the bone metabolism Question becomes, well, why am I losing bone faster than I'm building it?

Let's fix that problem first so it gives you something to aim for when you decide that you want to do something about it.

Speaker B: 00:10:33

So when you look at a DEXA scan or some diagnostic tool, someone comes to you. I'm assuming that's the first layer of diagnosis. And then you start investigating what is wrong with your bone metabolism.

Why did you end up in this place?

Speaker A: 00:10:48

Most people come in who already know it. They come to us because they have osteoporosis. They've had a DEXA scan. Usually they've had multiple, and it's been a whole journey.

And they come to us and they're like, why can I reverse this bone loss? Why am I losing bone? So we already have the first step in place. Sometimes we get an additional imaging modality.

So that would be the EchoLight REMS, that's a company out of Italy. It's an ultrasound device, which is really cool, and it's gaining momentum and steam in the bone health space.

I really like it because it tells us about both bone density, but also bone quality, and bone quality is a whole half of the equation of fracture risk. So that's a really cool additional bit of information if you can get it.

But either way, you have to then take that next step, which is, okay, let's figure out why you're losing bone faster than you should. And that's how we start the process.

Speaker B: 00:11:33

And then are you looking at nutritional approaches like nutritional deficiencies, mineral deficiencies, lifestyle factors?

Speaker A: 00:11:42

We started out just doing consults and just looking for that thing like, okay, what is the thing that we can fix? But what we found is that it is so lifestyle heavy that it really takes a comprehensive look and program.

So now we run a 12 month program and we bring people in, they meet with our dietitian, we walk them through an extensive interview where we're asking about all the lifestyle stuff, the history of exercise and impact and hormones, diseases and over the counter medications and just all the things. Did you have normal periods? Did you have painful periods, did you not ovulate? Did you have issues with fertility?

All of these things matter when it comes to bone. So you get that extensive history and then you look at what people are eating. And you mentioned nutrient deficiencies.

We see it, I don't want to say every patient, but it's very common that we see nutrient deficiencies coming from something missing in the diet. It's just probably true for people across the board, but it's really true in osteoporosis. And then we get our biomarker panel.

So we get a very extensive blood panel.

We're looking at numerous different biomarkers from the healthspan lens, not just for bone health, but we're looking for those obvious things like parathyroid tumors. We're looking for some of the no brainers when it comes to osteoporosis.

But then we're also looking at other things like thyroid inflammatory markers, cardiovascular risk, dementia risk, nutrient deficiencies in blood, because we have to do this with a comprehensive approach. Because if I just fix your bones, but I make your heart worse, I didn't do any good. So we have to really be smart about this.

Then once that panel is done and resulted, then you meet with one of our providers.

The providers goes through the panel, comes up with a custom supplement list, we talk about hormone optimization, we again discuss lifestyle, which they have already been doing. And then we put that forward with the help of their dietitian and group coaching for the next four months.

And then we rinse and repeat at the six month mark and then we go again by the end of 12 months. We generally know why was I losing bone, what can I do to improve it, what improvements have I seen so far?

And now we get imaging at the 12 month mark, which is a little early to be honest, but imaging at the 12 month mark should tell us what's happening and are we headed in the right direction. Even if it hasn't changed, I'm actually okay with that. But for most people, we see improvement. And sometimes we see dramatic improvement.

Not sometimes. Often we see dramatic improvement. Rarely do we continue to see it go down at the 12 month mark.

But our threshold of success is you haven't lost bone because most of our patients have been losing bone for a long time. So we want to flatten out that curve and then change it and go the other direction.

Speaker B: 00:14:09

And I bet you that when people go through your 12 months program afterwards, it's like, oh, I also lost weight. Oh, my body composition is better. Oh, I have less insulin resistance, I have problems, and my other immune issues I'm better with.

It's probably because when it comes to more of this holistic or nutritional approach, you fix all the systems in the body simultaneously. Because I'm sure bone health goes to cellular health and it goes to foundational health.

And if you start improving that, you overall become healthier. And this is why it's sometimes difficult when people come to you with one issue and oh, I just want to lose weight or I just want to do this.

We have to work on everything and we have to get you overall healthier.

And even when it comes to bone health, you can that focus in, in the approach, but you still have to have this systems approach of just making the whole person healthier.

Speaker A: 00:15:05

Our program actually didn't start out specific for bone health. We built this health optimization program for chronic disease reversal prevention, health optimization in general.

And then we just layered on the bone turnover markers and then got very specific to the lifestyle stuff for osteoporosis.

But the company started out, it's called Optimal Human Health, MD changed it to call it Optimal bone health because that's all we talk about, it's all we put out into the world. And our mission is to talk about bone health. So it has become that. But it was based on health optimization in general.

And you're right, we've talked about how can we reduce this blood panel because it's a lot. How can we make this more simple? What can we cut out? But then you start saying, well, what do I cut out?

Is it heart health, is it thyroid health, is it inflammation? You can't cut any of those things out. Osteoporosis is really a sign of something going wrong in one of those systems.

So we have to look at all those systems.

Speaker B: 00:15:56

Everything is connected in the body.

And I think this is the difficulty of an ethic system that's so siloed and everything is looked at separately that it's almost impossible to treat it.

From that perspective, besides the simple tools like some medications that they have and they always have side effects, the one lever approach almost never works. And so I really appreciate that you have this holistic approach to treating this. I just one more question to drill down a little bit more on testing.

You mentioned a whole bunch of blood panels and tools that you have. Do you go into GI testing, do gut health, do you do organic acid tests or hair tissue mineral analysis and looking at mineral balancing.

What are some of the other things you're looking at?

Speaker A: 00:16:44

So the answer is yes, we do potentially all of it.

Where we start though is we generally are going to do a stool study on everybody because we see gut dysfunction, microbiome dysfunction, just again globally in our patient population and that is part of the nutrient deficiencies.

So we used to have a just a budget for functional testing in the program and then our dietitians would then pick and choose with the providers what we wanted to use. But what we found is that really we need to start with understanding the gut and everyone.

So I pretty sure that every patient now is going down that pathway unless they've already had it and then we do something else. So yes, we definitely do that.

We often will do a detailed nutrient deficiency analysis like a nutri eval or an oats test, something that's going to help us to understand what are some of the things that are missing on a cellular level. The htma, hair tissue mineral analysis. We've played with it. I, I think it's relevant.

I just feel once you get so much data there's too many things to fix. So we have to say what's most important and let's start there and then, and then we'll go from there. I think it's all potentially relevant.

Some of the things like I love looking at neuronal cortisol. You could go down so many pathways.

You could look at total tox testing and look toxins and heavy metal and just go down every rabbit hole you can imagine. So we have the ability to do all those things, but we run into the issue where we just run into too many things to treat and it.

Speaker B: 00:17:58

Gets a little bit too expensive for people too. That's always a struggle. What test should I order?

Because the people have a budget and we would love to have all these tests because the more data points you have, sometimes the better plan you can have for people. But you do have to limit that just like how many supplements you gifted people. I have to be limited.

So I would love to dive into how many people in the United States have osteoporosis and osteoporosis and then out of that how many are women? What are the ratios approximately on men versus women?

Speaker A: 00:18:32

The numbers here are not very clear. So if you go to National Osteoporosis foundation, which is now NBAF, National Bone and Osteoporosis foundation.

But if you go to their website, I think you'll see numbers that say there's 10 million adults with osteoporosis in the United States. I think that number is very low probably because we're not screening Everybody until they're 65.

So most adults have not been screened for osteoporosis. So we don't know how many people have osteoporosis. And I see it in younger population all the time.

So I don't think we know the answer to that question. I think it's much higher than that 10 million figure would indicate. Osteopenia is even then a much bigger number on top of that.

And so I've heard again this, the statistics out of those organizations was it is 50 billion people with osteoporosis and osteopenia. As far as male, female.

If you look at the entire lifespan, about 50% of women and 25% of men will end up with some type of fragility fracture in their life. But most of those are going to happen at the last decade of life. So it is probably something like that. About two to one female to male.

I think we're also seeing though more men are going to develop osteoporosis even though they should have a better starting point because of all the lack of impact change in exercise and activity and also testosterone levels rapidly declining in our population. Overall, I think we're going to see men have osteoporosis at much higher rates now.

Females still going to continue to be probably more predominant because menopause is an absolute mandatory for women who live past the age of 50. We're going to see more women than men, but I think men are going to start catching up.

Speaker B: 00:20:06

Let's jump into talk about women. You mentioned menopause. Within that five years after menopause, it's like a critical window.

Let's talk about hormones and what happens when our hormones decline. How is that affect bone metabolism?

Speaker A: 00:20:21

So the sex hormones are very, very powerful when it comes to bone metabolism. So regardless, female, male, but in women it's such an important conversation because again women Go through this thing called menopause.

And once, whether it happens mid-40s to mid-50s, whenever it happens in that timeframe, you're going to see a rapid drop of estradiol, specifically of the, the estrogens. You're going to see essentially elimination of progesterone. Testosterone may or may not drop precipitously.

Most of the testosterone is not made in ovaries. So it's possible to maintain testosterone to some degree, but definitely loss of estradiol and progesterone.

Estradiol and progesterone are critical to bone metabolism. So we know that in women who are cycling, you have to have ovulation, you have to have normal cycles in order to maintain your bone.

There was a nice study that was done that looked at women who had ovulatory dysfunction. If they didn't have five cycles a year, they started losing bone and that was with normal estrogen levels.

So they actually were producing estrogen adequately.

But because they didn't ovulate, they didn't have the corpus luteum, they didn't have luteal levels of progesterone that we would expect, and they were losing bone.

Speaker B: 00:21:29

Is that also for women that are sort of a birth control method when they are younger and they don't have ovulation for sometimes years?

Speaker A: 00:21:37

Not all oral birth control will stop ovulation, but of the ones that do, we do see bone loss. And that is a big concern that I have around birth control, especially women.

Speaker B: 00:21:46

That are younger, because that is particularly scary when you haven't even potentially peaked your bone density yet. Right, right.

Speaker A: 00:21:57

Let's take our, our teenage girls and put em on birth control. For whatever reason, we're putting them on these synthetic progesterones that are potentially gonna prevent ovulation.

That's gonna have an impact on a lot of things, including bone.

Speaker B: 00:22:08

I would love to dive a little bit deeper into estrogens and then go into progesterone and then also talk about testosterone. So starting with estrogens, you mentioned estradiol.

And I think this is sometimes controversial in, even in the functional medicine space of hormone replacement therapy. Is it replace estradiol only or is it by estrogen?

Can you speak to the importance of estradiol for bone density and how specific type of hormone replacement therapy can help or not help?

Speaker A: 00:22:40

So I actually was trained in the clock channels based on hormones. I was trained to use bias, I was trying to use topical. And when I started in practice, that's what I did.

One of the early efforts, I did on bone health research. I ran across a paper that changed my practice though.

So this is a paper from the, I, I forget the author of the journal, but it was a paper from the late 90s and they were basically looking at different levels of estradiol and the impact on bone mineral density over the course of 12 months. This is a really cool study. We don't see studies like this anymore.

But what really blew me away is not that they had different levels of estradiol, is that they used estriol, which is the other hormone in bias. Generally they used estriol as a control.

And they said very clearly in their, in the abstract we chose estriol because we know that Shreya doesn't protect bone. And I was like, what? What? Are you sure?

And so you can see in the paper that the control group or the estriol group lost what you would expect to see on somebody on placebo. They lost about 2% of bone marrow density over the course of those 12 months. So estriol does not protect bone.

So if you're on an: 8020

Speaker B: 00:23:53

When I learned about this a few years ago, I switched to estradiol because I was doing biased as a part of my hormone replacement therapy. And I mean to switch now. Is there a difference between topical, oral, injectable, what form you replace estradiol.

Speaker A: 00:24:10

So you can do it any number of ways. So we prefer topical through a compounded cream because we want to be able to manipulate dose regularly up and down.

I don't like patches, cuz I don't like the rise and the fall over the course of the three days that you're on it. So I prefer a cream. You can do it. Pellets do work. I've interviewed some pellets gurus who are great with pellets.

But I think pellets present an opportunity for danger because you can't control it. Once it's in, it's in and you're on a ride. Hopefully it's a good ride. So I don't love pellets for that reason.

I do also know some women who prefer to do estradiol injections. It's a thing, you can do it. I just don't think most people need to do it. So I think a cream works, is reproducible, we can get adequate serum levels.

Speaker B: 00:24:54

With treatment and on the blood work, what do you like to see? See for estradiol as an optimal range for bone health, specifically in somebody who's already postmenopause.

Speaker A: 00:25:04

So we talk about this a lot. There is literature to support this range of 60 to 80 picogram per milliliter.

But what we found in our patient population is that some women, when we are looking at other biomarkers, like the bone turnover markers, like FSH, when some women have estradiol levels of 20 to 30, all of these other biomarkers start to line up.

So maybe we don't need to get to 60 to 80 in this patient, but then we have other patients, we drive em to eighty or a hundred and their FSH is still ninety and their ctx, the bone breakdown marker, is still eight hundred. We're like, okay, we need more estrogen, so we'll drive it higher. So I think there's receptor variability, there's genetic variability.

So I don't think we can use that 60 to 80 as a hard line. It's a great starting point, but you need the other biomarkers to understand what's happening in the body.

Speaker B: 00:26:42

Now let's talk about progesterone. Why is progesterone important? And also what happens to a lot of even younger women when they're stressed out?

Or a lot of perimenopausal women, they may not even be aware that they might need hormone replacement therapy. But what happens to our progesterone?

Speaker A: 00:27:01

Progesterone is critical for bone health. For a pre menopausal woman, there is a natural push pull in a woman that has normal cycles.

That push pull is so critical from a receptor level because estrogen provokes progesterone receptors to come up and vice versa.

So you need that push pull throughout the month once you lose it, or in the perimenopause timeframe when things get a little wonky, you can end up with progesterone deficits. And so you might have lower progesterone levels.

And so we hear now for a lot of your audience is probably on social media and they're seeing this perimenopause menopause movement, which is great, but there's a lot of confusing terms out there.

So you'll hear terms like estrogen dominance, you'll hear terms around like progesterone deficiency and adrenal fatigue and and androgen deficiency, testosterone, all of these things. I think it is all part of the big picture of just hormone imbalance.

We need to have adequate progesterone to balance estrogen is the natural yin and yang. But what that means in the perimenopause timeframe, pre menopause timeframe, what that means for postmenopausal women is very different.

And this is where working with somebody who understands how to look at this, how to ask the right question so that we can manipulate doses accordingly is really, really important. When I wrote the book I wrote about hormones, there was so much of it that people.

I get the all these stories, especially on our YouTube channel, thousands and thousands of stories of women who say hormones didn't work for me.

And when you get the opportunity to dig into that, it's usually because either they weren't offered hormones or they were put on a birth control pill, or the provider just never asked and they weren't willing to change anything, so they were put on a combi patch or whatever. And it's a one size fits all approach, which doesn't work for most women.

And so we have to be able to manipulate progesterone dosing, timing, estradiol dosing. It is a very unique thing from woman to woman.

Speaker B: 00:28:50

You mentioned the push pull between estrogen and progesterone.

As far as women that are postmenopausal, specifically progesterone replacement, do you still like to cycle progesterone or have two weeks on, two weeks off, or a consistent dosing of progesterone is sufficient, or do you feel like you still need to have a push and pull between the two organs?

Speaker A: 00:29:14

Yeah. So there's some interesting data on this.

If you go back again, back before the Women's Health Initiative, when studies on hormones were allowed to be a little bit wilder, just to say it that way, the protocols were all over the place. And when you speak to providers, I don't know if you've interviewed Dr. Gersh. She's awesome. She was practicing pre Women's Health Initiative.

that we're prescribing in the: 1990

And everybody had their own protocols and were optimizing and asking the questions and doing biomarkers. After the Women's Health Initiative, when everything changed, we've got into this idea that low dose static HRT is the way to go.

So I think most of our providers have lost the art. It's easy to put a woman on a low dose Combi patch and call it a day. You're not going to get very many side effects.

You're not going to get a lot of calls and complaints. It's just easy, but it's not optimal.

The literature for bone health would say that cyclic progesterone is more powerful than static progesterone levels. Just to clarify that. So cyclic, two weeks on, two weeks off, that's one way to do it. That matches the follicular luteal cycles.

There's a bunch of different protocols out there, but something like that is what I would consider cyclic versus static, meaning same dose of estradiol and progesterone every day. We see results in both, but I think you're gonna see better results if you're cycling progesterone but you run up into the wall of.

Well, if we're driving estradiol levels north of 80 to 100 or higher for a woman that has a uterus, are we providing adequate protection over uterine lining? Are we going to provoke some kind of overgrowth? So you do have to be cautious of that and that is something that we look for.

But I think from a bone health perspective, you are better off cycling so that you do get some push pull.

Speaker B: 00:31:03

Do you usually do oral progesterone, topical? What's your choice? And for oral, do you just go with the standard a hundred milligrams or do you sometimes go much higher with progesterone?

What is your typical starting point?

Speaker A: 00:31:16

So we start, we start low, go slow. A lot of our patients, patients are not the typical within five years of menopause.

So we have a very unique patient population, anywhere between honestly 45 and 75.

So we have some women that are 10, 15, 20, 25 years out for menopause that are asking to start HRT, which is a challenging conversation and oftentimes possible. But we start logo slow because they haven't experienced hormones in a long time.

So we need to start them slowly, get the receptors upregulated, get things moving. So sometimes we'll start as low as 50 milligrams, but when we're doing that, they're not on estradiol yet. So we'll start low, we'll build it up.

My goal is to get them to probably 200, sometimes even higher if they can tolerate it. Cuz again, we're gonna drive estradiol as high as we need to to get fsh down. So I'm okay with women are 200.

If women are 300 milligrams of progesterone we just have to watch for side effects. But higher, better.

From my perspective, when it comes to bone, there is a, a ceiling as to how high you can go with oral progesterone before you're gonna get side effects. You mentioned topical. So we only do oral unless somebody can't tolerate it. And if they can't tolerate it, we will consider topical.

But then we have to be very careful with the urine lining because you can't measure it. So you don't know in blood if you're getting adequate protection of the uterine lining.

So you have to monitor it, you have to get ultrasound, you have to look or go.

Even the next step, which is to actually go to the step of physiologic restorations, you're actually restoring menstrual cycles in postmenopausal woman, which is a way to shed that lining, which you're going to be building. But that's a whole nother conversation.

Speaker B: 00:32:50

I'm assuming it's better to restore that cycle for younger women that are just post menopause or just going into menopause, and it's harder to venture there.

Speaker A: 00:33:00

You can do it, but is it tolerated? Is it advisable? This is a challenging space because there isn't enough research here.

But if you think about the physiology that we've talked about, the cellular, the push pull, the cyclic progesterone, higher levels of estradiol, it naturally leads you down this pathway to physiologic restoration.

Speaker B: 00:33:17

What's your take on something like the Wiley protocol that cycles all three hormones? Assuming you're trying to restore your youthful cycle completely, what's your take on that?

And what's the danger of hair and lining building up potentially for somebody who's postmenopausal?

Speaker A: 00:33:33

When I read the book. So Wiley's book, Sex, Lies and Menopause, it's a trip.

But I've actually talked to Julie Taguchi, who was the medical, I don't know what her title was there, but she was one of the co authors in that study and she's actually a, a really amazing physician to talk to because she's an oncologist and specializes in breast oncology and hormone therapy. So really interesting conversations around hormones and breast cancer.

And so while I think that Wiley took it to a really interesting space and created an entire industry around it, it was an interesting time. And then I think, unfortunately it didn't work out. Well, I'll just intentionally leave out the details there.

But I think that what happened is the, the, the providers that were practicing that protocol once.

That whole thing blew up, not because people were getting hurt, but because of the way that Wiley was working with the doctors and the, the pharmacies. It was just a mess. A lot of these doctors went underground and they just continued to practice.

They were afraid to talk about it because they were afraid that she was going to come after them and sue them for using her protocol. So they changed the protocol. They weren't using her protocol. They all had their own little recipes.

But I've talked with some of these providers that are still out there practicing and it's really interesting to hear their stories because what they see in hormone replacement is tremendous benefit from cycling hormones, from provoking menstruation and postmenopausal women. You see some really interesting things that are unfortunately just not well proven in literature. So I think that there is potential benefit.

I look forward to seeing studies and the studies are coming. So there are studies that are being funded by the NAH on physiologic restoration.

I think it's a thing that we're going to see the potential benefit for. The question is, is it worth it? It's a lot of work. So we offer it out of our practice. So we have women that are doing it.

But it's a lot of work and it is like a low dose combi patch. It's the easy button. Physiologic restoration, not the easy button.

You're going to get side effects, you're going to have complaints as you get things dialed in. It takes time and it's a lot of work for both the provider and the patient. So is it worth it?

I don't think that it's unsafe as long as you are doing all the right things. And that means looking at the uterine lining.

For women that have a uterus, if they are shedding like they're supposed to, then you can get a sense of what does that menstruation look like, how long is it, what does it look like, how heavy is it? Then you can do an ultrasound after the menstruation and see are they shedding their entire lining. You can do it safely.

I don't think that there is intrinsic danger there, but again, it has to be done because these women are on higher levels of estradiol and it's relatively unopposed. So they're cycling progesterone.

And if you don't have enough progesterone and you're not shedding, then yeah, you could absolutely get some buildup of the endometrium. So it's just gotta be done right and it's not easy to do, I'll put it that way.

Speaker B: 00:36:12

I. I wanna also touch on older women. So when I say older, you mentioned you work up to like 75. I use my mom as an example.

So she's in her early 80s, she has osteopenia. She had a full hysterectomy in her 40s. So she hasn't had hormones for a very, very long time. She's still healthy and mobile.

And when I say healthy, she has typical issues that you see in people in their 80s like high cholesterol, high blood pressure, those kind of things, but still fit and exercises and mobile and so forth. But I've been thinking, would she still benefit from some hormone replacement? What's your thought on somebody who has not been on it?

Older, Relatively still healthy older.

And I can also see a lot of her health conditions are also related for to the fact that she hasn't had hormones for four years, that those could improve too. But I'm too afraid to go there. So what's your thought?

Speaker A: 00:37:14

We get this question a lot. I think we're just do a patient review once a week with all of our providers and I think we're like four or five patients.

They're mid-70s to early 80s and they're interested in HRT. And so you have to have this conversation with them to say it's been a long time. But let's say it's been 25 years.

25 years without sex hormones is a long time. The body's gonna change. So I don't. I think that we overdo the risk statement for women 10 to 20 years out have a different conversation.

But once you get over 20 years out, it's been a long time. Your arteries are different, you likely have calcification, you have atherosclerosis, you have cardiovascular disease.

Would she benefit from hormones? Absolutely. Because remember, the organ of longevity is muscle mass. How do you maintain muscle mass? Estrogen and testosterone.

It's so clear and obvious. Also cardiovascular benefits, there's cognitive benefits. But is it safe to start? That's the question.

So we know that it's the first year after the introduction of hormones. If it's been a while, that is presenting the potential risk. And this was shown again the Women's Health Initiative.

Other studies for women, after 10 years there is supposedly increased risk.

And I do that in quotes for anybody that didn't see me say that the 10 to 20 year group, there actually isn't increased risk compared to placebo there's just increased risk compared to people 0 to 10 years out from men out. So put that on the table. But over 20 years out, that risk does start to go up. But it's unique and it's an individual.

So for us, we would take your mom, for example, we would say, okay, why do you want to do this?

Let's say you have osteoporosis, you've lost all your muscle mass, you're unable to maintain strength, all these things you say, okay, it might be worth considering. So what is your cardiovascular risk? And then you said she has high cholesterol. Okay, but is that developing atherosclerosis?

If we were to get a coronary artery calcium score, if it's a zero and she's in her mid-70s, is that a sign that she's got relatively good arteries? Absolutely.

I would probably, for a woman who's, you know, 25 plus years out for menopause, go the next step and let's get a CCTA with clearly, let's look at the soft and the hard plaque and the arteries. We've done this on some women in their mid-70s and it's been absolutely pristine. Their arteries don't have any atherosclerosis whatsoever.

So in that patient, am I afraid to start estradiol because they're going to have a coronary event? No, there's nothing to break off. So we have started it for some women who are 25 plus years out.

But it gets less and less common because you start looking under the hood and you realize they're not as healthy as they look because of that absence.

Speaker B: 00:39:39

Of sex hormones for so long chicken or eggs situation. When people are older, that estradio could improve so many of their other health conditions too.

But because they already have those now it's too late to start takeaways. The younger you are, the better just to take preventative action. If you're in your 20s or 30s, awesome. There's so much you can do to prevent this.

But if you're in your 40s and 50s, well, it's reversible still. And then as we get older, the harder it is to make changes.

Speaker A: 00:40:07

It gets harder. But even in our 70 plus year old patients who are not candidates for hormone replacement, we still see them improve. So it's possible it's slower.

We see some incredible double digit improvements in a year increase, 10, 15 rate of a guy that just did 18 month rems, 25% increase in bone density, some unreal numbers when you start stacking it all Together.

But even for women who are over 75, no hormones, doing the lifestyle, the nutrition, the gut health, doing the work, we can still see a plateau and go up. So I want to say it's never too late.

Now, if you're 90 years old and you're in a wheelchair and you had a hip fracture, probably pharmacology is your solution. But if you have the ability to do the things, then you should be able to improve your bone health.

Speaker B: 00:40:51

I want to touch on testosterone, so clearly incredibly important for men. But there's also a role to play for women. For hormone replacement therapy. I always like to start with estrogen, progesterone.

But then when do you bring testosterone in for women?

Speaker A: 00:41:06

So we start with estrogen and progesterone. We want to get that optimized first.

And what we have found is again, most testosterone for women is made in the adrenal glands and in the periphery out of adrenal precursors. So a woman, even a postmenopausal woman, can have pretty reasonable levels of testosterone naturally.

Now, it's not that common because adrenal glands are impacted by stress. Most of us are under stress. So we now, I think as a population see lower levels of adrenal driven testosterone in women.

I think that's why menopause has gotten harder for so many women. It's not because women are any different now than they were 50 years ago. I think they have lower testosterone as they're going through it.

I think that's a big part of it. So testosterone is very important. But if you optimize estrogen and progesterone first, you might see a rebound in natural testosterone production.

If you don't, then we would consider it, but only after we've started with it.

The other part of that is we have also found that for our older patients, our patients in their 70s, even 60s, they don't tolerate very high doses before they start complaining about side effects like hair loss. So while it would be great, I would love to, for, let's say your mom, for example, she's not a candidate for estrogen necessarily.

Well, what if we did cyclic progesterone and testosterone? Obviously off label uses. But what if we were to give her some androgens through testosterone and then cycle progesterone?

She's going to still get a push, maybe not a pull, but a push of hormone. Maybe there's some benefit there. Never been studied like that, but it's a thought.

But I can't give her adequate testosterone generally because she's going to tell me that her hair is falling out. And we see that pretty globally in our patients over seven years old.

Speaker B: 00:42:41

I would love to cover before we run out of time talking about some fitness strategies. Weight bearing, exercise. What are the ideal type of fitness activity that people can benefit from?

And then if you see benefits from things like Osteostrong, some of these outfits that are specialized in reversing osteoporosis. Can you speak to that a little bit?

Speaker A: 00:43:01

So let me just hit the stuff you can do on your own first, and then I'll talk to you about the modalities. So there's a lot you could do on your own.

But we have to be careful here because so many people with osteoporosis, especially women, have never lifted a weight. We see this in this generation, really. It's two generations of women who were just told, if you lift weights, you're gonna get.

You're gonna get too big, you're gonna get bulky. So skinny's better. Stick to the treadmill, stick to the StairMaster, and you got it. And they got it, and they got skinny.

But now they have osteoporosis and they don't know how to lift weights. And that's okay because it's never too late to start, but you have to start safely.

You see a lot of influencers talking about all this weightlifting stuff you can do for osteoporosis. And it's true. But if I told your mom to go do a deadlift and a back squat and an overhead press with a barbell, she gotta hurt herself health.

But those are the exercises that are gonna help her to improve her bone density. So we have to find out what your starting point is and then work your way up to that if it's possible.

But we also have to remember, too, that weightlifting, while really important for muscle mass, actually doesn't build bone. And this is a big misconception. So people will say, oh, resistance training builds bone. It doesn't actually.

If you look at the studies, there's only one study on a resistance training program that shows improvement of bone marrow density. And they also paired it with impact.

So you have to have some form of impact to bend the bones, to stress the bones in order for them to stimulate bone growth. And that's where the modalities like osteostrong come in.

So this principle of osteogenic loading is a term made up by John Jaquish, who is the PhD that designed the equipment for both OsteoStrong and BioDensity, two companies that have A similar product. And the idea is, if you put certain body parts, let's say your legs, for example, we all know that it's hot part of a squat.

So it was last 15 degrees. We know that you can lift so much more weight here than if you go all the way down and all the way up.

So those last 15 degrees, you are a very strong mechanical advantage.

eks ago, and I was able to do: 1400

I'm strong, and I'm not that strong. That is over four times my body weight. And that's what you have to get to to stress the bone.

What's really cool is when you look at this, they have pressure sensors in the devices, so you can see how much you're pushing, but the device doesn't actually move. But my legs are moving. And if you look at it and you're like, no, that plate's gotta be moving some, but it's not. It's fixed in place.

What's happening is you're bending the bones, you bend the bones, the bones will react to that by laying down more bones. So that's why OsteoStrong, Biodensity, these companies, they can help to build bone.

The challenge I have with the modalities is that the research is just not that robust. There is research, it's out there, but there's small studies.

And these devices are controversial because there hasn't been a big study that shows that it's helpful, to what degree. So I tell people, if you have access to it, great, be careful on it.

If you're pushing that much weight, you could potentially hurt yourself, but you're controlling the weight. So just be careful on it. And I think it could be helpful. But know that you can do impact on your own at home. Heel drops, box jumps, whatever.

You can do the impact, add it to resistance training, and you could do it without the modalities, too. So we don't necessarily need those things, but they are good adjuncts.

Speaker B: 00:46:22

And I want to just bring it back to what you mentioned of you having osteopenia in your 20s and that you were doing Valium, because that has a lot of impact, right?

Speaker A: 00:46:32

Yeah.

Speaker B: 00:46:32

Like you're jumping, you're doing a lot of things.

So I really would like to know, based on everything that you know about osteoporosis, all your holistic health background, what was the reason that you developed it?

Speaker A: 00:46:45

I think I never had good peak bone mass. And I talk about this not infrequently because people always want to know, why does Dr. Doug have osteopenia? It's getting better, by the way.

So I live in a household. My mom was a nurse and my dad was a cardiothoracic surgeon. So heart health is all we talked about. And I was born in 78.

So the: 1980

I probably ate a 85, 90% carbohydrate diet growing up, so I didn't have adequate protein. I was an active kid, but didn't do a lot of sports, so I think there was not enough activity, not a good diet.

I probably just never had good peak bone mass, even though I grew tall, Definitely higher than average for my family. I'm over 6ft tall. I probably never had good peak bone mass.

Speaker B: 00:47:32

So nutritional deficiency or lack of protein.

Speaker A: 00:47:35

Primarily in your diet and dietary fat. So I probably had low. All those things that go along with dietary fat.

Speaker B: 00:47:40

I guess this is really important that we also touch on protein and the relationship of muscle mass and bone destiny. Maybe you can just speak to that real quick.

Speaker A: 00:47:49

They're linear. Everybody that has osteoporosis has sarcopenia, which is the loss of muscle mass. So again, chicken or the egg? Which one comes first?

I don't really know. But we know that we see them together, and if we're gonna fix one, we need to fix the other.

So when people hear me say resistance training is so important, we have to wait, train to improve our bone health. Again, it's not for the bones, it's for the muscles. We have to improve them both.

You asked about protein, though, and so I actually was just prepping a talk for Longevity Fest next month in Vegas. And what they wanted me to talk about is protein and longevity. Protein and osteoporosis and muscle mass.

I already had some studies, but I just sort of went down this rabbit hole of like, okay, how many studies show this relationship between protein intake and bone health and protein intake and sarcopenia? It is just so crystal clear. People that eat more protein have better muscle mass.

People that eat more protein have higher bone density and lower fracture risk. You see it in every single study. So it is very, very clear that we need to eat a protein forward diet. If we Want to tain maintain muscle and bone.

If you want to have good health span, good lifespan, you want good longevity, you gotta eat more protein.

Speaker B: 00:48:57

What would be your advice for women that want to have a more longevity, a more optimized health span and you, you have to give them just one advice. What would that be?

Speaker A: 00:49:07

Is it diet or is it exercise? One of those. Or hormones? Can I give them three? Can I give them?

Speaker B: 00:49:12

Yes, you can do it.

Speaker A: 00:49:13

From a nutrition perspective, what we just said, protein, forward diet. If you track nothing else, track protein. That's it. And I would say one gram per pound of ideal body weight. Exercise. Resistance training is king.

It's absolutely king. Impact's important for both, but resistance training is king. Don't be afraid to lift weights. Prove me wrong.

Take a picture after you've been training and show me that you got too big. It's yet to happen. And then number three, hormones. Please, please, please.

If you're a woman who has just gone through menopause or at least in the last 10 years, have a conversation with the right provider about the risk benefit of hrt. It is a no brainer for the vast majority of women in my opinion.

There are so many benefits that are underrepresented and the risks are overrepresented. So you gotta find that right person.

Speaker B: 00:49:56

You mentioned a couple of different exercises that are the best.

Obviously the 80 year old woman may not start doing deadlifts or back squats with a barbell in their back, but somebody who's still fairly healthy, still younger, what would be the top three or four movements that could be the most beneficial that you can do in the gym?

Speaker A: 00:50:17

I think those are them.

So these free weight barbell or dumbbell, but full body exercises, so the reason why the back squat, the deadlift, the reason why these exercises are chosen is because you're holding the weight with your upper body, you're using your core to maintain your balance and then you're lifting with your legs. Those are the biggest impact exercises you can possibly do. But you're right, they're not easy.

Doing a back squat properly, doing a deadlift properly requires a lot of training. Honestly, I'm still trying to figure out how to do a deadlift correctly. So using a trainer, I wouldn't do this online.

Figuring out how to do these full body movements in the meantime, you can, if you have access to a gym, the mimicked version of these, the pseudo version of the squat, which is like a leg press. It's hard to screw up a leg press. You just sit in the machine and you push the thing. So if you can mimic some of these things, I think that's great.

The machines make it very safe and controlled.

It's a really good starting point, but probably no substitute for working with a trainer and learning how to do free weights because you're going to get all that balance, you're going to get all that proprioceptive training. Once you hit that point, you could train on your own, then it sky's the limit. But you got to start somewhere. You probably got to put some effort in.

Speaker B: 00:51:30

Thank you so much. That was such a great conversation. Dr. Doug, how can people find your work? Your website? I know you have an amazing podcast. Tell us all about it.

Speaker A: 00:51:39

If bone health is what you're interested in, the YouTube channel, the Dr. Doug show, is a great starting point. So we have at this point, I think 230 videos. We do bi weekly masterclass coming out of that.

So go to the YouTube channel. I think if you just search Doug on YouTube, you'll find it. It's done that for us, so that's awesome.

And we have a community for bone health called the Osteo Collective. And if you just go to osteocollective.com, you can learn about that.

Our full service program is@optimalhumanhealth.com, but all of the things are linked to all the things. So if you go to one, you'll find the rest.

Speaker D: 00:53:07

Thank you so much for tuning in. This is Maya. Our production team pours our hearts into the show because we believe women deserve better.

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