Menopause, Frozen Shoulder and the Joint Pain Wake Up Call with Dr. Jocelyn Wittstein - Part 1

The other thing I always do whenever I have a woman with frozen shoulder, I always take basically a perimenopausal or menopausal history. I always ask them, are you having hot flushes? Are you having night sweats? You know, like what else is going on with you? And I make a lot of referrals to women's health, probably three to five per day in my orthopedic clinic to women's health because they're having these concomitant symptoms. and do I have proof that initiating systemic estradiol reverses or makes your shoulder better or makes you not get on the other side? No, but I'm studying that. But does it make sense to me that it would? It does make sense to me that it would. And they need their other symptoms treated anyway. the views and opinions expressed on unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only no part of this podcast or any related materials are intended to be a substitute for professional medical advice diagnosis or treatment. One day, I came across a social media post from an orthopedic surgeon, Dr. Jocelyn Whitstein. She was explaining the key lifestyle strategy she uses to prevent osteoporosis. It caught my eye because I'd been receiving a little bit of flex on social media by the weighted vest haters. Immediately, I shared her post on my page. I know my followers would want to hear this too. I was right. It blew up. Tens of thousands of women were tagging their friends saying, why has no one ever told us this before? I quickly learned more about Dr. Whitstein. She's a practicing orthopedic surgeon, a researcher, and an associate professor of orthopedic surgery at Duke University, and a mom of five. She isn't just another expert giving bone health tips. She's lived this science from every angle, as an athlete, a clinician, and as a woman navigating midlife herself. I knew I had to invite her to the podcast. Her research interests are female, athlete across the lifespan, post-traumatic arthritis after knee injuries, frozen shoulder, and the musculoskeletal syndrome of menopause. She's the president of the forum Women in Sports Medicine. She's also a core leadership member of the Duke Female Athlete Program and a member of the Milken Institute Women's Health Initiative. She is the co-author of the Complete Bone and Joint Health Plan. Dr. Whitstein's work is changing how we think about musculoskeletal health across the female lifespan, from injury prevention to joint health, and how menopause, hormones, and movement intersect with our long-term independence and quality of life. Today, she and I will talk about osteoarthritis, how it disproportionately affects women, why frozen shoulder loves midlife, and how hormones influence pain and bone strength, and how hormone therapy fits into the bigger picture of prevention versus treatment. This conversation will challenge how you think about movement, hormones, and aging, and it might just change how you care for your own body. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. Well, welcome to Unpaused. Thank you for having me. I am So glad you came in from North Carolina to New York to film. So tell me a little bit about your background. What kind of kid were you? Where did you grow up? I grew up basically up and down the East Coast in Connecticut, the D.C. area, North Carolina. My dad was an ophthalmologist. Like any child of a medical practitioner, we followed the chunks of his life, you know, medical school residency and his first practice. So I'm an East Coaster mostly. Why did you go into medicine? I actually thought I would not go into medicine, which I think is also common among children of doctors. And I hear my own kids saying it now like they don't want to be doctors. But when I was an undergraduate, I thought I wanted to do something related to nutrition. So I studied nutrition as an undergraduate at Cornell University. And somewhere along the line, probably when I was a junior, I decided I wanted to go to medical school. I think I had been suppressing that. That's exactly what happened to my daughter. Yeah. And then I had to take all those prerequisites all in a year and catch up and go. And, you know, I'm glad I made the decision. But for some reason, I saw myself in health adjacent fields, areas I was interested in. But I'm really glad I studied those things as an undergraduate because I apply them now. My daughter undergrad ended up being nutrition as well. And then she kind of second year ish decided. So she was able to catch up. But she never got to go to Europe or do the fun things, you know, because she was like playing catch up to make sure she had all the prerequisites. Sometimes you realize you don't want to do anything else, but it comes to you late after you study a lot of the adjacent things. Did anybody try to talk you out of it? Oh, yeah. When I told my dad I wanted to go to medical school, the first thing he said was, are you sure you want to do that? And my youngest, who is now 18, just said to me the other day, you know, do you think I could study this and still apply to medical school? And I thought to myself, oh, my gosh, he's going to tell me he wants to go to medical school. And I'm going to have that feeling of I don't want him to have the stress and the sacrifice and the lack of sleep and things like that. But at the same time, if he ultimately decided he wanted to do that, like I know he would be happy with his decision in the end, for example. And it's the question that people ask you all the time. If you could go back in time, would you redo it? Yeah. And it's hard to say. But yes, because I like where I am now, but I wouldn't want to redo it. Yeah, exactly. Go through that training all again. So why orthopedics? There's very few women in orthopedic surgery. Right. About 6% of orthopedic surgeons are women. I've been accused of being naive about many things, but I was actually quite naive about that when I applied. I didn't actually really know that, which is odd. It's very obvious. It should have been obvious. You do a vizzing rotation here or there, and you don't see many female orthopedic surgeons. But I think I just see people for people. And so I've always had like a lot of male friends. I also have female friends. And it's kind of funny why we go on these rotations. I just had a great experience everywhere I was. I really enjoyed the people I was working with. It was fun. I was learning a lot. It didn't really cross my mind that there was there were like no female attendings or maybe one or two at various places. And, you know, one female resident. I mean, I, of course, noticed it, but I didn't kind of think about like, what is the true statistic? Yeah. I mean, I know it now and the number is growing, but there's a very interesting study that looked at the rate at which orthopedic surgery will get to parity in terms of sex in the field. And it's well over 200 years before we will be at parity. At the current rate of attrition. Yeah. I think for a lot of people, athletics is a gateway to orthopedics. So student athletes are often very aware of nutrition, musculoskeletal health, often have an injury here or there, often have a chance encounter with someone in the field of orthopedics who then, you know, it just gets you thinking about it. And when I originally went to medical school, I thought I wanted to be a pediatrician, actually, because I love children. Same. And I did one block and it was just like not for me. It was either. I mean, I adore our pediatricians that are children of fat over the years and they're amazing, but I couldn't do it because for me it was like either boring or very sad. And I just it was not for me. And I wanted to be in the operating room doing surgery. I really like taking care of people in a way that I can acutely make them better. You know, they have an acute injury and I can solve it. And then I gravitated to sports medicine, which is, again, that is something that a lot of former athletes do. Just sort of an area of interest for many people who have that background. Yeah. So you were a collegiate gymnast. Has that really shaped part of, like you said, you know, coming from the athlete world? Were you injured? I mean, most gymnasts. You know, I had so many teammates that had like an ACL tear. I had multiple teammates who had Achilles ruptures over the years, which are those are common things that happen in that sport. Stress fractures in the spine. I actually didn't have any of those things, ankle sprains, a minor disc herniation one time, but, you know, nothing too crazy. But yeah, so I think sports have benefits and disadvantages, risks. And every sport has its risk. You know, in soccer, it's ACL. In baseball, it's, you know, shoulder and elbow. In gymnastics, there are, you know, there's a variety of random things that can happen. But sports also have major benefits for children. children who participate in weight-brewing sports like gymnastics and soccer, for instance, arrive at the age of 30 with greater bone density than those who don't. They have a better basis for lifelong fitness in terms of regularity and participating in things like strength training, cardiovascular exercise. And especially for girls, I mean, Title IX was a huge shift in terms of increasing women in sports and more like lifelong athleticism for women. So people always talk about risk of sports in young people, but overall, there are so many benefits. But each sport does have a certain risk profile. My kids definitely have more exposure to sports than I ever did. I danced my whole life, so that was my sport, but it was ballet, tap gymnastics, and a little bit of acrobats. Yeah. And nowadays, children do specialize sooner in sport. And there are issues with early sports specialization and overuse injuries and things like that. But overarching theme, like participating in physical fitness and impact and load-bearing activities and things that build muscle is very beneficial to people in their youth, you know, for their long-term musculoskeletal health. I mean, it's benefited my kids for sure. And they didn't go to a high school where like if you wanted to be a cheerleader, you pretty much needed a round off and a smile. If you wanted to play soccer, you just showed up. You know, it wasn't like this huge competition I see in the suburbs around the Houston area where these kids have been like kind of groomed from like young childhood to like go into one sport. Yeah. And one thing about the sport I did, it is a year. It is a year. Once you get to a certain level, you don't do other sports. But in that vein, it is a whole body strength, you know, bone muscle building sport. I personally feel like it gave me a really good foundation for strength as an adult, you know, bone health as an adult. And you do live off of that for a while, but then you have to start working harder and maintaining. yeah well do you still tumble? Which becomes apparent uh on trampolines I will do uh flips you know back tucks front tucks. Do you like impress your children or like mom yeah do a back handspring? Uh I do like an aerial cartwheel probably once a year but I do it on sand in case because I don't want to rupture my Achilles when I hit the ground. Yeah now five kids that when I read all I read your most impressive resume in your in your bio and I had to stop at five kids. Holy cow. That is amazing. I'm in awe that you're able to live your life. I don't want to seem like too amazing of a human being, because there is a caveat to this, which is when I married my husband, he was a widower with three children. Okay. And so I married him plus a five, eight, and 11-year-old. And then we had two more kids. So I had two kids. But you still had five kids. Yeah, I had two kids during residency, one at the beginning of my second year of orthopedic residency and one at the beginning of my fourth year. But yes, I have mothered and raised five kids. And but the funny thing is, and I just think this is such a funny comment all the time that I get because patients will read my bio or something. So you have five kids. How do you look like you look? And then I feel funny. Also, it's a funny comment for people to say, like, you look amazing after having had five kids. And so I have my little thumbnail story that I say, because first of all, it is a funny comment, but I also don't want to, I guess this is a weird thing to say, take credit for having birthed five children. I'm just thinking time management. Yeah, time management has always been crazy in our house and people think we're nuts. My husband is also an orthopedic surgeon. And there was definitely one year where we had, or maybe two, where we had one in preschool, one in elementary, one in middle, one in high school, one in college. and just the craziness of schedules and things like that. Well, let's dive in to musculoskeletal issues in women. Of which there are many. Of which there are many. So here you are, orthopedic surgeon, you know, putting bones back together. When in your training did you start realizing, you know, besides the presence of a breast, you know, of larger breasts and uteruses, that there's a difference, you know, their physiologic difference between men and women and how their bones and muscles function, how the musculoskeletal system functions? I think the first like sex disparity that I was most aware of was in younger patients. And part of that is because I chose to specialize in sports medicine. And so I mean, and I do see patients, I see, you know, queens, adolescents, college age, and, you know, women of all ages. But the first and most glaring disparity you see is actually in sports medicine. That's the most obvious one because girls are about eight times more likely than boys to tear their ACL, which is a poorly understood phenomenon. There have been many theories and hypotheses tested, but there's probably some hormonal component related to this. So you want to talk about that some more? Eight times? Some say 10. I mean, yeah, but there's a huge propensity for girls and women to tear their ACL more than boys. And was that like in a text, but girls will tear their ACL more than boys. Like, did you, you know, was this like recognized? Well, you see it. I mean, it's recognized. It's in studies. If you look at, you know, how many. And did anyone try to figure out why? Oh, people have been trying to figure this out for a long time. Because every woman who's torn an ACL listening to this is flipping out right now. People have tried to figure this out for years. I think there's been a lot of focus on this. in the world of sports medicine, actually. And so I think credit to that subspecialty The people who have been trying People have been trying to figure this out People have hypothesized it must be the size of the ACL or the size of the notch which is the space for the ACL or neuromuscular control or women have more valgus knees. For our listeners, what is a valgus knee? Being like a little bit more knock-kneed. Yeah. And to simplify. You know, you'll get one research that shows this, then someone else can't reproduce it. And, oh, we find the ACL is smaller because the knee is smaller, it's proportionate to size. You know, so we, there are a lot of theories that have been explored, but never really truly figured out. And then people have also looked at, you know, timing, cyclical timing of injuries. There are some researches. Meaning menstrual cycles. Yeah. Some researchers have shown like, well, there's more likelihood of knee injury, like in the luteal phase. Is it a lower estrogen state, perhaps with more muscular fatigue or like worse collagen synthesis, something like that? Or is it in a higher estrogen state where perhaps there's more laxity of the ligament. That is something that we are actively studying, and we have the most amazing study to look at all of these issues that I am so excited about. But? Is there a but? No, it's not. We have done pilot. We've done some early data collection, and it's a NIH-funded study, and we are proceeding with. Which is kind of a big deal right now. Yeah, yeah. Because there's not a lot of NIH funding floating around right now. So this study... And women especially. Yes. This study, I'll try to explain it in not too boring or complex a way, but I'm so excited about it because no one has ever really been able to study real-time estrogen and relaxin levels with laxity of the ACL. And we have a way that we do that. Okay. So let's break it down for the audience. So estrogen, everybody knows. Normal hormone. I know what relaxin is, but explain what relaxin is. It's more stretchy. And is it a steady state? Relaxin, is that a steady state? Or is it something that kind of ebbs and flows with the menstrual cycle? You know, I don't actually know the actual ebb and flow of relaxin with the menstrual cycle myself. We get a lot of it in pregnancy. Yes, in pregnancy. But we're including it in our study with the estradiol levels. But what we do is we check real time because obviously these things change over the course of a month. or in women as they get older, you know, they're not steady state. But so we have these hormone levels. And then we basically make these models of knees from MRIs. And we've developed machine learning so that in just a couple minutes, we can create a whole three-dimensional model of the knee that shows traces, the whole ACL, all the cartilage surfaces, all the structures of the knee. Then we have women who we have their blood levels. We can test them with and without fatigue. So we're combining hormone levels plus fatigue as a component. And then we have them do a test where they kind of jump off of a block and land, basically. And then we have this fancy setup with live fluoroscopy or x-ray from different angles. It's called biplanar fluoroscopy. And we overlay the model, the three-dimensional model we made of their knee, on their knee with movement. And then we can actually measure in these moments of jump landing how much the ACL stretches or how much strain there is on it. The ACL is the ligament you hear about, Tara, you talk all the time. So we're going to be able to actually measure how much strain there is on the ACL. Does it strain more when estrogen or relaxin are higher? Does it strain more with fatigue? Is there a relationship between fatigue and hormones? But every other study that has tried to look at this kind of looks at, say, oh, these women tore their ACL and we asked them what part of their cycle they were in. Right. They weren't measuring it. Yeah, it's I mean, it's it's hard to capture because people have these injuries randomly. And it's not like you took a blood test on them that morning or something. And so it's this is, I think, an amazing study design that's going to answer a lot of questions that people have been asking but not been able to. How hard is it to get something like that funded? Well, you apply round after round and, you know, you have to get scored typically in the top eight percent, you know, in order to get funded. And then sometimes there's delay in funding and things like that. But I mean, these studies cost millions of dollars, a few million, really. And they, but this study in particular, I feel it could really change, could be a very meaningful study. study. So if we find that there is this relationship, you know, that may impact training or maybe timing of games or events, things like that, that might, you know, put women more at risk for ACL injury. And there's this other body of literature which looks at oral contraceptive pills and risk of ACL injury. And there's some mixed evidence. Some studies show that use of oral contraceptive pills reduces risk of ACL injury. Some studies don't, especially if control for things like comparing to other women who use IUDs. So you're kind of getting a good control group, things like that. And I think one funny thing is you've got sometimes orthopedic surgeons trying to figure out how to study these things, and they're not necessarily maybe differentiating between, you know, phasic or continuous or different forms. It's just oral contraceptive. There's 50 different ones on the market, and they're all different. They have different projections. This gets into my whole thought process about I just feel like we need less siloed approach to studying musculoskeletal conditions that have this intersection with women's health because people really want to answer this question, but they're using insurance databases that pull, oh, these people were on oral contraceptives. And it's more nuanced. Yeah. There's so much nuance in my field that people outside my field are not going to know. And there's so much nuance in women's health that I don't know. And I'm an orthopedic surgeon with a very high interest level in women's health, but I consult all the time with my partner, Ann Ford, who is in women's health at Duke. I constantly ask her questions, help me clarify things because, and I pull her into studies all the time because I need her expertise in the study to do it right. Because we trained in silos. Yes, exactly. Perimenopause is not early menopause. It is its own distinct biological phase and it has been largely ignored. My new book, The New Perimenopause, is about the seven to 10 years before your period stopped, A transition that is anything but gentle. Hormones fluctuate wildly. And for many women, this is when the anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of, I don't feel like myself anymore, begin. Long before anyone says the word menopause. Perimenopause often starts quietly. It shows up in the brain first. Then the body. Then everywhere else. And too often, women are told nothing is wrong. I wrote the new perimenopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The new perimenopause is now available for pre-order everywhere books are sold. Learn more and pre-order your copy at thepawslife.com. I broke my foot when I was pregnant, 25 weeks, tripped on a curb, you know, had a fifth metatarsal fracture. They brought in a pregnant woman, you know, into the ER with a broken foot and like the entire orthopedic team came in and like I was a space, like, you know, I was an alien. They didn't know what they were so scared to hurt the baby. I'm like, you can put a cast on me. Like you can do what you need to do. You know, I just realized I'd never met any of these people. I rarely saw them. There was no interaction between our two specialties other than when the one pregnant resident comes in with a broken foot. I mean, I want to get back to orthopedic conditions with sex disparities, but I will tell you, the gateway to my connection to women's health and all this work that I do came from the fact that my mom's favorite doctor over the course of her entire life, my mom's gone now, but was Ann Ford. And so for like 20 years, she'd be like, I just love Ann Ford. Ann Ford is the best doctor. This is her women's health doctor. She was like, she's like, she, oh my gosh, she just, my mom raved by her. So one day I'm in the break room and thank goodness my office is directly on the same floor across the hall from Duke Women's Health. And I'm in the break room and I see this woman with a badge on and it says Ann Ford. And I said, you're Ann Ford? I have heard about you for at least 15 years. And, you know, we started talking and ever since that moment, we have worked together. That's awesome. But because she meant so much to my mom. Yeah. No, that's a great story. I often wondered how the whole frozen shoulder story, and we'll get to that. We'll dig into that later. But let's talk about, let's go back. So we talked about ACL. Right. So then I think the next most obvious condition, I mean, there are little ones you see here and they're like dequeer veins, tenosynovitis, which happens to like new moms, but also like perimenopausal women. So much. So much. Plantar fasciitis, you see more of. But the one that's really, really obvious to me is frozen shoulder, like we've talked about. It's just a condition that mostly strikes women. And really, the only men who get frozen shoulder are men with diabetes and usually poorly controlled diabetes. So, you know, another inflammatory state. So, frozen shoulder is a condition that for many decades was described as idiopathic, which is a fancy word for we don't know what causes this. I hate the word idiopathic. Because you're an idiot. Yeah, but, you know, something cannot be idiopathic that almost entirely affects women, but not men, and almost entirely affects women between the age of 40 and 60. That's the typical time frame. But what a person's older is, and it's also called adhesive capsulitis, if you see that term, but it's typically a non-traumatic or sometimes minimally traumatic situation where you didn't have a big injury, but your shoulder becomes very painful and then subsequently very stiff. It's a process where the lining of the shoulder joint, you may hear the term capsule or synovium. Think of just sort of the lining around the whole ball and socket joint of your shoulder becomes inflamed and thick and fibrotic. And our phases, one of my friends, Johanna Fenn, who is in the forum with me, the Women's First Medicine Group, has described this very well over the years, including, you know, looking at the actual, you know, pathophysiology in the capsule or tissue. But there is an inflammatory phase where the shoulder becomes very, very painful, you know, like pain at end range of motion, just like, okay, with the mid range, we get the end range and ow, like super painful, leads to guarding. Then a frozen phase where it becomes not so painful, but just really stiff with women can have extreme lack of motion. I mean, I've had women come in who cannot rotate their arm out to the side or lift it up at all. and I just don't know how they can be at home. So they can't brush their hair, they can't put their bra on, they can't put their arms behind their girlfriends in a picture. Oh, yeah. Common things are, I can't shave under my opposite armpit, cannot tuck in a shirt or fasten a bra, washing your hair, things like that, all very common. And then there's a thawing phase, which could take one to two years. And if a woman has diabetes, that is the worst case scenario. Women with diabetes can have a really prolonged course of frozen shoulder. But, you know, I really believe this is hormonally related. This happens mostly to women between the age of 40 and 60. There are a lot of estrogen receptors in the synovium or, again, lining of the shoulder joint. And estrogen has been shown to inhibit cells called fibroblasts in the lining of the shoulder joint. So these cells that can like thicken and stiffen the capsule. I think you're aware we presented a study on this at NAMS, or now the Menopause Society. So I want everybody to understand, women have been having this condition forever. And she and her team, you know, the co-authors, were the first people to even suggest that this may have something to do with menopause, since it usually happens in women between the ages of 40 and 60. Yeah. And it didn't go over well at first, right? Yeah, I mean. What made you think of this? What made you wait a minute? So I work in a network where I can, it's a closed network, not a closed network, but the primary care doctors, all the notes, everything are in there. I can see what's going on with my patients. And I can see that they're seeing their doctor for sleep disruption, night sweats, hot flashes, lipids creeping up, things like that, anxiety, you know, all these other symptoms associated with perimenopause and menopause. and I just started, I also started asking my patients. So, you know, the first clue was like, I have all these women with breast cancer who have this. And I started thinking, well, I mostly see this in women. And then, you know, it's in this age group and estrogen is an anti-inflammatory hormone. I just, I sort of started just putting these pieces together and these other, you know, complaints that they're having all kind of together. And I just, I think the thing that first set me down the path was the effect of aromatase inhibitors. And I, Ended up talking to Anne about this and I said, this has to be a symptom of menopause. So this was like actually during COVID. I spent hours and hours and hours, days and days and days manually doing chart reviews of like thousands of charts. I just, yeah, this is the important part. I want our listeners to understand is that the work that goes into getting the scientific proof. Yeah. That this could be correlated because the whole world is going to tell you no. Yeah. as being the first person to make this correlation. As you know, use of menopausal hormone therapy is less than 5% in women in the United States. Now, in our population, because I work with women's health doctors who are ahead of the curve, I would say on top of things. Not to say other people are on top of things, just they're, I think, have a higher percentage. I think it's about 8% or 9%. Typically in academics, we see that. Right. But even so, if you only have 8% or 9% of people on hormone therapy and the rest are are not, and you have several thousand women that you're looking at, it's hard to get the numbers you need statistically So we need to do more research on this And what we ended up finding in our study was that women who used menopausal hormone therapy that included estradiol systemic not just local had half the risk of developing frozen shoulder as compared to those who didn't. However, we approached statistical significance, didn't reach it. And then the other thing is when you look at our confidence intervals, they didn't overlap. So if we could have just had some more patients, I think we would get there. And I mean, just the number of cases of frozen shoulder in the hormonotherapy group were so small. But again, you know, we need larger numbers. So I did a post hoc power analysis, you know, and I know how many we need, but I can't go back and get more because this was it had to be. I used patients that were in an enclosed system, meaning they were within our HMO. So there's not leakage. I'm not missing data. But I have ongoing perspective work that I do with our women's health group. We enroll people in something called our musculoskeletal symptoms of menopause registry. We survey them every few months, you know, follow them with timing of onset of hormone therapy or not. So we're doing that prospectively. And I have a very large cross-sectional study that we'll be coming out with that I actually collaborated with Vonda right on in terms of distributing. And that was great that she was able to collaborate with us. And we have huge numbers and we'll be coming out with that. And I don't want to say what it shows yet, but it does confirm our suspicions. I have that in submission. And so I think it's becoming more and more obvious and people are recognizing this more and more. When that paper was presented at the Menopause Society, I talked about it on social media. And it was one of the most viral videos that I've ever had. I remember that. And so many people reach out to me. They're like, are you the doctor she's talking about? Because you're like doctors at Duke University. And I was like, I think I am. But I do want to say there are I think about this all the time in women's health. If you look hard at older data, there are pieces here or there. Right. There are clues that just haven't been brought together because they're, you know, siloed. There are clues. There are clues as to why, you know, women have more arthritis than men, a lot more. And they're here and there. Some of it's in the orthopedic literature, you know, some of it's in women's health literature. But when you if they're not all brought together, they just don't work as well. Have you published in orthopedic journals any of this data? No, not the frozen shoulder data I've tried. I've also tried, I wrote a piece on managing, you know, hormone therapy and oral contraceptives perioperatively. And I sent it to so many orthopedic journals, even got pre-approval to write editorials on this. You know, yes, this is approved, submit it, submit it to JAMA surgery, all these places. And then they would get it and review it and be like, oh, this isn't, you know, no, just kidding, we're not going to publish this or I don't know if this is of interest to our readers. And, you know, and it's like 51 percent of the population. So I eventually published it in a journal. Women's health is niche. What on earth? So that paper, for instance, I eventually published in a journal that Miho Tanaka, who's at Harvard, is the lead editor of, which is Journal of Women's Sports Medicine, to give people guidance about how you manage exogenous estradiol perioperatively in orthopedic surgery. Oral estradiol has some increased risk, transdermal, much less, little to none, vaginal, zero. You don't have to hold that around the time of surgery. But it's just interesting, like sometimes these things that are so significant and affect so many people, it's just hard to get it to where I want to get it. Oh, regards to first shoulder. This is very interesting. In some cultures that are highly prone to frozen shoulder, such as Asian cultures, like there are certain Asian cultures that have their own term for frozen shoulder, which translates to 50 year shoulder. Like that is also not a coincidence. Like their term is 50 year shoulder and some women just full on expect to get 50 year shoulder. Oh yeah, my mom got 50 year shoulder. So again, if you listen to people and it's just, this is not random. So I wanted to share that anecdote because that's actually meaningful to me. Like if you just listen to terminology within various cultural groups, they're telling us this is something that happens to women when they're 50. Yeah. Especially. Since we're talking about frozen shoulder, I am a gynecologist, have zero training in orthopedics. But because it's such a popular theme on social media and, you know, I'm always asked, how do we avoid it? What can I do if I develop it? You know, is there prevention? And then how do we take care of it? What do you do? Yeah. So one of the most important keys to treating frozen shoulder is if you think you're developing it, so you didn't have a traumatic event really, or something very mild, then you have this new onset severe shoulder pain, and you start to notice you're losing range of motion, even just a little bit. Like if you look down, and you try to like rotate your arms out to the side, and you see even just like a 10 degree difference, like that's not normal. Like normally, you're going to have normal range of motion. Yeah. I tell people this all the time, especially when they're in treatment for frozen shoulder, like just check yourself, make sure you're not losing it after we gain it. But go see someone early. This is not, ideally, I think an orthopedic surgeon, or you could see like a primary care sports medicine doctor, someone who will give you a glenohumeral joint injection, an injection into the ball and socket joint. You're basically trying to combat or reverse as soon as possible the inflammation of the lining of the joint. And frozen shoulder is the best indication for use of a steroid injection, I think, in all of orthopedics because it is not a Band-Aid. It's like a cure. Is it ever too late? So if you're three or four months into the process and you've already started to lose motion, there is less efficacy of the injection. I'll still give it to people because they're still in pain. It just doesn't work as well. If I catch someone within three months of onset of the symptoms and I give them an injection, it'll often restore their motion, make the pain go away. And And half of those people, I never see them again. Okay. And they hug me when they come back, if they come back, because they're so happy. What percentage will get the contralateral, the opposite shoulder? You know, I don't know an accurate statistic on that. I would say anecdotally in my own patient population, you know, maybe like 20%. Okay. But so some people need a second injection. The idea is you keep the inflammation at bay. You're shortening the course of the inflammatory phase, trying to get them to not freeze up so much or shorten the course of the frozen phase that they can then thaw. What about physical therapy? You will read in textbooks and are like examinations. The correct answer is send people physical therapy. But physical therapists and I will tell you, if I send you to physical therapy in the throes of the inflammatory phase, it is not going to help. So if you're in that very painful phase and I send you to physical therapy or your primary care doctor, whoever send you physical therapy, oftentimes the physical therapist is going to recognize you have frozen shoulder and be like, I can't help you right now and send you for an injection. because if you have pain and range of motion and someone is trying to help you move it and let you move it and at the end of each end range, you're like, ow, ow, ow. By the end of the session, it's inflamed and you guard more. It's kind of exacerbating. Okay. So if you're in physical therapy for frozen shoulder, but it's making you worse, not better, it's not that your therapist is doing something wrong. It's just that that's the nature of the condition. It's not the right phase. I think you don't get as much out of physical therapy. So doing the injection early is helpful. Once we get you out of the painful phase, and I will bring people back usually six weeks later and check them, if I can rotate them and at the end of the arc of motion, they're not painful, they're just still a little limited, then we do physical therapy and it's more helpful then. And then rarely people need surgery for this. I mean, I don't operate on many of these because it is a self-limited course and people do get better. And most people don't need what we call lysis of adhesions or manipulation, but some people do. I think certainly less than 10% of people. So I think using physical therapy at the right time or phase is important so we don't exacerbate things. And then the other thing I always do whenever I have a woman with frozen shoulder, I always take basically a perimenopausal or menopausal history. I always ask them, are you having hot flushes? Are you having night sweats? You know, like what else is going on with you? And I make a lot of referrals to women's health, probably three to five per day in my orthopedic clinic to women's health because they're having these concomitant symptoms. And do I have proof that initiating, you know, systemic estradiol reverses or makes your shoulder better or makes you not get on the other side? No, but I'm studying that. But does it make sense to me that it would? It does make sense to me that it would. And they need their other symptoms treated anyway. And that your data so far suggests that HRT could be preventative. Is that a correct statement? Yeah, or evolving data. I don't want to like, I got to get it out there in the right way. But yes, that's what I'm seeing. I want to do this the right way and get it accepted and reviewed and everything. But yeah, that is my feeling. Okay. So frozen shoulder is part of the musculoskeletal syndrome of menopause, which is a new term. Is everyone like arms open wide accepting this term? Is the terminology receiving pushback in certain organizations? I mean, I think people question, is menopause arthritis? Do you just have arthritis because you're aging? There are a lot of things that we can attribute to just aging. Progression of arthritis, loss of bone density. But some of these things accelerate in a different way at age 50-ish in women versus men. And what we see is the premature, what really stands out to us is some of these conditions in the people with premature ovarian failure. Yes. You see this rapid. Rapid. You know, in their metabolic health. Or surgical menopause. Yeah, or surgical menopause. Right. Which is, again, like takes me back to the aromatase inhibitor revelation. Or the AI patients. You know, it's like, yes, these people have the most exaggerated version. surgical menopause is the human equivalent of the studies on the oafrectomized rats. I'm in no way comparing my lovely female patients to rats. No, but we don't have a perimenopause model in animals. There's no perimenopause model. They either take out the ovaries and they're surgically menopausal, and then they do the experiments, or we don't have, there's no transition states in the rodents. Yeah, there's not a mouse perimenopause model. Yeah, model. They're trying, but it's so complicated. We are so complicated. Yeah. Muscle and skeletal effects of menopause are multiple and some are more silent than others. So more accelerated loss of bone density, increased joint inflammation and risk of arthritis. Women over 50 are 35% more likely to have arthritis than men. And that difference doesn't equilibrate until age 80. So that is a disparate aging of joints. And so that's just not normal aging. Well, I guess it is normal aging for women because women do normally go through menopause. But I'm saying it is probably a modifiable thing, right? As is osteoporosis. We know that. And we're Asian TAS FDA approved for the prevention of osteoporosis. And then getting back to the mouse versus human situation, we talk about muscle mass and maintenance of muscle mass. As we age, both men and women do lose muscle mass. Now, there are some studies that show that men and women don't have different rates of muscle mass loss over 50. There was a recent systematic review that looked at hormone therapy that included estradiol and showed like in this meta-analysis that it didn't actually make a difference in terms of helping women maintain muscle mass. On the other hand, some of these studies use like older forms and older ways of assessing for sarcopenia. And then there are some new studies coming out that I read one recently out of Thailand where there was a positive effect of hormone therapy with estradiol on muscle mass. There's a very interesting Finnish study where they have followed these sets of monopsychotic twins for years and years and years. And it's a small study, but they have these 15 twins sets where one woman was on hormone therapy and one wasn't. Oh, my gosh. And they've followed them for years. And they show that they're again, this is a small city, but so niche. And how would you get this group? Because they have such good studies in Scandinavian countries. And they show a positive effect of hormone therapy on maintenance of muscle mass. So I think that is evolving. And I think in terms of the whole muscle mass aspect of thing, like I would like to see more research on. And it's possible I just haven't found it because I read a lot of research, but I also have a full clinical and surgical schedule. So I could easily I could miss something. But don't be shocked. We have so many listeners. Someone is going to do a deep dive for you and you're going to get an email. I would love this. I haven't seen some researchers going to be listening. to this and being like, I have the data. If someone is doing research and has data on more like muscular endurance or fatigue with or without hormone therapy, I don't know the data on that. And I wonder about that. And I think about that because we think about it in sports medicine sometimes in terms of, you know, and that's one of the hypotheses about maybe potentially having increased ACL risk during luteal phase is there more muscular fatigue at a lower estrogen state. We know that estrogen relates to glucose utilization and metabolism in muscle. So it would make sense to me that there could be some effect on fatigue. But in any case, so we have potential effects on muscle. Some of that thought process comes from what we know about mice, O-fractorized mice having less satellite muscle cells, loss of muscle mass. Now, like you said, we don't really have a perimenopause or menopause model necessarily with mice. It's more like an equivalent of surgical menopause. And there is some data that suggests that women with surgical menopause maybe are more at risk for sarcopenia as compared to just regular menopause. And we talked about it previously on the podcast but sarcopenia for new listeners is the loss of muscle mass to the point where you lose function So if you want to explain what sarcopenia is Yeah obviously a more extreme version is you having so much weakness that you're frail. I mean, like grip strength less than 17 kilograms or something like that for women. But in general, obviously everything is on a continuum from a large amount of muscle mass to less and weakness. But there's some data suggest that surgical menopause would put people more at risk for having some loss of muscle mass than someone who had natural menopause. Yeah. Or more at risk for like completing a survey that indicates your strength and muscle function being more at risk for sarcopenia than natural menopause. So I think we need more information about there are basic science things that make sense in mice models. I think maybe we'll learn more going forward about actual, you know, what actually happens to muscle mass with some of the more modern-day utilizations. But those are kind of the components. So you've said that musculoskeletal health might be the most overlooked dimension of women's health. Why do you say that? For multiple reasons. So one of the largest impacts lifelong of estrogen withdrawal is osteoporosis, which largely affects women and is a silent condition. So it's easy to overlook it until so late in life that you have a hip fracture or, you know, a vertebral compression fracture. And then who are you seeing at that point? Usually a male surgeon. Yeah. And at that point, you know, yes, you know, for instance, where I work, we have a fracture, a fragility clinic that we send people to after a hip fracture, vertebral fracture. And we, you know, many of these people haven't been tested for the bone density or haven't ever had like a zelendronate infusion or something like that. And we're getting them down that path, but it's so late. And so I think there's this weird thing that happens where women are obviously receiving a lot of lifelong health care through their women's health providers. There's a silent disease, which prevention of osteoporosis is and has been for a long time, an FDA-approved indication of menopausal hormone therapy for protecting your bone density. But the end result of declining estrogen levels and more bone resorption than bone building is this progression to osteoporosis than fracture. The end result is so far down the line that the people seeing at the end of the line were not there at the beginning of the process. And so again, it's this siloed approach. And I'm on our fracture fragility committee, and I'm pushing really hard to get our distal radius fractures, your wrist bone fractures, which peak for the first time in women between the age of 50 and 60. I want that group to go to the fragility clinic. The silver lining, if you fall and break your wrist, I mean, there's good and bad things to this. If you're a 50-something-year-old woman and you fall, same level of fall and break your wrist, depending on the study you read, you have a nearly 50% or maybe 200% greater risk of eventually breaking your hip as compared to a woman who never had a distal radius fracture. But this group of people, if you had a distal radius fracture, you are the group I want to focus on because if I get you to a fragility fracture clinic and I get you a DEXA before the age of 65 and you're diagnosed with osteopenia and you make your hormone therapy decision about potentially bone health as the driving factor may be, and you're in the window where you can safely start. You're in the window of opportunity because, again, these are happening in women in their 50s. This would inform you and you may say, okay, I don't want to have a hip fracture. I am at increased risk for a hip fracture. Maybe you have osteopenia, not osteoporosis. And we know that hormone therapy that includes estradiol will increase your bone density over time and protect you against fractures quite significantly. So I think we need to shift our thought process towards obviously earlier prevention. But in my world... We try to get a bone density on everybody. Yeah. In my world, I think we need to focus, like capture these wrist fractures because at least we're not so far down the line. So bone health is silent. Some of the other things are less silent. What else can a woman do to prevent osteoporosis? So many lifestyle things. That's how I found you. Yeah, yeah. Yeah. Many lifestyle choices will help you protect your bone density. And so many people, as you know, are not candidates for hormone therapy. Right. So hormone therapy alone will not be really enough, probably, or certainly isn't the only way to protect your bones. So lots of data. And, you know, you've talked about a lot of times about strength training. and everyone hears the saying, you have to lift heavy. And I do want to say, because I'm an orthopedic surgeon and I see people, not everyone can lift heavy and that's okay. But there is evidence that heavier strength training, higher intensity does increase your bone density more than moderate and lower intensity, but there's still benefit to moderate and lower intensity. Yeah, they both, they both will, can help you increase bone density. And of course, the classic trial that everyone knows, which is an amazing trial, the LIFMORE trial, you know, a great trial that used Women who are menopausal with some of them osteopenic, some of them osteoporotic, and they did back squats, deadlifts, overhead presses, and jumping chin-ups, and they kind of ramped them up to high intensity over eight months, and they gained 3% in their lumbar spine and also significant gains in their hips. Strength training is very effective. But for people who cannot do that high intensity, you know, 85% single rep max type lifting, like, don't give up and just be like, I can't do that. There's definitely benefit to moderate and low intensity. So I just want to say that. Yeah. Jumping or impact is also a great way to improve your hip bone density. Most of the load-bearing strength training exercises will have a larger effect on your lumbar spine than the hip region. So that's your back. Yeah, your back. There is still some benefit with strength training to your hips, but there is a specific effect with jumping and impact. This mechanical load or this process called mechanotransduction, which basically creates a biochemical reaction in your bones and stimulates bone formation. is more effective in perimenopausal women than menopausal women, but there's still benefit for menopausal women. So one study showed over a six-month period that included jumping a few days a week, maybe 30 jumps each time, that there was about a 1% improvement in hip bone density in menopausal women. But if you look at similar studies of perimenopausal women, you may see gains of 2% in the hip region with these interventions that could be, one study compared 10 versus 20 jumps a day. Another did 50 jumps a day. And that study in perimenopausal women actually showed an increase of like 3% in the hip region. So impact is very effective. And we know that from studies of children, you know, participating in exercise impact, they have, they accumulate more bone mass. So impact is great. Now there are people who cannot do impact because again, I'm a orthopedic surgeon. I have so many patients like, that's great. I would love to do that. And I get tons of messages from people. That's ridiculous. I can't do that. You know, and I'm like, I'm sorry, I'm just trying to share information about what jumping can do, but there are lots of modifications. And so if you have terrible knee arthritis and every time you jump, your knee swells, that is not going to be a good option for you. You can do heel drops. You can do jumping on a rebounder, which doesn't do as much as land-based jumping. You can do jumping in a pool. Again, not as much as land-based jumping, but better than sedentary. And so impact, that's a broad category. What about vibratory plates? Yes. So those have mixed results. If you look at meta-analyses of these, you're certainly going to see half of studies that had no effect, half of them had some effect. The most effective, I would say, formulation, if you're trying to think about using a vibratory plate, uses a 30 hertz speed. So that's high speed vibration or frequency, I should say. Low magnitude. So you don't want the big magnitude of vibration. The studies show 0.3 G, so that's called low magnitude. not like 1G, which is like a larger vibration, actually. Interestingly, there's something about vibration that seems to be beneficial of this like low magnitude. And then the exposure time matters. So the downside of using vibration plates is the studies that show benefit, you're basically having to do this 20 minutes every day. And that's probably most people aren't going to do that. But I do tell people who are, you know, there's so many people like, I can't do this, I can't do that. I have all these limitations. And that's probably a reasonable thing for you to add if you can do that, you know, 20 minutes a day. And then other components people need to include, because it's not all about just bone density for fracture prevention, balance, some agility work. So when we talk about fracture prevention, we talk about limiting your chance of falling. Right. You want to reduce falls. So balance is key here. So what do you do for balance? I was a gymnast. I literally love standing on one leg. I mean, it is the most natural. I love standing in tree pose. Sometimes I just stand on one leg. If I'm waiting for an instrument, I just stand on one leg. Me too. I do it without thinking. It's so comfortable to me. And I think, but I have patience. I'm even teenagers. I ask them to stand on one leg and they're wobbling. That's not good. So, you know, single leg balance is a really easy thing to practice. You can brush your teeth standing on one leg and switch. you know when you switch i don't know your top and bottom teeth or whatever that's easy to do um but yeah i think tree pose is a very easy thing to recommend uh and you can try to do other things while you're standing on one leg but it's such an easy thing to do if you're waiting in a line you can stand on one leg you can practice you know like bending over and picking something up standing on one leg it's like a little mini single leg deadlift things like that if you have balance issues or inner ear issues or you know you fall frequently like maybe like keep yourself near a a wall or something. But yeah, I think it's important to just practice balancing. And agility work is just sort of anything that makes you move your feet kind of quickly. That's another thing when I recommend it to people like, I can't do that. And you can do less intense forms of agility work. It's just a matter of helping yourself respond to your external environment so you're less likely to fall. What about the weighted vest? There's a lot of weighted vest, misinformation, hate. I have one and I love mine. Yeah. So the funny thing is like rucksacks have been around for years. The military uses them to train their members, their athletes. So the data on weighted vest is it's the problem with it is that some of the studies are very small and then some of the follow-up studies are on even a smaller portion of the original study. And they're usually using mixed methods. So they're not only wearing the weighted vest, the subjects are also doing some strength training and some other things. So we can't attribute necessarily improvements in bone density to just using a weighted vest. But there are some studies that indicate there are improved parameters of balance and strength and things like that. And I like it for cardiovascular exercise. It adds to my walk. If I walk my dog, I put on that or a rucksack. If I wear a rucksack, I feel like I get a little bit more maybe core work. But so it's they're certainly not harming people. I like it for balance training Yes. And there's so many things that I like to tell people are the opposite of disuse. And now we think about data on things that stimulate bone density and jumping. You know, we want to create a big impact, something that's going to create a force more than three times your body weight to stimulate bone formation. But if you think about the opposite extreme of things, like if you're an astronaut and you're in microgravity and you're not putting any weight on your bones, just the absence of standing or having like your body weight on your legs will make you lose 1% of your bone density per month. So in contrast to that, what if I were on crutches? If you're on crutches for like six weeks, you get diminished bone density in your whole leg and loss of muscle mass. And it may take one or two years for your bone density to return to normal, like in all parts of your femur, for example, from just not walking. So then what about walking? Does walking put a load three times your body weight with every step? No, but it is the opposite of disuse and it does slow bone loss over time. And people who walk regularly have less risk of fracture. And the end point isn't always bone density. It's not fracturing, not fracturing, which is different than your. And so I really like to tell people use is the opposite of disuse. It's not like everything you have to do has to like make new bone or it's worthless. Like if you're not these other activities are beneficial, too. And so, you know, you're adding a little bit to your walk. So I don't think weighted vests are like the magic cure-all, but I think they're a nice addition or tool. And they get people excited about going out and walking and getting a little extra workout in. I always feel a little breathier if I'm out walking. My followers tell me it's like the perimenopausal badge of honor. You know, like when you see someone walking with their weighted vest, they're like, hey girl, I got you. I don't want to exaggerate what they'll do for you, but I think they're a nice addition. Now, if you have terrible knee arthritis, the funny thing is, they're not for everyone. Yeah, I tell people, you know, because we know if you lose like 10 pounds, your knee is going to feel a lot better. You're taking some load off your knee. So I have patients have terrible knee arthritis. I mean, that might not be for you, especially downhill walking with weight of S. That's going to, you might make your knee hurt some more. But if your joints are tolerating it, I think it's fine. It's fine. As a reminder to our audience, you can follow Dr. Whitstein on Instagram at Jocelyn underscore Whitstein underscore MD. Her book, The Complete Bone and Joint Health Plan is available on Amazon. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawselife.com. My upcoming book, The New Perimenopause, is available for pre-order on Amazon. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also follow full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. 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