Kim Vopni (00:01.476)
Hi Dr. Lucas, welcome. Thank you so much for joining me. I've become obsessed with your video, your YouTube channel, your podcast, as well as all things bone health. And I recently accosted you at the A4M conference so I could introduce myself to you. But I really appreciate you taking the time. Thank you so much. I would love for you to start out by telling us a little bit about who you are and what got you into the world of bone health.
Dr Doug (00:27.83)
Yeah. Well, thanks for having me on. I really appreciate it. Any opportunity to get this message in front of particularly a younger audience is really important to me. So I'm happy to be here. so my name actually go by Dr. Doug usually, and I'm an orthopedic surgeon by training. So I dealt with fractures and I watched people struggle with poor bone health and we did the surgery thing and I did that for about a decade before I realized that I really had a passion for helping people to prevent chronic disease.
And so I left before the pandemic, made the plan to start exiting out of orthopedics. The pandemic really accelerated it because I was able to leave my practice. I was able to work kind of like remotely during all of the chaos. And I did additional training in functional medicine, integrative medicine and hormones. And then I started a telehealth practice because all the telehealth laws changed. And initially we didn't focus exclusively on bone health, but it was on our radar.
But as we continued to build out the practice, it just kept showing up to me as an opportunity to really make a difference with the way that we were helping people. So we eventually just niche down. All we talk about now is bone health. We talk about preventing, reversing osteoporosis and using bone health really as an indicator of health span, more so than a disease that's considered to be a disease of the elderly. This is a much bigger picture that we really need to be talking about at a much younger point in an adult's life.
Kim Vopni (01:50.8)
Yeah, 1000%. And we definitely share the passion of getting this to people ahead of time. But prevention is always a harder sell when you don't have the problem to fix. But so why, why, like, how would you describe a healthy bone? What is a healthy bone? How do we know we have a healthy bone? And why is healthy bone important?
Dr Doug (02:10.082)
Yeah. Yeah. So I, gosh, the problem is we don't know usually that we don't have healthy bones. And this is, you know, this is the challenge I've a lot of entrepreneurs, friends now, and you know, they look at my business and they're like, well, your business model is broken because people don't know that they have the problem. I'm like, well, I, I agree except that it's important. So we're going to push past that. But the thing is that you don't know. because generally the first sign of poor bone quality is fracture.
And that's what we want to prevent, especially hip fracture. That's what I fixed the most of. Now those are life-changing events that we absolutely need to avoid and can avoid. So the way that I look at this now is I say, okay, well osteoporosis is really not a well-defined thing. Actually, it's just something that was based off of this machine, the DEXA, that the World Health Organization decided in the 1990s to pick an arbitrary number to use as the treatment modality for pharmaceuticals. That's not really what osteoporosis is. Osteoporosis is
is poor bone quality and density as measured on some specific imaging, but ultimately it's just an imbalance of bone metabolism over time. So our bones are always turning over. We're always building bone. We're always breaking down bone. Our bones are very dynamic organs. They're doing a lot. They're not just our structure. And if you have certain inputs and you're missing certain outputs, then you will lean on more of the breakdown side than the buildup side. You can do the opposite too, but bone health
is really interesting because it gives us all these biomarkers that we can look at from a bone metabolism perspective. And if you're losing bone, something's wrong. And this is I think the really important conversation, especially for young women is that if you're losing bone as a young woman, there is something wrong, whether it be hormonal, diet, gut, whatever, there's something going on that's causing your body to be in the wrong state. It's not a good state to be in to be in a breakdown state all the time.
Kim Vopni (04:03.834)
Yeah. So you mentioned, the Dexa and, I don't remember if I first learned it from you or another bone health person, but, but there's the REMS and I recently had, I've had a Dexa before I recently had my own REMS and I was looking at your video where you were going through your own REMS report. And I also recruited all of my girlfriends and I said, you have to get your baseline established. And we were all having a competition about who was going to be the best. So what's the difference.
What is REMS and why would you consider it to be a better option or at least done at the same time as DEXA?
Dr Doug (04:41.134)
Yeah. Yeah. So I'll be just back up and talk about Dexa because everybody has heard of Dexa for the most part, but we think of it as again, a screening tool for older individuals, right? Like women get screened at 65 minutes 70. If they're lucky, uh, they, they get a Dexa, right? Um, and the Dexa isn't, isn't X-ray machine, right? This little arm goes over your body and it shoots X-rays through your body and it tells you what your bone density is and then compares it to your, your sex and ethnicity cohort. Um,
Kim Vopni (04:55.44)
which is crazy.
Dr Doug (05:10.958)
The DEXA gives us information. The problem with DEXA is that it only tells us about bone density. It doesn't tell us about bone quality. So the fracture risk really is a combination of density and quality. And it's a little bit unknown as to which one's more important. Some people would say density is a little bit more important, but quality is really important too. And so you can have a DEXA that looks terrible, but have good quality bone and be really mismanaged because you're not actually at high fracture risk. But the opposite's true too.
You can have reasonable bone density and have poor bone quality and be at much higher risk of fracture. So then we need better understanding of what's going on with the bone and the ultrasound device, the REMS device made by the company Ecolite out of Italy. The REMS device is available. It is not covered by insurance in the U S but it's, it's gaining momentum and steam and we'll see what happens in the future. but the REMS is a device that can tell us a T score similar to what a DEXA would tell us, but it also gives us a fragility score.
And that's the really important part about understanding our REMS is because it can help to differentiate poor bone density, but good bone quality, because we're going to treat those patients very differently than someone who has both poor bone density and poor bone quality. Right. And so it allows us to not only look at people who have osteoporosis in a different way, but now we can also screen people without radiation and we can do it younger. can, you know, screen young adults, we can screen pregnant women, like there's no danger in using an ultrasound and then you can follow it.
more frequently over time. And that's what I think is really important about an ultrasound device.
Kim Vopni (06:42.65)
Something else that I've heard you talk about is the blood markers that you can ask your doctor about and you recommend when you're getting screened that you also ask your doctor for those blood markers. What are they and and how is it important for it to be on the same day that you do your REMS or as close to as possible for that to be as meaningful as possible?
Dr Doug (07:03.214)
It doesn't necessarily need to be on the same day as the REMS. That's a tough day of imaging and blood work. there are, let me just describe them because there are some nuances that we've learned about these things because I do think they're really important, but if they're not done right, they can be misleading too. So the blood markers we're talking about are CTX and P1 and P. And CTX is the breakdown marker. So your osteoclasts, the cells that break down bone, they make CTX as part of the process of breaking down the bone.
P1 and P is made by the osteoblasts, the cells that build bones. Part of the collagen production is the P1 and P. And so we can measure the relationship between breakdown and buildup by looking at these two biomarkers. But what we've learned about these biomarkers, because they're used a lot in research now, which is great, but what the research doesn't do a good job of is making sure that people understand that you have to test these things under the same conditions as much as possible because they are affected by...
When you last ate they do rise and fall after a meal they change throughout the day they change if you work out So we want to do these under this on as much of the same condition as possible and so that would be a morning fasted blood test and try to make the previous day as similar to the other time that you tested as you can so if you worked out work out if you ate You know like a big dinner eat a big dinner like try to do all the same things now. They're not going to change that much
but if they're shifting a little bit one direction or the other, could change the way that you feel about your bone. So it's important that they're at least consistent. Another big point of that is that for women who are cycling, you have to do it on the same day of your cycle or at least in the same section of your cycle, right? So if you were somewhere mid follicular, it'd be mid follicular, somewhere mid luteal, it'd be mid luteal because the flux in estrogen, specifically estradiol and progesterone will have an impact on these biomarkers too.
Kim Vopni (08:49.594)
So it's best to do it mid-fellicular. That would be the best time to do it.
Dr Doug (08:52.59)
You know, that's a great question. so we have taken to doing it either either day 12 or 22 for a 28 day cycle. So we're trying to hit the peak of either one. I don't know. It kind of makes sense for me to go follicular because they're going to look better. But I don't know that that's necessarily right. We're just we're picking one because we have to pick one. But yeah, definitely one of the two. So usually days 12 or 21 or 22 for a 28 day cycle. That'll be about the peak of each of those.
Kim Vopni (09:08.964)
Right, yeah, yeah.
Kim Vopni (09:20.688)
Okay. And so somebody's done the testing. Let's say they come back with, with osteopenia, which I know is being now replaced by low bone density, whatever wording we want to say losing bone density. So somebody comes back with that. What would you, what would your recommendations be from a nutrition perspective? Um, and from an exercise perspective, and then we can touch a little bit on hormones as well.
Dr Doug (09:47.758)
Yeah, of course. Yeah. So this whole like osteoporosis, quote unquote diagnosis is frustrating because it's not actually a diagnosis. I'm sorry, I see me back up. Osteopenia diagnosis is not actually a diagnosis. So osteoporosis is that threshold of negative 2.5 and this is a, the T score of the Dexa, or below. So, you know, a negative number and that is technically osteoporosis.
But between negative one and negative 2.5 is osteopenia, but that's not actually a diagnosis. It's not a diagnosable condition. It just means that you have lower than average bone density. That doesn't necessarily mean that you need to do anything different depending on your starting point. And this is a really important point for people to understand is I see women get really scared when they get diagnosed with osteopenia. They say, my gosh, I have osteopenia. And I say, well, where were you five years ago? Well, I don't know. Well, of course they don't know because we don't screen young adults.
but they may have, that may have been all they ever achieved in the first place. Cause I think we're going to see lower and lower peak bone mass, which occurs in for women in early twenties. Right? So we're going to see lower and lower peak bone mass as we have young women that are on hormonal birth control, sedentary lifestyle, poor diet. They're not going to achieve peak bone mass. So then they get screened for the first time and they have like, my gosh, I have osteopenia. It's like, well, that might've been all you ever had. So looking at trajectory over time is really important.
So like I shared in my video about my ramp. So I have osteopenia and I think it's because I ate a, like a entirely fat free diet as a young child because we had very poor nutrition recommendations in my household. And so I had no dietary fat and I was active, but I wasn't an athlete. And so I think I just, didn't, I probably never had good peak bone density, but my T-score has been the same.
since it's now it's a little bit better, but it's been essentially the same since I was in my early 20s when I did get a DEXA actually early on in adult life. So I'm not concerned that because I have osteopenia, I have an increased fracture risk because it hasn't changed in two and a half decades. If anything now it's getting better because I follow my own advice.
Dr Doug (11:54.816)
So, first thing I would say is try to understand what's happening. And if you have osteopenia and good bone quality, then that's again, not necessarily something to worry about. Just make sure you repeat it at some point and to make sure it's not getting worse. If it is getting worse or if it is pretty low, then this is something that we probably need to be doing something about. But the good news is that the things that we do for bone health are the things that we need to do for health span overall. So if we look at from a dietary perspective, the biggest issue we see is that especially women, but men too actually,
tend to be under protein consumers and under calorie consumers. They're just undernourished, they don't get good quality food and they don't eat enough protein. There's a lot of reasons for that, but that's just the biggest flip we could make is let's look how much protein we're getting, track it if you're comfortable tracking it, and let's make sure that you're getting somewhere around a gram per pound of ideal body weight. And that's a lot more than most women are consuming and men.
Under nourishment overall is a problem just because most people are eating a more highly processed diet. There's less nutrition in it and more calories than we struggle with that. But eating a whole foods diet is important. I don't get wrapped up in extremes or I'm not going to tell anybody to change their ethics or morals if you want to eat a vegan diet or a carnivore diet. I actually don't care. Make sure you're getting adequate protein with the right amino acid profile. If you want to go plant-based, okay.
I wouldn't recommend it, but if you want to, that's your choice, but then make sure that you're doing the things you need to do to get all the nutrients in and your gut can tolerate it. So that's the biggest thing we tell people from a dietary perspective.
Kim Vopni (13:29.828)
from an exercise perspective, the population I work with, some of them have been told not to lift anything over 10 pounds, not to do any impact exercise. And so when we, and sometimes this is the people who have developed pelvic floor dysfunction in their thirties. And so maybe, maybe they achieved peak bone mass, maybe not, but now if they are stopping exercising or they're not doing impact or they're not doing heavy resistance training.
Maybe they might be doing bar or Pilates or something, but then they're getting to the point now, especially post menopause now, even more accelerated bone loss. And, and, and then now again, they get, they get this diagnosis, they're afraid, they're not sure what to do. And now they're thinking, well, I can't do impact and they can't do resistance training. So I'm trying to say, okay, let's optimize the pelvic floor first, then progressively load it so that we can do those things. But
To my understanding, resistance training impact from an exercise perspective are the most important. Are there any things that we should be avoiding that could be, like if somebody already had osteoporosis?
Dr Doug (14:37.74)
Yeah, yeah. So, and you're saying they're told to restrict weight because of their pelvic floor, right? Not because of their bones. Yeah, right, right.
Kim Vopni (14:43.46)
because of the increase in intradolent pressure, they're thinking will protect your pelvic floor because lifting heavy is going to increase intradolent pressure. It's going to make your prolapse worse or what have you theoretically.
Dr Doug (14:51.694)
Right. Yeah. So I actually get this question a lot. So we have a lot of questions when, we talk about resistance training and high intensity resistance training. And I get a lot of women who ask like, well, but, but I can't because of my pelvic floor. Like what do I do? So similarly to you, I would say, well, let's, let's optimize your pelvic floor. There's a lot of great tools out there. I know you've got a program. Um, and this is a really important, this is really important work to do if you have pelvic floor problems. Um, cause it it's, you know,
I hear it all the time and it can be really debilitating. And it limits what you can do from an exercise perspective. there's kind two ways to look at this. So one is I would say if you are limited, just like somebody who was limited because they have severe bone disease, they have severe osteoporosis, they're recovering from a fracture or potentially severe arthritis can limit how much somebody can lift as well. In those scenarios, there are other things we can do.
So the most important thing to stimulate bone growth is actually impact. Resistance training is important for muscles and high intensity is important for muscles, but you're not gonna build bone just by lifting weights. You have to do impact. And I do these videos all the time because I hear this mistake made, especially on social media, like all you need to do is weight-bearing exercise and lift weights. It's not true. You have to do impact to stimulate the osteoblast to build bone.
So that impact could be done without increasing intra-abdominal pressure. Now, whether or not it would be comfortable, that's a whole different story that maybe you and I should do a study on. But impact could include things like heel drops, that simple, like rise up on your toes, drop down on your heels. You can stimulate bone just by doing that. It's free, do it a hundred times a day, and it's amazing. When you do that, you can generate a lot of force. It'll shock you the first time you do it. That is potentially all somebody needs to do.
in addition to resistance training. So it's pretty amazing. There are also ways to work around it and kind of cheat the system. So some biohacks around it would be using whole body vibration. If that's something that somebody can tolerate, osteogenic loading through the company of bio density or the franchise osteostrong. Like those are tools that people can use that are going to simulate impact without actually doing impact if that's uncomfortable. And then the resistance training part, it does need to be as high intensity as possible, meaning
Dr Doug (17:14.23)
as heavy as it can be, but don't get hurt. So that's the balance. Because a lot of people that have osteoporosis have never lifted weights. And so our job is to help people to learn how to lift weights later in life for people that have been told not to lift weights.
Kim Vopni (17:28.826)
Yeah. Yeah. Yeah. And I mean, I don't, disagree with the recommendation of don't lift over. Like you, how can we ever determine what is a safe or not safe way to it's all relative to the person. But I think we can absolutely build up tolerance to be able to manage increased loads. all about the person's execution and their breath and all the other things that we're doing. So one thing question I have about, so I do heel drops and I recommend those in the programs that I'm doing. The other thing that I thought is.
Dr Doug (17:39.34)
Right. Right.
Dr Doug (17:49.518)
Thanks, sir.
Kim Vopni (17:57.912)
Some people who come into my program are maybe in wheelchairs or they already in, they can't hardly get out of a chair. They may be seated. And so I do heel drops or stomps when they're seated. However, this is my mind. That's not necessarily going to translate up the whole chain to influence the hips, to influence the spine. We do need more of a whole body load. Is that accurate to say?
Dr Doug (18:11.488)
Mm-hmm.
Dr Doug (18:23.832)
Probably, yeah, it's hard. When somebody reaches the point where they have some kind of a disability where they can't get out of a chair, they can't load their bones, it's hard to maintain bone. And I dealt with this as a surgeon when we had people, especially who were paraplegic, they had no motor control below their waist, their bones were marshmallow, right? Because they just had no load, they had no muscle tone, and their bones were never stressed. So obviously that's an extreme, but the more disability you have in that way,
Kim Vopni (18:51.748)
Yeah. Yeah.
Dr Doug (18:51.852)
the harder it's going to be to maintain bones. And again, this is where like prevention, prevention, prevention, prevention.
Kim Vopni (18:56.26)
Right. Yeah. Incontinence and prolapse are independent. They're correlated. would say risk factors for hip fracture. And we can look at that as saying, is it because maybe those people haven't been lifting? it because of diet? Is it because like many different factors, but another one is, waking at night to pee falling in the dark, that type of thing. What are some things that we can do? So we've talked about protein, diet, resistance training impact.
How else can we reduce our risk of hip fracture?
Dr Doug (19:29.016)
Yeah. So I think that the primary thing is know where you are. screening for bone health is going down. Less and less taxes are being done. More and more people have the problem. So we're, we're missing, I think probably a tidal wave of people that have osteoporosis that we just don't know. So number one is know where your starting point is. and then start doing something about it. And there's a lot of fear around the drugs for bone health. And I'm not, I'm not a fan of the drugs for the most part, but there is a time and a place. Our goal is to prevent fracture. So,
The drugs can be used to increase bone mineral density. do reduce fracture risk, although arguably, you know, short term, not necessarily long term, but depending on your starting point, that might be okay too. And so I would say, you know, consider pharmaceutical therapy for those that don't have another choice. If you can do the things that we're talking about, resistance training, impact, eating a better diet, et cetera. Like if you can do that, especially if you can optimize hormones, I'm here to tell you that you can absolutely reverse osteoporosis if you can do those things.
Even without hormones, you can do it. It's just slower. you know, know where you are, create a plan to move forward and continue to monitor things over time. Actually, preventing a hip fracture is more about strategy, really. It's more about balance. You know, what is your balance like? What is your, like you mentioned, getting up at night? Like, we have to be smart about this. And, you know, I have aging parents and I look at their house and I'm thinking, pfft.
Kim Vopni (20:53.936)
Yeah.
Dr Doug (20:55.118)
Can we let's get this area rug out of here, right? Like they just got a puppy. I'm like, oh my gosh, like this, you're going to trip over this dog and you're going to break your hip. I don't see any way. I don't see any other way around it, but I just seen that happen a lot. Um, but making sure that you have adequate lighting, making sure that you don't have loose things on your floor, watch out for dogs. shouldn't have your dog in your bedroom anyway. Um, and just make sure that you can be as safe as possible, uh, but still live your life, right? There's just some unnecessary risks that people take, you know, like.
sleeping with five dogs in their bedroom. It's a bad idea.
Kim Vopni (21:26.704)
Yeah. hormone wise, if so there's the, the world has exploded with menopause conversation, hormone therapy. This is something that you have in your practice. There's evidence about estrogen being number like a prevention for osteoporosis if started as close to the start of your menopause as possible.
you can touch a little bit on that but then also the people who are listening who are but i'm 65 and i've either never had it or i only had it for a short period of time i was i think it was dr killen was recently sharing something about there still could be bone benefits for estrogen even if started later so can you talk a little bit on that
Dr Doug (22:05.87)
I am absolutely. Yeah. I was actually just, I'm recording right when we're done. I'm recording for my channel. And one of the things I want to talk about is that 65 plus hormone conversation. Right? So let me just back up and talk about hormones in general. So when we started really niching down on osteoporosis, we were already doing hormone replacement for women and TRT for men. But when I started looking at the literature, it just blew my mind.
how powerful these things are and how little they're utilized. So actually I was, I think it was before I met you, the previous A4M event I was at was the BHRT Symposium and they had asked me to speak on this topic because a lot of people in the hormone space don't look at bone health literature. But if you go back and look at the bone health literature from the 90s and early 2000s, they were doing some incredible work looking at different doses of estradiol, different strategies, different timing, like.
There's all these studies that show the benefits of bone mineral density. And so it just, gives you this wealth of information to say, oh my gosh, not only is HRT beneficial and it can help prevent osteoporosis, but if you use it as an intervention, you can see, you know, up to 10 % improvement in bone mineral density over the course of 12 months as an isolated intervention with nothing else. It's more powerful than most of the drugs. So the fact that we don't use it more is absolutely a shame, but
We're here to tell people, yes, let's optimize hormones. I think we are in this new age of the menopause conversation, a better understanding of the research. We know that there's not as much risk as we thought, certainly 20 plus years ago. Not saying that they're without risk, not everybody's a candidate, but so many more women are a candidate now than they ever thought they were. The Menopause Society just released this at their last meeting that 4 % of women over the age of 50 that are candidates for HRT are on HRT.
Kim Vopni (23:56.592)
Crazy. Yeah.
Dr Doug (23:57.422)
So there's a lot of room for growth here. So now we have started really looking at optimizing hormones. So we do, we measure levels. We're looking at estradiol levels. We're looking at FSH levels. We're looking at CTX and P1 and P. We want to make sure that all of these things are coming into alignment. And we're not afraid to drive estradiol quote unquote high because there's not an increased risk by doing that if you look at the literature. But we want to drive it high enough so that FSH comes down. That way we know that the brain receptors are saturated.
we could look at CTX and P1 and P and we can see when the bone receptors are saturated. So just a different way of looking at hormones. And then we also will consider cyclic progesterone, potentially even physiologic restoration for someone who wants to go down that pathway. We can support them in doing that because clinically what we see is that people that are cycling, that are cycling and optimize their cycles, their bone grows like crazy. For postmenopausal women who start cycling progesterone, you see improved benefits. The studies on cyclic versus
Static therapy cyclic always wins hands down doesn't matter if it's even like PR or not. It always wins You're gonna say something
Kim Vopni (25:05.412)
I was just going to say, so for the people who are thinking like myself post menopause, I'm not interested in bleeding anymore. So I've always like, I've been looking at the research and they're like, I don't want to, don't want, I just don't want to do it again. but is there, is there negative if you are not cycling? So cycling is better, but if you're static dosing, is there any
Dr Doug (25:13.762)
Yeah. Yeah.
Dr Doug (25:24.152)
Yeah. We can still win with static. And so I would say in our population, mean, less than 5 % of women are excited about starting a cycle again. And I don't argue. I just say, look, this is an option if you want to consider it. Happy to talk to you about it, because that's not my experience. So I'm fine with that. And we still see improvement.
Kim Vopni (25:36.592)
That's even high for me.
Kim Vopni (25:44.816)
Yeah. Yeah.
Dr Doug (25:50.062)
I do think I would love to see once we have enough data in our patient population, I think we'll see that cycling is better. I think we'll see that because you can get a better push-pull of estradiol and progesterone, but we don't know that yet. So I'm not pushing people down that pathway. But you mentioned the Over 65 group and this is such an important conversation and this is exactly what I'm going to script as soon as we're done because I have this conversation all the time. In fact, at our osteo collective as our community meeting this week, we actually had a
somebody who was new to the group and she wrote this kind of like strongly worded question about, I'm, you know, over 10 years out from menopause and I've done the research and my doctor agrees that it's too dangerous for me to start HRT. Okay. So, you know, I, what I like to point out is that if you look at the recent data, if you look at the 20 year follow-up from the women's health initiative, which is where most of the doctors get this data from anyway, if you look even at that study, yes,
It is protective, HRT is protective of cardiovascular disease if you start within the first 10 years after menopause. That's true. And then if you start between 10 and 20 years out from menopause, it is no longer protective. So technically your doctor's correct when they say it's more dangerous to start HRT 10 to 20 years out from menopause. But they're missing the big picture there, which is that it is not more dangerous than placebo or non-users. So if that's true, I can't go back in time and start HRT for you 10 years ago.
So let's talk about starting it now. And if it's not more dangerous than placebo, let's look at your other risk factors. Now, I won't start all webinar that are between 10 and 20 years out on HRT. If they have, you know, credit cardiovascular markers, they've had a heart attack or a stroke, like that's probably not a good idea. The risk is not going to outweigh the benefit or the risk is going to outweigh the benefit. Um, but so many, especially like osteoporosis is a really unique population where they tend to be very healthy otherwise.
Right? Like you can do cardiovascular imaging, you can look at the arteries, you can look at their other risk factors. And in general, they look really good. So we are pretty bullish about starting HRT for women 10 to 20 years out from menopause. 20 to 30, it gets a little less consistent. But even then, I have women in their 70s who have crystal clear CT scans of their coronary arteries. Why would I deny them HRT? There isn't a reason to deny them HRT.
Kim Vopni (28:07.802)
Yeah. Yeah.
Dr Doug (28:10.782)
And what I can tell you is, you know, the literature supports, there might be benefit. No, there's hands down benefit. It doesn't change. The benefit is dramatic. If you start a 75 year old woman on HRT who hasn't had estrogen in 25 years, her bone will take off like a rocket. There's definitely benefit. The question is, you know, like how quickly can you start it? You have to like start low, go slow. You have to be careful because 25 years is a long time, a long time without estrogen exposure. So you have to start slow. You have to, you know, like just
Kim Vopni (28:26.01)
Yeah. Yeah.
Dr Doug (28:40.268)
start low, go slow, ease into it, but they do really well.
Kim Vopni (28:44.228)
Yeah, progesterone wise. Also, if I look at Jerry, Dr. Jerry Lynn Pryor's research as it pertains to bone as well is also beneficial if it's progesterone, not the synthetic progestins.
Dr Doug (28:56.59)
Yeah, the progestins actually do show like loss of bone, which is really, it's a really important distinction because it messes with the estrogen receptors. But micronized progesterone, there's not a lot of great data here. But if you look at women who are cycling, you have dysfunctional cycles, especially if they have ovulatory dysfunction, they don't end up creating a progesterone surge in the luteal phase. They'll lose bone even with normal estradiol. So we know progesterone is a part of the picture.
but it's never studied independently for bone. I can't say, cause we have some women who say, look, you know, estrogen is not an option for me, but I'll take progesterone. I'm like, okay. But I can't answer the question of how effective is that alone? No one knows, right? I don't think it's going to hurt her. but I don't know how effective it's going to be. So we definitely want to balance the two. And then of course, you know, if you're willing to cycle, that's, that's great. But if you're not willing to cycle, cause you can also cycle and not bleed.
So there is this in between where you can cycle progesterone, make sure that you're not overloading the uterus and actually not have a monthly bleed. But that's just got to be done very carefully.
Kim Vopni (30:01.636)
Yeah, yeah. And then what role would testosterone, I know that's also something that's not very accessible for women. In general, there's no FDA Health Canada approved testosterone for women, which is bonkers. But if you, yeah, if you found somebody who was able to like yourself to prescribe or to work with somebody, is there help from a bone perspective with testosterone?
Dr Doug (30:15.566)
right or US.
Dr Doug (30:26.934)
Absolutely. Yeah, so mostly studied in men obviously There's one study that I found using testosterone in conjunction with an estradiol and progesterone pellet So not how I would do it But it was kind of a cool study where they looked at the estradiol and progesterone pellet alone versus all three together So they added testosterone and then they compared the two and I think it was a 12 month study It's been a while since I've looked at it, but the testosterone group outperformed the estradiol and progesterone alone group
And it just makes sense because testosterone in a woman's body is going to be anabolic. It's going to help with muscle mass. It's going to help with energy. It's going to help with like probably with sleep. It's going to convert a little bit to estradiol. So you can get higher levels. Like it all makes sense. It just isn't well studied. Um, the other challenge I have with testosterone in the U S uh, because we're all telehealth, the telehealth laws in the U S are restrictive of using controlled substances, which testosterone is unfortunately, um, in some States. So we can't prescribe it.
across all state lines, which is a challenge. I also find that the older a woman is, especially somewhere this threshold of 60 to 70 years old, I can't drive their levels very high with exogenous testosterone before they start complaining of hair loss. And so I think we're a little bit limited with testosterone. think it's a really powerful tool potentially for younger women, especially women that have low testosterone and should be measuring it.
But I think it's limited as we get older. And this is why we've really come back to just focusing on optimizing estradiol for the women where we can.
Kim Vopni (31:55.978)
one more question on hormones before I move on the, the way that you test saliva serum, dried urine, wet urine, what is your preferred and, and is it, I was looking at a recent study that was looking at there. You could, you could have the same dose of estrogen with three similar, like, well, even 30 similar aged women.
And what their concentrations serum wide would say is different. Yes. Yeah. So how do we, how do we decide on dosing? But, first of all, what testing do you prefer? And then how do you decide dosing for that person?
Dr Doug (32:25.528)
Wildly different. Yeah, I know.
Dr Doug (32:37.314)
Yeah. I mean, this is why so many doctors will say it like, don't test, just don't test because it's all over the place. And that's kind of true except that otherwise you don't know. So, so we, you know, we do the best we can. we like to use serum for the most part. So we're looking in blood. I don't use saliva cause I just find that it's inconsistent. It's just all over the map. I know that the company is to do it, say that it's great, but gold standard is blood. We stick with blood for the most part. I do use dried urine too. So we use Dutch.
Kim Vopni (32:42.308)
Yeah. Yeah. Yeah.
Dr Doug (33:07.485)
Mostly though to look at estradiol metabolism, especially because we are driving levels higher than, you know, would say like a low dose patch for sure. I want to make sure that we're not overloading certain pathways, that their detox pathways are open. You know, we have the conversation about about regularity. Like, you know, are you getting your are you getting your estrogen detox appropriately? Dried urine really helps with that. I don't use it for dosing though. So I use I use serum and symptoms for dosing. But you're right.
So we were just having this conversation today because we have a, you we have a protocol. We always veer off of it, but we, we have a starting point. and it's what's wild is, we will start people on a, we we use topical creams for the most part. We'll start them on the same dose and we test them at six weeks and it could be like unmeasurable or it could be over a hundred. It's like, I mean, like you don't know. and so then you have to talk to them like, know, where did you apply it? And did they like put the needle like through the
place where you applied it in your skin. So there's just a lot of variables there. But that's why we look at other biomarkers too. So yes, we're looking at estradiol levels, but we're also looking at FSH. FSH is not going to change as quickly. So if a woman's estradiol is high, let's call it whatever, it's 100. But her FSH is still 80. She doesn't have enough estradiol. If it's, this is where it gets really interesting. Her estradiol level could be 20, which is below, if you look at the literature on bone health,
is somewhere around 60 to 80 pkg per ml. There's this threshold. But I've seen women that on serum it looks like their estradiol is like 20 or 30, but their FSH is 10. I'm like, well, I don't think you need any more. CTX is under 200, FSH is almost single digits. I don't know why I would give you more estradiol. Ask about symptoms, but from a blood perspective, I don't think that needs to change. And so that's the challenge is that most doctors aren't looking at
Kim Vopni (34:43.962)
Yeah.
Dr Doug (34:58.796)
these variables, they don't have the bone turnover markers, aren't measuring FSH or if they are, they're not looking at it. And then estradiol does move all over the place. And then you're always chasing it, right? Like decrease your dose, increase your dose. now you're having hot flashes. Now you're having breakthrough bleeding. You know, it's just like this, whee, this roller coaster of uncomfortable symptoms. And that's where hormone replacement can be challenging.
Kim Vopni (35:20.25)
If somebody had post menopause few years, they have been taking hormone replacement therapy, including estradiol and their marker head, like their DECSA T score had gone down, but their fragility score was okay. So meaning they went from not being osteopenia to being osteopenia in you know, three to four years, let's say.
Even though they're eating and they're doing resistance training, doing all the things, what could some of the reasons be? Why? So that's where this person doesn't have the blood markers, but what could some of the reasons be why they could be losing bone even though they're doing all of the right things?
Dr Doug (36:03.31)
Yeah, and this is the scary thing, right? So I have a case that I tell actually, this is a guy who, this is a guy, so slightly different scenario, but a guy who had been on the drugs already too. So he'd been on Fosamax, he'd been on Forteo, and continued to lose bone. Was doing all the things, and then he started fracturing. That's a really bad place to be, right? So.
Similarly though, your case example of a woman who is post menopause, maybe on some form of HRT, feels like she's doing all the right exercise, eating a protein forward diet, but still losing bone. Yeah, something's wrong. We need to look under the hood and figure out what it is. My guess would be probably her diet's not as good as she thinks it is. She probably has some gut dysfunction, so she's not absorbing what she's consuming, right?
Kim Vopni (36:48.72)
I was going to say the get. Yeah. Yeah.
Dr Doug (36:51.93)
so I generally would start there and that's what we do on our program is the first thing they do, we come in, if they're, if they're okay tracking, we have them track food, meet with the dietician. Like it's number one. We also do a stool study and almost all of our patients to look for gut function and, know, deficient enzymes, et cetera. So like, that's just really, really common. outside of that, then I would start talking about, I would look at the hormones next and say, okay, you're on HRT. What does that mean?
Right? Like we get women that'll come in, they're like, oh yeah, but you know, I've been on HRT since I went through menopause. Oh great. Like, what are you on? Oh, I'm on birth control. Like, that's not HRT, you know? And so we need to figure out what it is and then look at their levels and like, are they optimized? And they're almost never optimized. mean, like, unless they're coming from somebody that I know who especially like our PR providers, right? They'll come in and they're like, oh yeah, my estradiol is 350. I'm like, oh, okay, cool.
Kim Vopni (37:25.968)
Yeah. Yeah.
Dr Doug (37:43.682)
But for the most part, women come in on a low dose patch and either it's like a combi patch, right? So they're on a progestin or they might be on micronized progesterone, but at a low dose, like a hundred milligram dose of micronized progesterone and then a low dose estradiol patch that they change every two to three days. So that's not gonna get you adequate estradiol in most people. I've seen it work for some, but generally it's not enough.
Kim Vopni (38:07.748)
Got it. Okay. I'm taking a, like a kind of a 180 away from hormones. And I want to talk about back to your orthopedic surgeon days from a hip fracture perspective and a hip replacement, hip osteoarthritis, at what point and where I'm getting at is the incontinence challenges pre hip replacement, post hip replacement, and how it can vary depending on the type, like the route of entry for your hip replacement.
So what would necessitate a hip replacement in the first place? And then I'll carry on with questions.
Dr Doug (38:44.098)
Yeah, so kind of two things. So fracture, generally we don't replace at the time of fracture just because it's a much, it's usually a harder surgery depending on where it breaks, can not go as well. So generally we're not going to replace at the time of fracture, but sometimes we do. I didn't, but joint surgeons do because that's what they do. And so it can happen with a fracture, but usually you're going to do a replacement because of arthritis. So hip arthritis, you get to the point where you can't do anything else from a conservative perspective, you go through the hip replacement and hip replacements are
great when they go great and they usually go great. When they go south, it can be ugly, but for the most part, it's a really, really good surgery. But there are a lot of potential factors and I think you're gonna go down this hole with me.
Kim Vopni (39:25.85)
Yeah, yeah. Okay. So to my understanding, and the research that I've done an anterior root of entry would be more favorable from a pelvic floor outcome perspective. Is that your experience and then versus the posterior which is cutting through more of the musculature the obturator internist that? Yeah.
Dr Doug (39:45.752)
Right? Yeah. Yeah. It's funny. I've actually never thought of it this way, but yeah, it's, very, very intuitive, right? So the anterior approach, if you have the body habitus to do it, meaning you don't have a a big panacea, a big belly that's going to lay over the front of the body, or that there's sometimes there's some bony things that will prevent a surgeon from being able to do that. But the surgeons have gotten really good about going in from the front. And what's great about that is that you, don't cut through any of the muscles. You just move them out of the way.
And so you literally just kind of go down in the middle, move them out of the way and the joints are right there. It's amazing. But it's hard to get to the cup part. It's hard to get to the acetabulum. So you have to have special tools and a special table and it's a whole thing. But if you can do it that way, mean, patients do really well. They can usually wait their day off. They're usually walking, you know, that afternoon with a walker. Like it's amazing. When you go in from the back and this is how we generally do it. If, if you, if someone has had a fracture because doing a fracture from the front is really hard.
So if you go in from the back and this is how we're all trained, right? So if you're doing like a partial hip replacement and an older person after a hip fracture you go in from the back because it's fast You can get it done get them off the table But you're right You're cutting through some really important muscles like all of those deep rotators that attached to the top of the hip You just slice them right off there. Now you suture them back But do they stay you know, the bone was terrible to begin with the muscles weren't in good shape to begin with
So what does that healing actually look like? It probably heals in a big, you know, massive ball scar tissue. I've never thought about the impact of the pelvic floor, which is just because I'm an orthopedic surgeon, right? Why would I? they all have fully catheters after surgery anyway. but I could only imagine, I mean, those are the muscles that wrap in and go through the pelvic floor. Right. So I don't know. Do you know of research that's looked at that? Cause I bet it's there. Yeah.
Kim Vopni (41:32.794)
Yeah, yeah, yeah, it is there and and definitely favorable from an anterior but there are as you say there aren't as many people doing. So most of the people that I'm hearing from, I would say probably 70 % of people who've had a hip replacement have had the posterior repair and some of them, especially in my population with women, many of which the age at which they're going through this they already have had years of inactivity sedentary lifestyle challenges that their pelvic floor already wasn't
optimal. And then they have the hip like they've noticed it worsening as they need get closer to needing it, then they have a surgery and now it's even worse afterwards. Yeah. And so, so I just am I I'm, you know, wanting to speak to more surgeons as to what else could be done. And there was an interesting research about men preparing for prostate surgery. I know this is not hip replacement. But of course, it was men and not women. But I've
Dr Doug (42:10.981)
Yeah, yeah, I imagine.
Kim Vopni (42:32.522)
I had a pelvic surgery myself and I looked at this as I am training for my surgery, just like I trained for my pregnancy, my childbirths. had a recovery protocol. I did my progressive load back. I had my pelvic P I did all the things and ended up creating a program out of it. Cause I said, nobody's talking about this. We should be preparing for surgery or training for surgery. And so this was looking at in the prostate side of things, men who trained for their prostate surgery, doing pelvic floor muscle training had better outcomes afterwards. And I could think.
The same would apply to really any surgery, but in this case, from a hip perspective.
Dr Doug (43:06.04)
Yeah, it'd be interesting. It'd be a great study to do. And actually I think really looking at complications from pelvic floor dysfunction after hip surgery, because incontinence is a big deal after a surgery like that, right? Especially if you do go in from the back, people are laying on that wound, right? So you're laying on the wound. If someone has incontinence in a hospital bed, like it's going to get saturated with urine. Like these are the things that nobody likes to talk about, but this, you know, that wound then breaks down and it gets infected and that's a massive problem. So yeah, it's a
Kim Vopni (43:14.894)
Yeah. Yeah.
Dr Doug (43:35.337)
That would be a good study to do for sure.
Kim Vopni (43:37.326)
Yeah. Yeah. Yeah. Okay. Well, if you need anybody, I'm open to collaborating. I think I've, just one more thing with regards to supplementation. So people think of bone. think of calcium. need to drink more milk and eat more dairy. I should be taking all these calcium pills. Is that accurate? And then also I want to ask about, so I know the other supplements that you're going to mention as a, conjunction with calcium, but.
Dr Doug (43:40.854)
I'm a little full. My calendar is full.
Kim Vopni (44:07.217)
collagen and creatine.
Dr Doug (44:08.846)
Yeah, great topics. So let me hit the dairy part separately actually. So dairy is an interesting one and I looked at the research of this in depth because there's some really strong opinions about dairy. The truth around dairy is that the people that dislike dairy and like Mark Hyman, and I love Mark Hyman, so this is not a bad thing, but he really hates dairy very strongly and he makes some really bold comments about some research that shows that consumption of one glass of dairy increases your risk of hip fracture by, I don't know.
like 7 % or something. But it's all taken out of context. That's talking about kids who consume dairy and they have a higher risk of fracture later in life because they grow taller and height is a risk factor for fracture. So that's not the same thing as a woman who's 60 years old drinking milk to get calcium. So if you look at dairy as an intervention, it actually does show improvement in bone mineral density. It does show an improvement in fracture risk. So not everybody can tolerate dairy, especially as we get older, but
There is a role for dairy. I personally prefer like full fat dairy, fermented dairy, cottage cheese, kefir, yogurt, all those things. I think they're really great sources of dietary fat, protein and calcium. But for the most part, osteoporosis is not a calcium problem. Very few people, especially in the US and Canada, are calcium deficient. So it isn't generally a calcium problem. And I think it's a little funny actually that we even say like,
you have osteoporosis. The gold standard is 1200 milligrams of calcium and vitamin D. Like, where did that even come from? There was not a study that showed that anybody was calcium deficient. It just makes sense because its bones are the calcium storage side of the body and it's made up of a lot of calcium. But we do need to get adequate calcium. And so again, our patients, we have them come in, we have them track and see like how much calcium are you getting through diet? If they're not consuming dairy, they very well...
might not be getting enough calcium, not necessarily to maintain bone, but to build bone, we do need the building blocks. And so we will put people on a whole food form of calcium. right now we're using an algae form of calcium. I don't think the best product is out there yet. I think I need to make it. But there are lots of different versions. We'll mix and match products to get all the things that we need, which is generally going to be a combination of minerals, combination of fat soluble vitamins, so the D, A, E, and K.
Dr Doug (46:30.732)
And then you get into some of the more fun things. like, what about creatine? What about collagen? and I think the answer is all of them have potential benefit. If I look at, know, with all of our labs that we get, and some people want to do genetics too, we kind of stopped doing it for everyone because it just makes too many targets. There's so many targets to hit that I can overload people in a second with supplements. So the question is, does it make the list? Right. but I find that creatine is a very powerful supplement. It's very, very safe. It's well tolerated.
Most women aren't using it already. It can help with muscle mass, cognitive function, energy, recovery, like, it is great. I think everybody should be taking creatine. Collagen, there isn't as much evidence for. So we know, obviously, collagen is the most prominent protein in the human body. We can make it. It's not essential, but we stop making as much of it as we age. So just like so many things in the longevity space, it's like, well.
I'm not making it anymore. If I take it, it should have benefit. And we know that it does for skin, hair and nails, so that's obvious. There's only one study that I know of that showed benefit for bone. And it was an industry funded study by the company Jalita, which makes the product Fortibone. Fortibone's out there in a lot of different products, Mary Claire's products, AlgaeCal products, like it's out there. But the challenge I have with collagen is you gotta know where the collagen come from.
So a big company like Jalita, they have this vague statement about where they source their cows. But if it's coming from an area where they were getting nasty food and exposed to lots of toxins, it's going to be in the collagen. So it's got to come from a good source. So I like it. I use it personally. I recommend it to my patients. I put it in coffee. I think it's a great way to add 10 more grams of protein, albeit they're incomplete.
Kim Vopni (48:08.122)
Yeah.
Dr Doug (48:22.83)
I like it for the most part. just, I can't say how much it's actually helping their bones, but I know it's helping them otherwise.
Kim Vopni (48:30.48)
Fair, Awesome. You mentioned you have a community called the Osseo Collective. Where can people learn more about that? Follow you. You have an amazing YouTube channel.
Dr Doug (48:39.502)
Thanks. Yeah. So the YouTube channel is the Dr. Doug show. Um, and it's all things bones, hormones and health span. And it's where I'm spending most of my professional time right now. Um, the osteo collective is relatively new. So it's a little less than a year old, but the osteo collective branched out of our practice. The practice is great, but it's small. We can only serve so many people and we have an international audience. So we created this community to take all the content we're creating, which is a lot of content.
and put it in front of people who are interested in DIYing their bone health. And so now we have, actually just moved to a new platform. It's awesome. So we have community, people can ask questions, you know, and these are monitored by our team. So we have dieticians in there. We have a couple of doctors in there actually from other countries who are big advocates for what we do. You know, they're always answering questions. The community helps people, supports people, you know, all the different topics, supplements, hormones, all the things.
We have a lot of resources in there. So we have nutrition resources. have, you know, menus and like we have, if you're in the U S you can get labs. We have access to our dieticians for gut health, for, CGM use for people that are concerned about metabolic health. you can order genetics. and I said labs already, we do a weekly Q and a in there. So I lead it if I'm available. So it's usually me or a team member or a guest who's talking to the community. And right now we'll.
We'll get 175, 200 people to show up on a weekly zoom. And then of course it's recorded, people watch it asynchronously. And then we actually chop that up into bite-sized pieces that are then searchable within the platform too. So it's just like, our goal is to educate people that they need to get screened. If they have a problem, this is the resource. Come in here, find what you need, figure out what's missing for you.
get the information you need, and then if you need help from there, like if you can't put it together, then become a patient. But most people can do this. It is so readily available. We just have to put the right pieces together. and I didn't tell you what it's called. It's called the osteo collective. That's important. It's called the osteo collective and it's osteo collective.com. If you just go on any of our, like my Instagram or YouTube, you'll find it, but osteo collective is what it's called.
Kim Vopni (50:42.448)
Yeah. Yeah. Amazing.
You
Kim Vopni (50:57.646)
Yeah. Yeah. And we'll have the links in the show notes as well. So thank you so much for your time. This was amazing. as I say, I will continue to binge your show. I love what you're sharing and doing. So thank you so much.
Dr Doug (51:10.306)
Yeah, thank you, Kim. And I love what you're doing. When you approached me at A4M, somewhat aggressively, I agree. But when you assaulted me at A4M, yeah, I was like, yes, absolutely. This is an important conversation that, again, nobody's having. Nobody likes to talk about pelvic floor dysfunction. It's so important. So yeah, so thank you.
Kim Vopni (51:26.628)
Yeah. Yeah. Except me. Yeah. Yeah. All righty. Thank you so much.
