Strong Bones, Strong Body, Stronger Second Half with Dr Jocelyn Wittstein - Part 2

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. In our last episode of Unpaused, we started a conversation with Dr. Jocelyn Whitstein about what really happens to our joints, bones, and muscles as we move through midlife, why osteoarthritis hits women harder, why frozen shoulders seems to love this life stage, and how hormones weave through all of it. It was one of those conversations that made a lot of invisible dots suddenly connect. And we had far too much to talk about for just one episode. So today we're back with part two. Dr. Whitstein is a practicing orthopedic surgeon, researcher, and associate professor of orthopedic surgery at Duke University. Her work focuses on female athletes across the lifespan, post-traumatic arthritis, frozen shoulder, and what she calls the musculoskeletal syndrome of menopause. She's president of the Forum for Women in Sports Medicine, a core leader in the Duke Female Athlete Program, and a member of the Milken Institute Women's Health Innovation Initiative, and co-author of the Complete Bone and Joint Health Plan. She's not just treating fractures in patients. She's asking the bigger questions about why women's joints and bones behave the way that they do and what we can actually do about it. In this episode, we get into hormones, pain, and cartilage in a way that most of us have never heard before. Jocelyn explains how estrogen and progesterone modulate pain, why fibromyalgia and diffuse joint pain so often show up in midlife women, and the role testosterone plays in arthritis risk for women. She walks us through her current research to understand how aging and sex hormones change the resilience of our joints and whether hormone therapy might one day help narrow the arthritis gap between women and men. And perhaps most important, she outlines a real-world prevention plan, including what she does to protect her own bones and joints. This conversation is detailed, hopeful, and incredibly actionable. If you missed part one, I hope you'll go back and listen. And if you're ready to rethink how you move and take a 360-degree approach to protecting your bones and joints, then you need to listen to this conversation. All right, let's move on to pain. Hormones, pain, and musculoskeletal health. So you've talked about estrogen and progesterone as pain modulators. How does that work? How do you think these hormones actually influence our pain? And this isn't my own research, just things that I, you know, read that make sense. There's a study out of, and again, a lot of this relates to animal data, which is where we learn so many of these things. And maybe hopefully eventually apply to humans and learn more. There was a study done on UCSF on mice looking at basically cells located like centrally in the spinal cord and showing that estrogen and progesterone stimulate these cells to create like an endogenous analgesic, basically. Okay. Which is a pain reliever. Pain reliever. You know, so suggesting that maybe there's like some central pain modulating effect. There are some studies on people with fibromyalgia showing relationships between progesterone levels and pain. What is fibromyalgia? That's a tough thing because the actual definition of fibromyalgia relates to these very specific number of painful points on, you know, myofascial tissue. I think we'll learn more about fibromyalgia over time because I have wondered, we see it a lot in my, a lot of menopausal women get diagnosed with fibromyalgia. So some people, Vonda, you know, has stated in, you know, to me that she wonders how much of fibromyalgia is just musculoskeletal syndrome of menopause. I mean, it's a clinical definition based on you're having pain in certain areas. You have pain in myofascial tissue. You know, she thinks a lot of it, rather than just being this de novo condition, could just be a symptom of menopause. Yeah, it could be. I mean, we see, I do see many more women with fibromyalgia than men. I didn't know any men had it. Yeah, I think, I don't know if I have any. Yeah, it's definitely more common in women. And it may be something I think we understand more over time. Again, these things get named something and, you know, do we figure out what they are later? I also have a lot of women who get worked up for rheumatologic conditions because they have this new onset joint pain many times, but x-rays that don't look abnormal yet. And they're just having, you know, a lot of polyarthralgia. And I sometimes think that is just related to systemic inflammation. And even, you know, some of the earlier studies from the Women's Health Initiative did show reduction in number of and severity of pain and, you know, painful joints with hormone therapy that included estradiol and then even like rebound or worsening of joint pain with withdrawal of that. When they stopped it. And there are like some systematic reviews and analyses that don't clearly show a relationship of joint pain and use of menopausal hormone therapy. And I think even the Menopause Society has a statement like that on the website, like, you know, that we need more research in this area. And I'm studying that now. But I do think we need to understand that better. But there's got to be something if women have this really disparate rate of especially like knee arthritis at age 50. It's just, you know, there has to be. Comes out of nowhere. Yeah. So it's a combination, you feel, of the tolerance to pain. You're saying we have less of an analgesic effect combined with increasing inflammation from estrogen withdrawal. Does testosterone have a part anywhere in here? Because we don't tank our testosterone like men do, like estrogen and progesterone do. More gradual. It's a more gradual with age. There's some data coming out that seems to relate. there was a large study that looked at women and men over time. I think it had like 9,000 subjects in it, about 5,000 women in it, and they followed them over time with sex hormone levels and rates of arthritis. And they did see a correlation with lower testosterone levels in women over time in terms of risk of knee and hand arthritis, but they did not see that correlation in men. So, yeah, we're seeing some, I think, more research about testosterone in women later in life potentially being also related to knee and hand arthritis, which are, of course, very common sites. Yeah. Yeah. I'm trying to get at the answer to that. I'm doing a study or trying to launch a study that we've done a lot of the preliminary parts for that will really look at early changes in cartilage in women and men, you know, in the early 50s, as well as correlating with testosterone and estradiol and progesterone levels using some of those models we built from the ACL research, actually, on these models we make where we, yeah, and if anyone is listening to this and wants to be my research for a godmother and wants to give me $3 million to solve this arthritis in men versus women, I have the study. So we took our same, all the work we did on the machine learning to build the models of the knees where we have all the cartilage traced all over the different parts of the knee. And we use a very similar model that we use to study post-traumatic arthritis in ACL torn knees, which is where we bring people in and we have them like rest for 30 minutes. So their cartilage is fully rested. We do a resting MRI of their knee. And then that shows us the thickness of their cartilage all over it. Then we have them walk for 30 minutes on a treadmill, which compresses your cartilage and your cartilage is the smooth gliding surface so that he compresses it. And then we put them back in the MRI scanner and we kind of re-scan them with this one sequence every six minutes for like 30 minutes. And over the course of those 30 minutes, we see how much the cartilage rebounds to its normal thickness. And then we generate a curve and it tells us how many minutes it would take for the cartilage to go back to normal. So like in a normal person, it'd be like 25 minutes. And people who've had ACL tears, even just like one or two years after their injury, because they're so prone to developing arthritis over time from the trauma, it takes like you know more than an hour it takes a long time so we're applying this same tool that we developed for post-traumatic arthritis after acl injury except for the injury is not the acl tear and ptoa or post-traumatic arthritis it's aging sex hormones yeah plus or minus hormone therapy and so then we'll have their testosterone their strength their progesterone levels and we will see how the early signs of arthritis are appearing in men versus women with and without hormone therapy with test, you know, knowing the levels. Basically, you know, my hypothesis is that I do think that, you know, maintaining or supplementing, you know, the estrogen levels will preserve that resiliency of the cartilage. That's my hypothesis. I could be wrong. So that it could be preventative, potentially. Right, and if we can, that's what we're studying. We want to know, because this isn't clearly answered. We want to know, is hormone therapy that may include estradiol, testosterone, progesterone, are these things protective of the cartilage, especially in women, so that we can narrow that gap, that 35% difference in knee arthritis? If we do end up showing that the resiliency or that ability of the cartilage to rebound is restored or maintained or related to estradiol and progesterone levels, you know, that may be another indication or it may expand our thoughts about like what is hormone therapy for. But we haven't clearly shown and a lot of the old research, again, is on like different forms of hormone therapy. Right. And only for the presence or absence of hot flashes. Yeah related to arthritis though it kind of it not necessarily looking at the actual health of the cartilage And so we yeah so that we submitted another grant to the NIH I just applied to another private foundation And yeah so if anyone wants to help me solve arthritis in women, call me. You can come to our lab. I can show you how we do everything. And I really, really hope we get money for this because that is one of the studies I'm extremely excited about. You mentioned that in your previous writings that, and help me say at EFOPs trial, M-E-F-O-P-S, which studied the effect of long-term exercise on bone density, fracture risk, and osteopenic women different than the LIFMOR trial. Did it show fracture prevention? Yes. One of the reasons why I like the EFOPs trial is, you know, we have all these studies that show, okay, jumping helps with hip bone density, strength training helps, you know, improve especially lumbar spine bone density. Again, what do we really want to prevent? Like, Yes, maintaining bone density is great and nice. And we presume in most cases, like we know from many medications, you know, that improving bone density reduces fracture risk. But what that trial did was they followed women. I think most of them were on average when they enrolled them like 55. And then they followed them for 16 years. So now off to like age 70-ish. This is really interesting. I mean, they had these, you know, supervised sessions, then independent sessions, and they carried this out like all this time. And then they followed their bone density over time, but they also followed, obviously, their fracture risk. And so there are a lot of trials that really show you the impact of an exercise program on, like, long-term fracture risk. Because it takes a long time to measure. Yes. Again, I just feel like we don't—sometimes I feel like, why don't we have these trials in the United States that are this—some of them are just not this good. But in any case, what they found was over time that the women who participated in the exercise group as compared to the control group had approximately a 50 percent reduction in fracture risk. But interestingly, near the end of the trial, you know, at first, the women who were doing the strength training, it included strength training and impact. And they kind of used periodizations. It wasn't always intense. Sometimes it was like less intense, but they did have periods of higher intensity. And what they found was obviously a major reduction in fracture risk. And earlier on, there were larger differences in bone density. The exercise group was like gaining, whereas the other group was losing, as you would expect. But over time, those gains like trailed off. And near the end of the study, you know, the exercise group was losing bone density, but at a slower rate. But my point is, and why I like that study so much, is it shows the effectiveness of exercise for fracture prevention, even as bone density is declining, maybe at a slower rate. But there's more to exercise than just the bone density. It's like your coordination and your balance. And there's more to fracture than just your bone density. Yes. Yeah. So if you don't fall, if you're more, if you're less stiff, if you have better mobility, better balance, like less likelihood of falling out. So I like that trial because I think they did such a good job of following through with the fracture risk. All right. So back to fractures. I get this question all the time and our clinic has dug into what research is available, but I'd like to hear it from you. How much estrogen, estradiol levels specifically, is needed for bone protection? Yeah, so this is a very interesting question. I read about this a lot. And I think the confusion around this question comes from, there was a study that looked at markers of bone turnover and associated levels of estrogen. And they found that if the estradiol level was 60 picograms per ml or higher, basically there was the greatest reduction in markers of bone turnover. So basically breaking down bone. So for our listeners, you know, bone is not static. It is constantly turning over. And until 30-ish, maybe in our late 20s, we're laying, we're building more bone than we're chewing up. But we're constantly like your bones turn over every 10 years. We remodeling. We remodel. Yeah, we're remodeling. Our muscles do something similar too. So when we go through menopause, and with aging, we accelerate how much we chew versus what we lay down. And in menopause, it goes crazy where we chew up way more bone than we lay down, and that leads to bone loss and then osteoporosis. And even maybe in perimenopause. Oh, yeah. Massive acceleration in perimenopause. And I read a study recently that showed that there are faster and slower bone losers in perimenopause. And just looking at basically the people who had the greatest bone loss or acceleration of bone loss and perimenopause were the women who had the lowest frequency of ovulation. Like they're, you know, had a, obviously as we get towards menopause. So they have lower estradiol levels. Yeah, yeah. They have like, you know, less, you have less cycles, but people who have like this longer period of more spread out cycles were the people who lose more bone and perimenopause. So it's like, you know, that prolonged decreased frequency of cycles is kind of a marker for being a fast bone loser and perimenopause. So the bone turnover marker is as we're chewing up bone and laying down bone, there's little chemicals that get excreted into the blood. So we can say, oh, she's going through a lot of bone turnover and bone loss. So that's a way to kind of measure how these medications are working without having to wait two years for a bone density scan. So this study showed that if you were at least at 60 picograms per ml, you had the greatest reduction in those markers. So suggesting you're having the least bone loss. And then once you got to 90 or higher, there was no difference, which makes sense because 80 is the level and luteal phase of many women who are menstruating. So why would you need to be higher than that? Probably not. So that sort of led to, I think, has made people think, oh, we need to be at least 60. But on the other hand, there is also data that comes from all of the studies of Menostar, which is the ultra low dose transdermal estrogen, the 14 microgram dose, showing that using that and even people not even exceeding a level of 20 picograms per milliliter protects bone and reduces bone loss and even increases density in the lumbar spine by like two and a half percent. And so I think that kind of leads to this confusion of where do we need to be is more better. And there's in my world, in the menopause society and in the OB literature, they're very hesitant. They do not want to measure estradiol levels. They're like, no, we treat hot flashes. You give her enough estrogen to treat a hot flash. But my bone people are like, just because you're protecting her from hot flashes does not mean her bones are necessarily protected. And I think they're very keen on dose. Yeah. And I don't want to like overstep my boundaries or my. No, no, no. But why do you think the hesitation? There was a trial, the ultra trial, where again, looking at Menostar, the 14 microgram dose, where if you looked at what level of estrogen women were at, there were all like all these women under 20, which would be typical of menopausal women. And people- You mean estradiol level of 20. Yes. Estadiol level. Yeah. Like the, that, there were within that- So that's how we define menopause to our listeners is an estradiol level less than 20. Yeah. Pretty much postmenopausal. But these postmenopausal women, there's even variation within that number under 20. So some people live like under five. Some people are at 15. So you could have these quartiles, let's say. And in the study of the menastar dosing, one study found that the people who were in the lowest quartile had the greatest response to the menastar. So they had the greatest reduction, you know, in their turnover markers. So I think maybe some of the concern about looking at levels is that people respond differently. Like some people just live at different levels. And then it's a relative change. So then if you're checking a level, what does the level mean for this person versus that person? And so I think that study actually made me think, well, maybe that's why people are hesitant. There's some nuance. Yeah. But on the other hand, if you look at dosing, I mean, if you look at femring, which is systemic estradiol, which can be protective of bone density, or you're looking at transdermal estrogen, if you compare the 50 microgram doses to 100 microgram doses, there really isn't a significant difference in the increases in bone density. They're very similar, but they're a little higher with the 100 microgram doses. So if someone is having side effects or symptoms like breast tenderness or whatever, and they don't have it at 50 micrograms, but they do it 100, you're not you're probably not doing them a disservice to have them at the 50. Because like so if you look at the 14 micrograms versus 25 versus 50 versus 100 in various studies, like the 14 microgram dose over two years increased lumbar spine bone density like two and a half percent, which is on par with a VISTA, you know, similar amount of increase. If you look at the 25-microgram dose, it does a little more. If you look at the 50 and 100-microgram doses, you're seeing, you know, a 5-ish percent increase as compared to 2.5% with the Menostar. So obviously dose matters, but when you get to the 50 or 100, not that different. Not much of a difference. As an orthopedic surgeon, that's my understanding. There's nuance. In our clinic, and most of my, you know, the menopause kind of people, we don't sit here and slap an estrogen patch on someone and be like, go and live. You know, it's like, if you want to protect your bones, you have to do all the things, which includes the lifestyle. If you are not doing the lifestyle changes, including diet, including nutrition and lowering inflammation and all the things, you are not, this is probably not likely going to have, you know, not the greatest effect. Yes, diets with less inflammation, reduced risk of fracture. You know, you need adequate calcium, magnesium, vitamin D, all those things. In our clinic, we talk about lifestyle as well as HRT and, of course, some of the other drugs, the bisphosphonates, you know, if they're already diagnosed. Right. But you know talk to me about the difference between exercise versus medications and what are the outcomes Yeah So certainly I don want to imply that you never going to need a medication Like if you have osteoporosis and, you know, your FRAX score says you have a more than 3% chance of having a hip fracture in the next 10 years, like you should probably be on some osteoporosis medication. What do all these things do for you? Lifestyle versus medication or hormone therapy? I do like to kind of just level things a little bit and think about, you know, what are your returns on investment? So if we look at, you know, the timeline for your effort and what you might get out of it, if you're doing like, let's say you initiate some impact exercise and, you know, over a six month period, you might increase your hip bone density by one percent. That's a six month investment. I mean, I think you should continue it, but you've got. So imagine that six percent, one percent. If you were doing the Lift More protocol, for instance, and over an eight-month period, we would expect you to see a 3% increase in your lumbar spine. So think about that. That's eight months, 3%. If we think about estradiol therapy over two or three years, giving you a 3% increase in your hip, 5% in your lumbar spine region, generally something like that. So that's three years of using a medication to get 5% increase-ish in your lumbar spine. You know, think about the impact of exercise. If you're doing an eight-month program and you're getting a 3% increase, that's really impactful. So I just want to emphasize the timeline. With the exercise, you're also getting so many other benefits. So many other benefits. For your insulin resistance. Building your muscle mass, yes. And then medications like Zalendronate, like the Reclast, if you know the brand, you know, once per year infusions of bisphosphonate, for example, those are going to increase your hip bone density about 5%, your spine bone density about 7%. You're going to get a 70% reduction in fracture risk, say, of the spine, 40% of the hip. You know, we don't have, like I said, with exercise, we don't have all those numbers. So that would be like three years of getting a once a year infusion. So those numbers are larger. But again, like if you just look at the scale of them, like the lifestyle things do quite a lot. And again, scale wise, it's hard to say, OK, for hormone therapy, if you look at a meta-analysis, we know that this corresponding increase in bone density reduces our hip fracture risk by about 30 percent or vertebral body fracture risk by about 40 percent. And we don't have those exact numbers for like exercise. And you can't really take the numbers from medication and be like, this percentage equals this much fracture reduction. It doesn't work exactly like that. But my point is, if you just look at the scale of these things, 1% gain is a really big deal. 3% gain is a really big deal. And if we think about that, I think it just helps people value these exercise interventions more. Okay. If that makes sense. So my grandmother had multiple fractures, not hip, but she had forearm, had ribs, multiple falls, you know, spent the last three to five years with dementia and then the last couple of years completely bed bound. And, you know, my mother is 88 and has Alzheimer's. So I'm sure her mother had it, too. Yeah. And on New Year's Day, had a UTI, hallucinated, thought she heard my dad calling her, got out of bed, fell, broke her hip. Delirium. has no cardiovascular issues whatsoever. So it's perfectly fine to survive the surgery and had her hip, you know, rotted and whatever the hell they did to it. And it still just scoots around in a wheelchair completely, you know, with her dementia. So talk to me about how I can, what would you recommend for me for avoiding this fate? I can handle the dementia, but talk to me about my bones. Yeah, the dementia, of course, you know, the benefits of exercise, which are huge. Like that is the most protective thing women can do to prevent dementia is exercise for our brains. But yeah, so for... Build me a protocol. What I recommend and what I do is a couple of days a week of heavier strength training, making sure you're doing like large muscle groups, again, similar to those lift more protocols. The balance work, I do some of that every day. Flexibility work, I like to. I don't have time to do like a yoga class every day, but I do incorporate that in my routines, again, because you do need joint mobility. And then I always try to build in agility. Sometimes I'll use agility work within my cardiovascular exercise. So I use it as part of the cardiovascular exercise because if we don't have it stack, we just like run out of time in the day. Yeah. And then, you know, dietary wise, you're a big fan of this. I know. And it's very important for actually reducing inflammation and helping our bones and joints is a high fiber diet, getting getting adequate fiber. And for me, that's a lot of variety of fruits and vegetables and seeds, nuts and legumes. All those things, yeah. And those foods generate basically short-chain fatty acids, which then impact the inflammatory pathways that contribute to bone resorption and your cartilage, you know, breaking down, actually. And I don't want to get too basic science-y, but there's a lot of that happening. Yeah. And then, you know, I use creatine monohydrate five grams per day. There is not a study showing that creatine specifically grows bone. It doesn't directly. But there are studies that when combined with strength training, you know, you can increase your gain. And secondarily, that has benefits for, you know, bone health. Oh, back to the exercise part, jumping. Yeah. I'm doing box jumps now. I love jumping. Now, the thing about box jumps is the jumping up is a soft landing, and then people step down. You want the jumping down. Yeah, and I have the little—I got the weightless jump ropes. Oh, yeah, the one I showed you. But they keep hitting me. I think my wrist angle isn't right, so I just need to go back to a regular jump rope. Yeah, you can do a regular jump rope. So, and again, the jumping, it doesn't have to be off a gigantic box. It could be an eight-inch step, and there's a really smart lady named Tracy Glisold, has done tons of basic science on how much impact is created from jumping off an eight-inch step with a rebound or heel drops, which also create that impact, jumping for sure a few days a week. Okay. What about I'm on HRT? Would you recommend that? Yes. And I think for sure menopausal hormone therapy that includes esteril is protective of bone density for those who are candidates for it. Definitely. There is some reasonable evidence, I think, behind, and I think you've highlighted it for, there's something called Fortabone, which is a hydrolyzed type 1 collagen, that, you know, they have randomized prospective studies showing, you know, improvements in bone. I was super excited. I was like, give me some of that. Yeah, and so I don't think that hurts anyone. What about, lots of questions I get on calcium, phosphorus, vitamin K. What are your thoughts on that? Yeah, I mean, most people have a hard time eating enough calcium. But yes, you want to get 1,200 milligrams of calcium per day, 400 milligrams of magnesium a day, 100 micrograms of vitamin K per day. Vitamin D, you want to get at least 600 units per day. You should not exceed 4,000 units per day if you don't have a deficiency. For various reasons and data that I've read, I do take 2,000 units a day. I'm not exceeding that upper limit of what's safe, but there are studies, correlative or not, that show vitamin D supplementation reduces risk of or is associated with less risk of dementia and depression. Also, at that level, at least 2,000 units per day is correlated with benefits for reducing joint pain. So there are some side benefits of it. So while you do need about 600 international units per day, I do take the 2,000. So those are important aspects as well, the dietary aspects. I have a hard time absorbing, I guess. So I take four. Oh, yeah, a lot of people do. and then low and diets that are like less inflammatory so there's something called the dietary inflammatory index which unfortunately they're not like that's what I built the Galveston diet based on yeah it's that because I went back for nutrition yeah and so that dietary index score you know we used to have a little quiz you could take on our website I've taken the quiz that would grade yeah it's based on that yeah so it's the poor man's version yeah and and there are studies correlating, you know, a less inflammatory diet with less risk of fracture. So that is another reasonable thing to do. So back to my mom for a little bit. You've talked in the past about this connection between UTIs, like general urinary syndrome and menopause and hip fracture. Yes. I think it's worth for our listeners. I think this is underappreciated. I know this is what happened to my mom. You know, she was a setup. Oh, I've had so many people with this story or tell me this is what happened to her mom. So big picture, and I'm not saying this to scare people or anything, but when you hear about hip fractures, which of course 75% of them occur in women, and then statistically speaking, just if you have a hip fracture, depending on the study or population you're looking at, the one-year mortality rate is some studies 15%, some studies 30, or two years out. I like to quote the 30. A third of women. Yeah. I know I try to always give nuance in numbers because some of the numbers sound more scary than others. It's not always 30, but it can be 15 to 30 percent in a year. So, you know, we don't want people to have this happen. But like what is causing death? Actually, a lot of it is it can be urosepsis, a postoperative urinary tract infection. So you have this hip fracture. Sometimes you've needed a fully catheter. There's urinary retention from pain. People can't get out of bed. And I think aside from the fact that urinary tract infections are the number one complication after hip fracture surgery, and it can lead to readmissions, urosepsis, septic shock, things like that. I think many of them are actually present, you know, prior to the hip fracture. And so people who have general urecyn or menopause, they may have increased urinary frequency, they may have, you know, recurrent UTIs. And what happens if you have that and you're an older woman, you're getting up in the middle of the night a little confused a little delirious more than you normally would and they trip and I mean almost every time you get called by the emergency room for hip fracture it like in the middle of the night I should actually look and see if there a study in this but I think most fractures happen at night. And it's so often the story. I'm treated to SM. Yeah, getting up, tripping, falling. And then so there are patients that are diagnosed with a urinary tract infection preoperatively, but you're not going to like, you can't delay surgery because outcomes are worse. Survival is worse if you delay more than a day or two. And so you've got these people who either have the infection pre-op or develop it post-op. And it delays, you know, they're in the hospital for longer. Women who have a urinary tract infection diagnosed at the time of hip fracture have like four times the rate of septic shock post-operatively as compared to those who weren't diagnosed with the pre-op. I actually think many of them are underdiagnosed pre-op. So I think it contributes to the falling, contributes to the urosepsis after, probably contributes to death. And we know that vaginal estrogen prevents urinary tract infections. 50%. Yeah, prevents a lot of them. And so if we could reduce those, I swear we would reduce hip fractures and we would definitely reduce urosepsis. It's not like you can just give someone vaginal estrogen right after hip fracture surgery and expect them to have less UTIs because it takes six weeks or so to be effective. To grow back the mucosa. To change the microbiome. So we're not going to like magically make someone not get UTIs by putting them on that right after surgery. But I do think we should actually educate hip fracture patients. Hey, you have recurrent UTIs. I don't want you to break your other hip. You might benefit from being on vaginal estrogen. And that's something I'm actually working on with our trauma team right now. We're looking at how frequently our hip fracture population, we're looking at our last 500 hip fractures in women and how many of them were on vaginal estrogen, How many of them have the UTI pre-op and post-op? And if you look at reviews of hip fracture studies, you know, you'll see anywhere from like 10 to 40 percent of people having a UTI perioperatively. So it is a really large problem. Since you're here this week while we're recording, this is the week that the box warning on vaginal estrogen has been struck and removed. in, just the normal warnings are there as there should be. You know, for those listening, vaginal estrogen is preventative. It is, it can be prophylactic. It is safe and effective. Almost 99.9% of women can use it and probably should for, you know, keeping their, the risk of UTI at bay and keeping their vaginal and vulvar health, you know, in tip-top shape. So they decrease their risk of delirium, of falling, and then a fracture, and then having a better post-op course if they do fracture. So I wanted to be clear about that. So women are going to want to know, what can I do for myself? You know, how can they better advocate for themselves when their musculoskeletal pain isn't taken seriously? I know. I can't tell you how many times I see a patient who feels like they haven't been heard when their x-ray is normal or their MRI is normal. Or even if someone does recognize that they have frozen shoulder, they may hear, well, that just happens to women. You know, just recognizing, yes, it happens to women, but is there anything else we can do? So I think health literacy is so important. And I mentioned to you earlier when we were chatting, I actually had like never even been on Instagram before January. And my 19-year-old daughter, Chloe, who is Chloe on Canvas on Instagram, she's a cute little artist, but she helped me make that page. And I'm using it for health literacy because I think if people have awareness, they can be more of an advocate for themselves. And I wrote this book with my co-author, Sadina Skorsky, The Complete Boundary Joint Health Plan, because people just don't understand their bodies. They don't understand arthritis and osteoporosis. Let me plug your book. It's excellent. You open it up. It's recipes. It's exercises. exercises. It is literally a how-to manual from the ground up on how to protect your bones and joints. So if you're like, okay, what do I do? 90% of it is pictures of people doing exercises and recipes. And we tried to explain like, what is arthritis? What is osteoporosis? What are the things you can do to change your course? But again, it's not only for women, but because arthritis is more of an issue for women and osteoporosis is like, I do have a lot in there explaining that because I just think if people don't understand, like if women don't understand that, yes, I am going to be more prone to arthritis than a man at age 50 and I am going to be more prone to frozen shoulder. You know, I think just having an understanding of that can help them advocate more for themselves. Or not let it go for so long because I think a frozen shoulder getting in there early is key. And like just taking an index of your own symptoms, like are you having this increased joint pain or your frozen shoulder at the same time that you're having like vasomotor symptoms and general urinary symptoms and like talk to your women's health doctor about that. I love my male orthopedic surgery partner so much and I have actually so many of them are now talking to women. I don't want to pick on my husband Tal, but he's also an orthopedic surgeon and we actually work with, we're like a rotation for our fellowship. So one fellow will come and work with both of us at the same time. and sports medicine too? Yes. One day one of the fellows told me, I think you need to help Dr. Lasseter. He's talking to women about the change. But I said, no, that's so great. He's asking women with shoulder pain about their symptoms and texting me, how do I refer to women's health? And some of my fellows are now doing this. And so I just think that because men don't go through menopause, like they're not going to experience this. They just, they don't have the same lived experiences. they may have less awareness of this connection. But I think, you know, I'm trying to educate my trainees. And I can't tell you how many of my, you know, male... Her Instagram is excellent. My male orthopedic residents are, they come out of a room telling me someone's like menopausal history and whether or not they're on hormone therapy as part of the orthopedic history, which is really cool. But yeah, but for patients, I think if you're feeling dismissed or someone isn't listening to you, I mean, it's okay to get another opinion. Like, don't feel like you're, you know, stuck with one person. And I just, I think what happens is it's hard when an x-ray is normal, an MRI is pretty normal, but you're having increased joint pain. You know, we've talked about some of the things you can use, an anti-inflammatory diet, certain supplements, things like that. But I just think taking a look at the whole person and collaborating. Stop siloing. Stop siloing. Collaborate with women's health. I'm not saying that magically going to hormone therapy is going to make your knee pain feel better. And that's what we're trying to study. But I think we need to kind of look at women as a whole person, not like a knee. And stop siloing women's health to the bikini area. Yeah. Yeah, exactly. Well, I'm so happy you came with us today. You've educated our listeners so much. And I will go through on the show notes. They will have how to find you on social media, how to buy your book, and how to find you. Get ready because you're about to get a lot more referrals for Frozen Shoulder at Duke. Get ready. Well, thank you for having me. And I like to say I am only an orthopedist. I am not an expert in all things women's health, but... You're changing the world. The most meaningful research relationships are my cross-collaborative ones, you know, with my women's health partners, with my biomechanics PhD, you know, with the PhD who does all of the biomarkers with me. I mean, we really have to be cross-collaborative to change, get rid of these disparities. Yeah. Excellent. Are you looking forward to menopause? I mean, I'm not fearing it. Funny story, my youngest, my now 18-year-old son was like, menopause sounds really terrible. And then my 20-year-old daughter said, I really don't want to go through menopause. And they're just talking. But I think I'm almost 48 and I feel like I'm getting into like a phase of life where I can have so much more, I don't know, like freedom of thought and independence and time. And I mean, I had my kids pretty early, so I do have more time now, but I don't dislike aging. You know, I change some of the ways some of my look. I don't exercise exactly in the same way as I used to. I don't do backflips on the floor only on a trampoline. But I, you know, I I'm not fearful of it. I feel very I feel empowered by the knowledge I have. But I have a strange amount of niche knowledge and I love to share it with people. And I think that you sharing that knowledge with your students, but also on social media, is going to continue to just elevate this conversation and empower women in a way that we haven't been able to in medicine before. As a reminder to our audience, you can follow Dr. Whitstein on Instagram at jocelyn__whitstein__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. 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.