Hormones, Bone Health and Aging: What you Need to know with Dr. Kristi DeSapri

Dr. Sameena Rahman [: 00:00:01

Hey y'all, it's doctor Samina Rahman, Gyno girl. I'm a board certified gynecologist, a clinical assistant professor of Ob GYN at Northwestern Feinberg School of Medicine, and owner of a private practice for almost a decade that specializes in menopause and sexual medicine. I'm a south asian american muslim woman who is here to empower, educate and help you advocate for health issues that have been stigmatized, shamed, and perhaps even prevented you from living your best life. I'm better than your best girlfriend and more open than most of your doctors. I'm here to educate so you can advocate. Welcome to Gyno girl presents sex, drugs and hormones. Let's go.

Dr. Sameena Rahman [: 00:00:49

Hey y'all, it's me, doctor Smyna Raman, gyno girl. Today I have a very special guest I'm excited for you guys to hear about. She is an amazing, amazing clinician and a menopause national menopause expert. Talk about something we haven't spoken about yet. And that's your bones, which I think sometimes gets neglected in everyone's evaluation and follow up. And so we're going to get into a little bit about menopausal hormone therapy and it's important for your bone health and what it means when your bones start to decline with midlife and beyond. This is Doctor Smyrman Gyne girl. For gyne girl presents sex, drugs and hormones, and doctor Christy Dsepri truly believes that women deserve function and optimal health and are gatekeepers to their families, communities and health.

Dr. Sameena Rahman [: 00:01:34

She's a board certified internist specializing in midlife women's health and is regarded as a national leader in the field of osteoporosis and menopause management. After fellowship training at the Cleveland Clinic, she has worked in private practice and academic medicine, including being the director of the Northwestern Women's Bone Health program at the center for Sexual Medicine and Menopause. At Northwestern Medicine, she's the founding physician and the owner of bone and Body Women's Health, a specialized midlife women's practice in Winnetka, Illinois focused on consultation and management of perimenopause, menopause, osteoporosis, fracture prevention and treatment, and sexual health. I will include all of her biography in the notes. Welcome, doctor Dasapri.

Kristi [: 00:02:22

Thank you, Doctor Rahman. I'm so happy to be here. Fellow clinician, fellow women's health advocate. So awesome you started your podcast and I just love your name. Gyno girl. Oh, thank you so much. It captures who you are.

Dr. Sameena Rahman [: 00:02:37

Thank you so much. Yeah, we had the pleasure of meeting, even though we are, like, down the street from each other. But we met the first time at the menopause conference. Was it last year, two years ago or something like that? Anyway. But we're both northwestern affiliates and love educating women on their own health. My tagline is, I'm here to educate so you can advocate. And so that's what I think we want to do today about bones, because you know a lot about everything, but we don't talk enough about bones, so I want to talk about that.

Kristi [: 00:03:09

Yeah. I mean, all right. This is a huge topic. I mean, even though you're right, it gets no, almost no attention when we think about gynecology and even in the internal medicine world, right, we think about things like pap smears and breast exams, and we think about, you know, hormones and contraception, but we don't think about our bones. But the reality is our skeleton keeps us mobile, active, secretes things that we need, like nutrients that we need to keep our heart and blood pumping. So really important to think about bones as, you know, a vital organ that we need to preserve as we enter menopause and beyond.

Dr. Sameena Rahman [: 00:03:44

Absolutely. Well, let's talk for a second about what osteoporosis and osteopenia are, because the reality is you're not going to get symptoms of it until you break a leg or break a hip, and you're going to have then the issues that come up and the sequelae from that. I think the statistic is, and you can correct me, for women past midlife who have a hip fracture within the first year, is it a 30% possible mortality?

Kristi [: 00:04:11

It is.

Dr. Sameena Rahman [: 00:04:12

So you can die within one year of a hip fracture. And I think we've all seen that in people that we may take care of or elderly patients that we take care of or even our family members. So let's talk about. Let's just define it for the people listening.

Kristi [: 00:04:25

Yeah, yeah. And I, yours, I'm really happy that you brought that up about the statistics, but also. Right. Like, why we don't want to become a statistic. No one wants to become a statistics. Right. And what we realize is that osteoporosis, you know, the word itself, doesn't really lend itself to. What does this actually mean? Osteoporosis is a silent condition, as you alluded to.

Kristi [: 00:04:46

There are no symptoms of osteoporosis unless you fracture or break a bone, like a hip, a clavicle, an arm, your forearm, your wrist, your spine, fractures. So these are all very fractures that have significant mortality also changes just your life trajectory, whether you're 30, 40, 50, 60. I take care of women who have pregnancy lactation induced osteoporosis all the way up to women in their nineties who've had fractures or we're trying to prevent fractures. And the reality is, when we look at the diagnosis and how we make the diagnosis of osteoporosis, or even osteopenia or low bone mass, we have a couple ways of doing so. One is if you've had a low trauma fracture, like the ones I just listed, that tells us that your bone quality is low, just like if you have an abnormal pap smear, that tells us something about the cervical cells that we need to stop and take attention to and make it and make a recommendation. And the other way that we can diagnose osteoporosis is via DeXa scan, which is a dual energy x ray absorptiometry, which is a image of the spine and of the hips that looks at the bone density and the bone quality to tell you what is your fracture risk, what is your strength of your bones compared to someone of a peak bone mass and someone of your similar age, race and sex match? So the DexA scan is really our gold standard, and it's something that we can, you know, get. And this is widely available where we live, also at hospitals, freestanding clinics, all of these places. Yeah.

Kristi [: 00:06:12

So when we look at osteoporosis again, and osteopenia, defined by Dexa, defined by osteoporosis related fractures, and all. All of those things also take into account when we look at your clinical history, right. This is why we, as physicians, doctors, clinicians, want to ask you questions, right? When was your first menstrual cycle? Did you have irregular cycles? Have you had things like pcos? What about childbirth? What about your nutrition, calcium, vitamin D, exercise, all of these things and time at menopause, right, these, all things, it coupled with the dexa scan help us determine what's your risk of having a fracture? What's your risk of having a low bone mineral density? And the reality is, we know that peak bone mass, as you mentioned, really is formed in our teens and our twenties. And so for a lot of women who are cycling, a lot of women who aren't even thinking about calcium and vitamin D and thinking about their postmenopausal bones, we need to move that paradigm to talk about that earlier, because that's when we're forming bone, that's when we're building our most bone, which is our osteoblast, laying down new bone. And sure, we always have bone remodeling, taking out the old bone, putting in new bone. Exercise helps us with that. Guess what? Estrogen helps us with that as well, of adequate amounts of calcium and vitamin D. So we know that, again, when we think about osteoporosis and low bone density and fractures, why do we start talking the time of menopause in mid life? Well, the reality is because we are losing our sex hormone estrogen.

Kristi [: 00:07:38

And estradiol is exquisitely sensitive on the bone. We know testosterone has some bone effects, too. But again, we as women don't make as much testosterone as men do. So this impact is less than the dramatic shift that we have at menopause with losing estrogen. And remember, menopause comes for all, but at different ages. This can be natural. This can be surgical. This can be due to medication related or chemotherapy, radiation, or just premature ovarian deficiency.

Kristi [: 00:08:05

So when we see these things, we know that the bone is affected regardless of when menopause happens. And if women who have a low bone mineral density or low bone mass to start with, they're going to be more impacted. We know some factors that increase your risk of low bone density and factors of reducing the rate of bone loss at menopause can be if you're a caucasian or asian ethnicity, if you're of a lower body weight and if you have low calcium and vitamin D. Right. Because our bones are trying to keep up and remodel and sort of maintain the bone density and strength. But oftentimes they're working against themselves at the time of menopause, when we're losing our estrogen. So that's where lifestyle kicks in just as much at the time of menopause or not even earlier.

Dr. Sameena Rahman [: 00:08:49

Right. And so you're mentioning hormones. And of course, you know, I talk a lot about hormones here, but I think that's really an important thing to mention because when we talk about the menopause society or what was formerly the North American Menopause Society and what our guidelines are for menopausal hormone therapy, which is the estrogen alone if you don't have a uterus, and estrogen plus progesterone if you have a uterus. You know, we always hear about vasomotor symptoms. And now people are talking a little bit more about potentially, like how it might help your heart, although that's not, not an indication right now, according to our guidelines. But one of the guidelines states one of the reasons to give hormone therapy is actually bone osteoporosis prevention. Right? Like, I think that gets missed in the headlines a lot because everyone always talks about the vasomotor symptoms and people are bringing up the heart and the brain more. We don't have the guidelines around that yet, but that is part of the guidelines for us to use menopausal hormone therapy, even if you don't have vasomotor symptoms, but you have maybe a family history of osteoporosis, you're small, like you said, or maybe have low vitamins d and calcium.

Dr. Sameena Rahman [: 00:09:53

You might want to go on the hormone for that reason, you know, even if you feel like you're not, because what's, you know, I think that that gets missed that message, right? Missed a lot.

Kristi [: 00:10:02

You're, you're absolutely right. And I think this is why things, podcasts like this, this is why the menopause society and, you know, using evidence based medicine matters, right? Because the education and awareness on hormone therapy is lacking. And there's a lot of then misinformation or challenges to prescribe for, you know, at the clinician level, at the patient level and confusion. But we know from like the Women's Health Initiative study that gets touted often as being a difficult study to interpret. The one thing that was very clear from that study is that women, again, on average, were in their sixties, but they included women in their fifties all the way up until their eighties. These women who are on hormone therapy, whether it be estrogen alone and estrogen plus progesterone, had a reduction in risk of fractures by, on the order of 30% to 40% of risk of reduction of spine fractures and hip fractures, which is actually very similar to the risk reduction that we see with typical osteoporosis medicines that are recommended by a lot of endocrinologists or rheumatologists, which are bisphosphonate. So hormone therapy in the right population, we know, can reduce the risk of fractures. The reason that it is only FDA indicated for the prevention of osteoporosis is that the, you know, the FDA requires women with osteoporosis to be studied with the medication.

Kristi [: 00:11:16

Now those, those things have changed, and so we haven't. We don't have a large scale study using hormone therapy in women with osteoporosis. Most of the women in the women's health Initiative study were defined as low bone density or osteopenia, although a few also had osteoporosis because they were 63 and they were caucasian and asian women. And they had strong family histories. And we know those risk factors are almost as significant as, you know, as a first 1st family. A first degree relative with a hip fracture is a very strong risk factor for osteoporosis. So the reality is we definitely know from our guidelines, whether it be the endocrine system guidelines or the Ob GYN guidelines and the Menopause Society, that we need to open up this discussion that hormone therapy for the right person without contraindication. If you have low bone density or you're at high risk for a fracture, you have family history.

Kristi [: 00:12:09

Some of those risk factors we talked about, you know, many women, this helps their bones. This prevents that, that inevitable bone loss. And. And the reality is we need to use standard doses. You know, a small amount of hormones generally isn't going to be enough. We need give a dose that's going to make an effect. And what I see in my practice, again, I have a direct care practice that treats comprehensive menopausal symptoms. And I also do Dexas and bone densities on all my patients, is that most women have bone health issues.

Kristi [: 00:12:36

But guess what? Like every other woman, like 70, 80% of women, they also have other menopausal symptoms that are either relieved by hormone therapy or non hormonal options as well. So we always can find an indication if you have low bone density, it's very rare to have that only symptom, you know, at the time of menopause. Right. When we start asking about sleep, vasomotor symptoms, hot flashes, libido, urinary issues, all these things, they all overlap. Right. And I think that's what you see in your practice as well.

Dr. Sameena Rahman [: 00:13:07

Absolutely. And I think that we sometimes focus so much on and you hear so much about vasomotor symptoms because obviously the new medication that just got came out, spent, I don't know, a trillion dollars on a super bullet, which is great, at least people are talking about it. And I think that's wonderful. But, you know, to say that that's the only thing women experience. I mean, how many women do we know in midlife that all of a sudden develop anxiety and depression and they get put on an antidepressant or a medication to control their anxiety when this is just a dramatic perimenopausal or menopausal hormonal shifts that are contributing. Right, right.

Kristi [: 00:13:42

But, yeah, I think you're so right. And I think we talked, you mentioned cardiovascular disease, and we do have some very exciting information looking at cardiovascular disease and cognition, particularly people who are maybe apoe carriers, that hormone therapy seems to reduce the progression to both atherosclerosis as well as maybe dementia. We don't have large scale randomized control studies, but we do have them in bone. And remember, when we think about prescribing, again, if you have no contraindications and we prescribe hormone therapy, we think about something called the timing hypothesis, which has been very well validated. Right. So if women are less than age 60 and less than ten years from met or less than ten years since a menopause transition, again, we know that chronological aging matters, but so does ovarian aging, is that the benefits of hormone therapy overall outweigh the risks of, for chronic conditions as well as obviously, treatment of symptoms. And I think that bone health is also in the same, should be, you know, thought of as the timing hypothesis. If we start hormone therapy early, if you're a candidate, you are going to prevent your osteoporosis.

Kristi [: 00:14:44

And that is the same as when we think about cardiovascular disease and preventing that progression to atherosclerosis. So we need to think about bone health. At least we have the data behind that to show. And we have RCT's, we have observational studies, we have many different ways and avenues to prescribe and treat and help patients understand that bone loss is not just inevitable and fractures and living in a nursing home or a hip fracture or kyphosis or loss of height is just part of aging. It's not. It's absolutely not right.

Dr. Sameena Rahman [: 00:15:17

And I think that with all the emphasis on longevity medicine and people are living longer and people want to live healthier. It's not just, it's not enough to just live longer. You want to live healthier, you want to live in a more productive way, you want to keep your brain healthy, your heart healthy and your bones healthy and your sex life, you know, like, all of that has to be in the equation.

Kristi [: 00:15:36

Absolutely. And we all, you and I, I think this is one of the gifts of practicing women's health, is that we get to see women across every decade of their lifespan. Right? So even, you know, women in their thirties all the way up until their nineties, and so their goals of health are different. But again, for bone health, most of even my patients in their thirties and forties are like, they want to know if their bones are strong, their bones, you know, they want to understand about their muscle health, they want to maintain all those things to be able to be active. I think, you know, we shift from like the childbearing years to like the, like, you know, maintenance years and the longevity years pretty quickly, actually. And so, you know, so I do think a lot of my patients, if their bone health is normal and I do a baseline bone density on all women and their bone density is normal, we're like, great. How can we keep it that way? And we can talk about calcium, vitamin D, hormones, exercise, lifestyle, all these things. And if they're in their eighties and I'm like, okay, we got to work on the bone density because we don't.

Kristi [: 00:16:30

You, your goal is to live independently. Your goal is to, you know, travel the world. Your goal is slightly different right across the lifespan.

Dr. Sameena Rahman [: 00:16:39

Just want to piggyback for a second. When we talk about the timing hypothesis, I often have patients that come to me and they're like, they're 60 or they've been in menopause for eleven years. You know, they're like, am I not a candidate anymore? And I just want to emphasize that, you know, you and I both practice precision medicine, as they call it, in the, you know, like, basically we're going to look at everything that you have in your history. We're going to look at all your medical conditions. We're going to do like maybe an eight ASCVD calculation to see what your cardiovascular risks are if we start it a little bit. But, you know, these are guidelines, but we're not cookie cutter. Right? Like, I just want to emphasize that this is not cookie cutter medicine, that we look at each patient individual as an individual being. Because, you know, I'm sure you get those patients, too.

Dr. Sameena Rahman [: 00:17:24

They're like, I'm, I'm ten years today, like on my menopause, you know, can I not qualify? And they're really worried about the fact that for the last ten years, nobody's told them, you know, that they couldn't go on hormone therapy and it might benefit them. And now because of the menopause wave, they're learning so much about it.

Kristi [: 00:17:40

Yeah, absolutely right. Every. Right. Every person is different. And I think this is where, like the time and the expertise comes in because I know people look at someone age 70, but remember, that can look very different. You know, I have women in their fifties with three, four fractures and women in their eighties who are going to the gym. So, I mean, again, we need to be thoughtful about, you know, how we recommend. And I think that we do have some studies that are looking at using hormones in the right patient for the right person.

Kristi [: 00:18:09

We obviously have tons of safety data on vaginal estrogen and all the products there. And I think people don't need to be fearful of that, even though they still are. And I think that sort of translates over to a lot of women's health, including bone health, right. Of women being scared about bone health medicines, about hormones, and also sometimes just being stuck on, like, what. What should they do? Or what can they do? Because they don't want to end up maybe potentially like a family member, like their mother or father who had osteoporosis, or a neighbor. I feel like a lot of bone health is fear based. There's a lot of fear based, you know, people who come saying, oh, my gosh, I know I have a bone, but 80 year old and I'm 50, I don't think that that analogy is very helpful. I think we need to, again, look at, like, what's your t score? What's your z score? What have fractures? Have you had? Let's look at your reproductive history, your family history, your medical history, your medications.

Kristi [: 00:19:01

Right? We have a lot. All these things are your sort of genetic footprint coming to midlife. And then how do we carry you beyond?

Dr. Sameena Rahman [: 00:19:08

Can you just elaborate for a second? With t scores and z scores, somebody doesn't get a chance to see their doctor yet, but they're able to log on and see their scores. Or like, you know, somebody sends them their Dexa scan and they're looking at it and they're like, what the hell does mean?

Kristi [: 00:19:21

Yes, jumbles of numbers. And this is where. Absolutely. I mean, I think these reports need to, you know, we're trying to work on making them more understandable and more, you know, again, approachable so that you can actually take some valuable information away from them. And what do they mean? But so, you know, these scores are, you know, what we're looking at again is the bone mineral density, which estimates about 60% of your bone strength. So that's why bone mineral density is one component. So is a clinical risk assessment. Talking about falls and your age and all the other factors that into it, we now can look at.

Kristi [: 00:19:55

So when we look at the bone mineral density, it's assessed by the bone mineral calcium divided by the area at different sites. And we use, like, something that the World Health Organization validated with the NHANES database, which is the National Health and Nutrition Survey. About 80,000 women studied from age 20 to 90. So we have generative norms for age rate, for age, race, sex, ethnicity, bmI. And it sort of tells us how far have our bones deviated from someone of a peak bone mass. And that's your t score. And then how far have your bones deviated from someone of a similar age, race and sex match. And so we use both of these.

Kristi [: 00:20:35

We use a t score more for the diagnosis of osteoporosis when you're post menopause, depending on if that means that once you've had natural menopause or if you've had surgical menopause, the t score score, the z score, again, can be helpful because some women who have low bone density due to other causes that don't seem maybe taken at face value. Things like nutritional abnormalities like low vitamin D or calcium or malabsorption conditions, or patients who might have diabetes or rheumatologic conditions or other causes that we screen for in lab and urine testing. Sometimes those are indicators that the score is. The z score, excuse me, is lower than. -1.5 tells us we need to look a little bit further. Your bones are not as similar to your age, and this is something off. Right. And so we use both of those to sort of help us guide, you know, the diagnosis of post menopausal osteoporosis or premenopausal if you have low bone mass due to your age.

Kristi [: 00:21:30

And so they need to be really interpreted correctly, they need to be evaluated by someone who knows how to read them. Just like if you got an ultrasound, you wouldn't want, just like, you know, the person working at McDonald's to read your ultrasound. It's the same, you know, for a Dexa, you want someone who is a validated. The study has been done correctly, can stand by the report that was done, and it's interpreted and read correctly, because, again, this is important information for many of our patients, and they go, and clinicians that go based on these results, where it is so important to have a Dexa done. If this is some quality information for you and important decision making that you have a Dexa done at a place that's validated. This is one of the reasons I purchased a Dexa scan, to be able to do these scans in my office. I want to make sure that they're done correctly and the information is shared, appropriate with the time and questions to be answered.

Dr. Sameena Rahman [: 00:22:22

Yeah, well, but Doctor Dicetri, I was told I should only get a Dexa at age 65. Like, don't you get that? Sometimes I feel like, I think most of us agree that when you see a person at midlife, you should, you know, capture that Dexa. Right then. Because by then, it's possibly too late.

Kristi [: 00:22:38

Right, right. So, I mean, right, this is where our guidelines need to shift and the problem, again, with looking at population based information like guidelines in the United States Preventative Services task force is they look at fractures as the outcome for doing a bone mineral density, just like they look at breast cancer for use of mammograms. You know, really, we know that breast cancer, you know, has shown to reduce the risk of breast cancer mortality, but not of, you know, of detecting breast cancer, you know, and we know that. Yeah, sure, we have, you know, good information to do that. But when we look at large scale studies, they're looking using the DExa. There's a low risk, low screening, low radiation screening test. But for women who are in their midlife who might be low risk for a fracture, well, sure, the Dexa is not going to predict, you know, doesn't seem to predict your fracture when, if you got a Dexa at 50, it doesn't predict your fracture risk at 80. But that's not what we're trying to predict at 50.

Kristi [: 00:23:33

We're trying to see capture people who might already have osteoporosis or low bone density so that we can make a change. Or we could recommend something like a hormone therapy or an exercise program or a nutritional program or, you know, all the information. Sort of the reason we do a screening mammograms now at 40, right, is to get a baseline. I see the same thing, and I think there is a movement to understand. Sure, we know that Dexa looks at fracture risk, but women in their, you know, hopefully women between, in their midlife from 50 to 60 are low risk for a fracture. Not always, because we know the most common risk. The most common fracture in women are 50. Sixties is a distal forearm fracture, which is a fall on an outstretched arm.

Kristi [: 00:24:10

We live in here in lovely Chicago. Right. It's icy. People fall this year, though. It feels like California, but I know 70 on Sunday. Yeah. Okay, so we'll go ice. We'll go rollerblading.

Kristi [: 00:24:23

But, so, but the thing is these, you know, these fractures do occur in women in their fifties, sixties, vertebral fractures, osteoporosis gets diagnosed on Edexa. So we definitely need to be moving the wrist, the age earlier. So what the medical societies do say, though, is, and again, you know, for your people listening is that, you know, if you're in midlife and you have, you know, risk factors for bone dense, low bone mass, being female is being one of the low body mass, family history, steroid use, you know, aromatase inhibitor patients who have diabetes, rheumatologic conditions. I mean, the list goes on and on, if you have one or two of those generally that meet the criteria to get a Dexa scan. Again, this is a low risk, one 100th of an x ray in terms of radiation. And so this is something that should be done as a good information base, like we do. Like you mentioned, the ASCVD risk and getting a cholesterol panel. This is, you know, this is the same level of evidence that we need for bone health in women at midlife.

Kristi [: 00:25:20

And I think you agree, and so do so many of the other menopause experts across the country.

Dr. Sameena Rahman [: 00:25:25

Yes, absolutely. Mentioning the ASCVD risk whenever, you know, I have. Obviously, I'm south asian. I have a lot of South Asians. When I put in the risk, it's always like, well, we don't take into account, you know, if you're south asian, because, you know, I think the statistic is we make up 25% of the world population, but 67% of the world heart disease. Is it something similar to. I can't. You might have mentioned this, but Dexa does accommodate four different races as well.

Kristi [: 00:25:51

Yeah, yeah. So, I mean, the. Yes, so the NHaNEs database. Yes, obviously, the databases are smaller for those for different ethnicities than it is for caucasian. You know, that's the evidence that we have. The Fracs, which is a fracture risk assessment tool that we actually have, which is an online, freely available tool to actually help, again, synthesize clinical information like your age, your height, your weight, your family history, smoking, alcohol. And the Dexa scan results to help determine what's your ten year risk of a fracture? Again, with a caveat of many women, you know, are going to have a lower risk when they're in their fifties and sixties, unless they've had a very significant event. And that does take into account some race ethnicity, country specific information as well.

Kristi [: 00:26:35

So there is some. But again, you're exactly right. I mean, some of this is 70% of our bone mass inherited, but lifestyle makes a huge, you know, discussion, and we can talk about that or not right now, but again, things like calcium, vitamin D, exercise, protein intake, these are all things that are very important, that also are, you know, when we do a Dexa or we have our midlife women's health visits, these are topics of discussion that are just as important as, you know, you know, are you getting your routine mammograms?

Dr. Sameena Rahman [: 00:27:05

Right. And I think that this is a good place for us to end this discussion, although I'm going to have you back to talk about all of the non hormonal osteoporosis prevention drugs. But what do you, what's your, what's your take home message for, for, okay, we know that estrogen, if you can take it and if you're a candidate for it, will help your bones. But let's talk about those other modifications you were talking about with the lifestyle and food intake and supplements.

Kristi [: 00:27:30

Yeah, and so much confusion out there, I think particularly if we start from the top at calcium. You know, this calcium conundrum just seems to, I think, like, you know, be something that seems to keep chasing us. So, you know, there's a lot of people out there saying, no calcium, it's bad for your heart. But the reality is the randomized control studies do not show that. We do know that getting enough calcium, both dietary calcium and supplement, if we need to, then is appropriate. So for women who are in the post menopause perimenopause, it's recommended to get 1500 milligrams of calcium in diet and or supplements. So again, there's calcium citrate, calcium carbonate, calcium phosphate. Generally some of the calcium algaes are not as well absorbed.

Kristi [: 00:28:13

So I don't recommend natural calcium as much. And then there's so many food sources. Right? So dairy and non dairy sources, a lot of them have good sources of protein as well. So I work very hard with my patients. Calcium can be constipating. It doesn't necessarily need to increase your cholesterol. We can talk a lot about that stuff. Vitamin D also essential.

Kristi [: 00:28:32

You know, the Institutes of Medicine, we really recommend 800 to 1000 international units of vitamin D. Three. Many women need more than that. So that's generally assessed by a blood test. A 25 hydroxy vitamin D. The level should generally between 40 and 60, sometimes higher if you have malabsorption issues or you have osteoporosis. And again, vitamin D can be found in food, but mostly often it's a supplement in vitamin D two or vitamin D three. This comes in shells, capsules, liquids, patches, atrocious.

Kristi [: 00:29:03

Lots of different ways you can get all of these calcium and vitamin D. And then obviously what doctor you're going to go to, every doctor is going to tell you, don't smoke. Bad for your bones. You're going to get worsening hot flashes and alcohol. We know excess alcohol, probably over seven drinks a week, is bad for the bones. Excess caffeine, meaning like less than. It's not that much. So just less than three cups of coffee or 300 milligrams of caffeinated beverages a day, is what's generally thought to be safe.

Kristi [: 00:29:33

And effective for bone health. Protein, this is, I feel like such an important topic these days, although I think sometimes we don't want to over blow. Just one thing is the most important, but getting adequate protein is more important just through, as we age anyway. Because guess what? Just like we're fighting against our bone loss, we're fighting against muscle loss. Every decade of life after 50, we lose eight to 10% of our muscle mass. So again, that's metabolically active. It's also going to help us, you know, prevent the cushion around our bones. So getting, you know, your ideal body weight generally in protein intake or aiming for that, whether it's plant form or animal based.

Kristi [: 00:30:09

I just read an article in the Osteoporosis International, my favorite journal, this month, and it was showing that both animal or plant based, you know, a protein was equally effective for maintaining bone mass. So that is good news. Yeah, really good news. And so, you know, and then exercise, right? Doing a combination, we all could exercise more. We should probably just be exercising all day, but, you know, trying to do like a resistance exercise two to three times a week using compound movements, using your upper body and lower body. There's some really great evidence that I recently reviewed on this and shared with patients in my practice, and it really is important to get in that resistance exercise also doing your walking or some sort of aerobic exercise, good for your heart, brain, bone and mental health. If you can do it with a friend, even better. And then balance.

Kristi [: 00:30:58

Posture, always important, right? Because again, that helps with our feeling. Again, coordinated in the world, confidence in the world. And again, this is different for every decade of life. Right? So my forties, if they can't balance for 30 to 40 seconds, I'm surprised. And they can do that in their eighties. I'm like, good for you. Awesome. You know, so again, it's tailoring it at every stage of life.

Dr. Sameena Rahman [: 00:31:19

That's wonderful. Well, I think that's a great take home message about diet, exercise, modifications, as well as the importance of a hormonal use, if we can. And we will do a follow up podcast on the other drugs that are out there.

Kristi [: 00:31:34

Yeah, level up, bone health. Yeah, good level up.

Dr. Sameena Rahman [: 00:31:38

There you go. Yeah. Because, I mean, right now we're just, you know, getting deep into it, but we could go on forever. So I really appreciate you coming on today. Thank you for supporting me with this endeavor. And I know you're a great advocate for women, so I appreciate that as well. And, you know, we're here to educate so you can advocate for yourself. Now, maybe you've learned a couple things and you can go tell your doctor, like, hey, Doctor Christy Di Cypri told me, blah, blah, blah.

Dr. Sameena Rahman [: 00:32:02

And, you know, hopefully people will listen and help you get to where you need to go. But let's not ever forget the importance of our bones because once you have a bone injury or a fracture, you know, things can really change for you and your life. So thank you so much. I really appreciate this. And you're a wonderful source of, you know, a vast amount of knowledge, so I love it. And so. And I'm so glad that you're, like, so close to me.

Kristi [: 00:32:26

I know. I know. We help each other out. That's the main amazing. I thank you for elevating this discussion, too. So important. Bones, hormones, female health. We all, we need all the, we need all the voices to say the same thing here.

Kristi [: 00:32:40

So thank you.

Dr. Sameena Rahman [: 00:32:42

Thank you so much. All right, guys, thanks for joining the podcast today and please like and subscribe to my podcast and, you know, leave comments. And if you have any other questions for the next time that I have Doctor de Sabre on, then you can chime in. Thanks so much. If you have a second, please subscribe to this podcast.

Dr. Sameena Rahman [: 00:32:59

I'd love for you to be a follower and learn as much as you can about the things that we're going to talk about with all the people on our journey. Please review us on Apple or Spotify or wherever you listen to podcasts. These reviews really help review us. Comment tell me what else you want to hear to get more information. My practice website is www.cgccago.com. My website for Gyno Girl is www.gynegirltv.com. My Instagram is Gynell Girl so please follow me for some good content. Additionally, I have a YouTube channel, Gynel Girl TV, where I love to talk about all these things on YouTube.

Dr. Sameena Rahman [: 00:33:39

And please subscribe to my newsletter, Gynell Girl News, which will be available on my website. I will see you next time.