Dr. Silverstein returns to Healthful Woman to discuss bone density and osteoporosis. In this episode, he explains what contributes to proper bone density vs. low bone density, when to supplement calcium and how much, and what women should do to support their bone health.
“Bone health, bone density, and osteoporosis” – with Dr. Michael Silverstein
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Media File Name: DLM_HW_2021_121_Silverstein-Osteoporosis_210405D.mp3
Media File ID: 2986032
Media Duration: 26:06
Order Number: 2003720
Date Ordered: 2021-04-07
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Dr. Michael Silverstein, Mike, welcome back to the podcast.
Dr. Silverstein: It’s a pleasure to be back. I love doing these things and I love listening to the ones that you’ve dropped already. And I keep forwarding them to all my friends, and family, and contacts, and they’re getting great reviews.
Dr. Fox: Thank you. Well, this is one you’re gonna have to forward to maybe people who are in the post-menopausal category for osteoporosis.
Dr. Silverstein: Very interesting. I think that that’s starting a little bit too late. I think that we tell all our patients how to avoid getting into this situation because, largely, the majority of bone loss is preventable.
Dr. Fox: Yeah. I was gonna say that it’s a topic that is typically thought of as post-menopausal, and that’s when people think about osteoporosis, and their bone health, and their bone density. And we talk about, talk about, talk about. But ultimately, it’s one of these things where, when you’re younger and, you know, teens, 20s, 30s, 40s, there are things you can do that could potentially either avoid this issue altogether, or maybe delay it, or lessen it, or improve it for later.
Dr. Silverstein: Yes. Essentially, what I tell my patients is that, kids are born with their bones, similar to a brick wall with perhaps every second or third brick missing. So kids have soft bones. Their brick walls will hold nicely, but not under trauma. They fracture easily. Thank God for newborns and little kids heal very, very nicely. As they progress through life in their mid-30s, these brick walls have gotten obviously much larger, but they’ve also filled in all the missing bricks. And so peak bone density, essentially, all the bricks in place on the wall, happen roughly in a woman’s mid-30s. So one of the biggest causes of bone loss is not getting to that point. So people that have eating disorders, people that have ovarian failure, cigarette smokers, people that are sedentary, these are all people that might be at risk for never achieving peak bone density.
On top of that, and we’ll talk about that a little bit more, you take estrogen, which is probably the most important provocative. Estrogen not only builds up the enzymes that make your bones stronger, they hold in check the enzymes that take away from your bones, so, during bone repair, bad bone is removed, good bone is laid down. With loss of estrogen, as I mentioned before, ovarian failure, menopause, a huge one, some people will lose a lot more bone. But let’s get back to the young people for a moment. Again, peak bone density by your mid-30s won’t happen in somebody that doesn’t have any calcium intake. It won’t happen as much in a sedentary person. The flip side of that is, if you’re an excess exerciser, elite athletes who exercise to the point of not having their periods, they might be strengthening their bones from resistance exercise, but they’re not making estrogen because their body has put that aside. And so, that goes along with estrogen deficiency.
And so we tell all our patients to supplement calcium. In general, 1,500 milligrams a day is a reasonable amount of calcium. The vast majority of calcium is a glass of milk, a container of yogurt, a Viactiv candy bar have about 350 milligrams of calcium. You take a multivitamin, most of those have anywhere between 350 and 1,000. And so, most patients will buy the 500-milligram calcium tablets, they’ll try to assess what they’ve consumed that day in terms of calcium and try to get it up to 1,500. If you have a well-balanced diet and a young woman, she doesn’t have to supplement calcium, the majority get enough calcium. But it becomes much, much more important as you go through the changes in your 50s because that’s when you really need the calcium and the weight-bearing exercise to drive it into the bones.
Dr. Fox: In terms of calcium, it’s interesting because people with a well-balanced diet typically will get that amount of calcium, but nowadays, I find that so many more women, people in general, are having less dairy in their diets. And so they don’t have milk, they don’t have yogurt, they don’t have cheese. Maybe it upsets their stomach, or maybe they think it’s unhealthy. And so, some women, you know, when you go through, “Hey, what are you eating every day?” Typically they’ll find, “Hey, having like very little calcium.” You know, it’s in certain vegetables and other foods, but for those women, it is recommended to get certainly over 1,000 or 1,000 to 1,500 of calcium a day and I find like, certainly, when I talk to pregnant women about calcium, very few of them are getting it in their diet because they don’t need as much dairy maybe as people used to. So that’s something to keep in mind.
And like you said, calcium is really nice because it can come as gummies, it can come as chewables, it can come as something you swallow. There’s a lot of different ways to get calcium. And the reason they can’t pack 1,000 or 1,500 in a vitamin is because they just take up too much room. Calcium is bulky, and so, frequently, you have to take it separately. And the other thing you talked about, which is exercise, and there’s this idea that if you work the bones, what’s called like a weight-bearing exercise. So maybe not like swimming, for example, or spinning, but things like running, certain weights, and, you know, yoga and planking where you’re supporting your body weight and putting some stress on the bones, it gives them sort of like an incentive to grow and get harder and get thicker, and so, people have better bone mass if they’re doing these types of exercises versus not exercising at all or doing exercise that’s not weight-bearing at all. Or as you said, if you’re over-exercising, it’s sort of be like past the point of being helpful.
Dr. Silverstein: That’s true. And so many of my patients, when I talk about exercise, tell me, “Oh, I walk to work. I walk two miles this way, two miles that way. I always take the stairs.” And I mention to them, “Get three-pound wrist weights, three-pound ankle weights. That’ll make your walking into a weight-bearing exercise because it’s adding more resistance.” And I tell my patients, “You don’t need to join a gym. You don’t need to buy exercise equipment. Exercise can be part of your daily life. Get off the train and a stop or two earlier. Get off the bus a stop or two earlier. Take stairs instead of elevators. Have an active lifestyle.” And for people that don’t have the opportunity, especially with COVID where people are working from home, there’s a hundred different workouts on the smartphones that you can do in the comfort of your house with little or no equipment. So, there are at least a hundred different applications on the smartphones that you can do in the comfort of your house and they last anywhere from 10 to 20 minutes, you set your alarm for a half an hour earlier, you do these exercises, you wear three-pound wrist weights or ankle weights. You’re getting your work out. You do that five times a week and you got the bases covered.
Dr. Fox: Yeah. I mean, taking a step back, the concept is that, in our lives, bones are constantly being broken down and rebuilt. There’s this constant motion in our bones, little parts are being broken down and other parts are being rebuilt. And as you said, when we’re younger, and particularly if we have proper calcium and we’re healthy and we’re not smoking and we’re exercising, your bones are gonna be building up to the point that they really have a very high density and less likely to fracture, to break, essentially. And then the problem with osteopetrosis is, if, as you get older, your bones are not very dense and they’re much weaker, you’re much more likely to have a fracture of one of these bones in your 50s, 60s, and 70s. And some of the fractures are what people commonly think of with fractures, which is, you know, you fall and you break your hip, you fall and you break your wrist, which is very painful, it can be morbid as you get older, it can even be fatal as you get older if you really break big bones. But then there’s these types of fractures that people don’t recognize, what we call micro-fractures. What is a microfracture?
Dr. Silverstein: Essentially, it’s a relatively asymptomatic fracture. So the most common fracture with bone loss is actually the vertebral body. The vertebrae, your spine, is really like Tonka toys that are stacked onto each other. And, again, if we go back to the brick wall model, and let’s say you’ve laid down peak bone density by age 35. From 35 to menopause, every fourth brick might be removed, every fifth brick, every sixth brick. You could self-sustain a blow, there’s no loss of structure, you’re not gonna injure yourself. With menopause, with loss of estrogen, with a family history, which is very, very important, some women plateau. They’re able to maintain the brick wall with every fourth, or fifth, or six brick missing. We can test that, we can assess that, and they’re good to go for the rest of their life. Some women lose a little bit of bone and we need to retest it every couple of years, but some women lose a tragic amount of bone to the point where they’ve lost enough bone that these Tonka toys you have that build up your spine sort of collapse onto each other. And so, the concept of little old lady are essentially women that have had multiple vertebral microfractures and lost height. Nobody should lose height. Not to mention, nobody should have a fracture. These are all identifiable disorders, not having peak bone density, assessing it before it has a chance to get to fractures, whether they’re micro-fractures, or hip, wrist, or others.
Dr. Fox: Right. So, you know, conceptually, what you’re saying is someone can enter let’s say their 40s or 50s at a certain height and then 10 years later they’re an inch shorter. And that happens in their spine, right? Their legs don’t get shorter, you know, their head doesn’t get smaller. It happens to their spine that it sort of gets compressed and sometimes also contorted so they lean forward a little bit with those. And, again, those are not…it’s not a normal part of aging. It’s common, but it’s really something that is preventable if you have strong bone and strong, you know, spine, the vertebra in the spine. So, as a preventative measure, we mentioned, it’s important to get calcium in your diet, it’s important to be active in terms of weight-bearing exercises. Smoking has a negative effect on bone density, so, you know, there’s many reasons not to smoke added to the list. This is another one. I think heavy alcohol intake also does that. Not so much, you know, social, typical, you know, let’s say drinking, but people drink a lot. It can be an issue.
Dr. Silverstein: More than three drinks a day is supposed to be deleterious to bone density.
Dr. Fox: So that’s something that women could do maybe to, you know, try to avoid this, try to prevent it, particularly if they know they have a family history, if their mother had it, their grandmother had it. When do we start even looking for these things to screen for it? So how would a woman know if she has a normal bone density or a low bone density? How is that done? And when do you start doing that in your own practice?
Dr. Silverstein: Since we think that estrogen is the most pivotal factor in maintaining your bone density, we think that menopause or shortly after menopause is an excellent time to start bone density assessment, which is just a very, very low dose of radiation to your wrist, to your hip, and your spine will give you a comparative score to peak bone density, which is at 35. And they use numbers that compare you to a 35-year-old. If you’re within one measure of a 35-year-old, you have completely normal bones and we’ll sometimes repeat a bone density a couple of years after menopause. If at that second imaging study you’re still within one measurement away from a 35-year-old, you’re essentially good for life. Sometimes we’ll repeat one 5 or 10 years later, but it’s really not necessary. This person does not have that predisposition.
If it turns out on that first study, you’re between one and two-and-a-half measurements of peak bone density below peak bone density, you have bone loss. You are not thought to have an increased risk of micro-fractures or major fractures, but you have a significant amount less than peak bone density, and that drives us to encourage calcium and weight-bearing exercise and repeat this study at least one to two years later. If they stay at 1 to 2.5 measurements below peak bone density, they’re essentially good for life, and just like that first category, we might repeat it at some years down the road.
Dr. Fox: That’s what we would call either low bone mass or osteopenia, is a term that’s used, which just means you’re a little bit less than you would like, but not in the danger zone.
Dr. Silverstein: That’s correct. And one of the major take-home messages here is, we have no tools that will put bones back together, we have no tools that will fill in the bricks that are missing. We have tools that seem to be effective at preventing further bricks from coming out. We seem to be able to, with reasonable confidence, arrest bone loss, but we can’t reverse bone loss. So if you’ve gotten to the point where you’re below 2.5 measurements below a 35-year-old, you’re at risk of fracture.
Dr. Fox: Right. That’s called osteoporosis.
Dr. Silverstein: And then those patients clearly need an intervention. And there are several medications that doctors use. They used to be daily, they used to be poorly tolerated. They got them to a weekly and then to monthly, now there is a three-month medication, there’s a six-month IV infusion. Most of these fall in the category of something called bisphosphonates since they are given in such a spread-out manner, they don’t have the gastrointestinal side effects that they were reputed to have when you had to take them daily or weekly.
Dr. Fox: Right. Now, so when you’re screening women who are let’s say right after menopause, and different people screen at different times. In your practice, you do it a few years, you know, after menopause. Some people wait a little bit longer, again, I’m not really sure what the advantages to waiting, maybe just, I don’t know, it’s easier. I’m not sure. What’s the most common result? Do most women get back a normal score? Do most women get back that’s osteopenia sort of that middle one versus osteoporosis? What is your guess sort of percentage-wise?
Dr. Silverstein: I could assure you that it’s exceedingly rare to find osteoporosis in a woman in her early 50s who has gone through menopause in the past three to five years. And perhaps some people wait so they could identify it or to have a greater sensitivity of finding osteoporosis. But as I mentioned before, what are you gonna do? You can’t put the bone back. I envision bone loss as a largely, not 100%, but a largely preventable disease, looking at somebody who just fractured their hip. And you don’t fracture your hip because you fall on it. You fracture your hip because you took a step and it sheared off because it couldn’t bear your body weight because the brick wall was missing four out of five bricks. Looking at that person and saying, “I wonder what their bone density is.” Is much, much too late after the fact. There was so much more that may have been done to prevent that outcome.
Dr. Fox: Right. And so, how often do you find women are at the point that you would recommend treatment when you screen them in their 50s?
Dr. Silverstein: So, if I find somebody between the 1 and 2.5 closer to 1, and then two years later, they’re are at 2.3…
Dr. Fox: You probably treat them. Yeah.
Dr. Silverstein: That patient would benefit from treatment because you don’t want them to have…
Dr. Fox: But then how common is that, would you say?
Dr. Silverstein: I would say less than 10% or 15% of patients end up needing treatment. The overall incidents of osteoporosis, meaning, a measurement more negative or greater in difference than a 35-year-old, greater than 2.5, about 10 million women in the country have osteoporosis, considering the hundreds of millions of women of a similar age that don’t, 10% is probably a reasonable estimate of people that can get an intervention to prevent them from getting to that point.
Dr. Fox: Right. But the main thing is it’s everyone’s theoretically at risk for it, some more than others. It’s a very simple screening test, right? It’s an X-ray essentially. They’re coming in, just get an X-ray ideally of, you know, a big bone like their spine or their hip. There are screening options like they could do in an office just of your hand, which is not quite the same, but there is some value to that, obviously. So, it’s not painful, it’s not dangerous. And if they find out they’re at risk for it, the treatments, as you said, nowadays are, they’re safe, they’re much better tolerated, and they’re effective. They work.
Dr. Silverstein: That’s correct. There are two other modalities. There is a CAT scan version that calculates bone density and much more exactly can give you an exact measurement of your specific bone density, not necessarily compared to a 35-year-old, but will tell you exactly how dense your bones are. But that’s a lot of radiation. That’s an expensive test. Interestingly, if you’re having a CAT scan for something else, they can get the bone density data from the exact same images. So, it’s just a note. If you’re undergoing a CAT scan in menopause, find out if they can give you a number of your bone density. Ultrasound can be used in a less quantifiable manner to roughly assess some of your bone density. But dual X-ray Absorptiometry, DEXA, what Dr. Fox was just talking about, is probably the gold standard for following bone density.
Dr. Fox: Of the women that you ultimately treat for either osteoporosis or hopefully prior to that, the osteopenia, that stage before, how many of them need to go on a different treatment? Meaning that, if either it doesn’t work or they don’t tolerate it and they have to go on a different type of treatment.
Dr. Silverstein: We don’t have a lot of options for treatment. After bisphosphonates, there’s fluoride, there are other measurements, there are other treatments. I will often send them to a rheumatologist who probably has more cutting edge knowledge of the ones who fall through the cracks and I feel my job as a gynecologist is to treat the preponderance of patients to prevent the disease from occurring, to be able to competently and effectively treat the ones who respond to the medications I start. And if they need secondary, tertiary, or more complicated medications that might be administered intravenously, they should probably go to somebody that does that as their main bailiwick.
Dr. Fox: When women start treatment, is this something that they take for 5 years, 10 years, the rest of their life? What happens typically?
Dr. Silverstein: That’s an excellent question. When these bisphosphonates were given on a daily and weekly basis, they were thought to be used for between two and three years because there is sometimes a stabilization of bone that causes them to be excessively thick and less flexible. The jaw was targeted for some unapparent reason. But now that they’re given less often, monthly, three months, and six months, they’ve extended it to five, and there are some programs that extend for 10 years.
Dr. Fox: Wow. Okay. And so, for the women who have, let’s say, osteoporosis or they’re very close to that point, what kind of recommendations do you give them in terms of their life? I mean, you’re gonna start treatment to try to, you know, hold it still, but are there things you tell them that they shouldn’t do anymore or just, you know, be careful, don’t fall. How do you, you know, work with these women?
Dr. Silverstein: I think be careful, don’t fall is excellent advice for people of any age.
Dr. Fox: Yeah. My dad told me that when his orthopedic surgeon said to him, “Jack, be careful.” That was his best advice.
Dr. Silverstein: In medical school, our professor stood up and said, “Don’t smoke, wear your seatbelt.” So, you know, we’re talking about life-saving advice. But clearly, exercise and calcium supplementation are exceedingly helpful. People with bone loss probably should do low-impact exercise. And the lower the impact, the better. Things like swimming, elliptical, Stairmaster, low resistance weights, indoor spin are things that leap to mind. There are similar things that we tell our pregnant patients. Pregnant patients have the problem of having a couple of enzymes in their circulation that loosened their joints and ligaments, so they are at greater risk of injury and they do low impact for that reason. But for bone density, as I mentioned before, hip fracture is not a result of a fall. Hip fracture is as a result of the thigh bone not being able to support your hips because you took a bad step, not because you fell. People who shovel their driveways with snow can have their wrist fracture. There’s close to a dozen bones in your wrist and they are stacked up like their own Tonka toy, and bending your wrist with too much flexion or too much extension can fracture one of those bones, and those are exceedingly painful. So, besides losing height, besides losing altitude, you know, fractures from excess activity probably should be avoided.
Dr. Fox: One of the things I always found interesting about the topic of osteoporosis is, it was really prevalent in training for OB-GYNs, right? This is something that when you go through an OB-GYN residency, when you take their boards, when you read about it. There’s a lot of talk about osteoporosis. And I find that it ultimately falls on the gynecologist to be the, you know, primary provider in terms of counseling to prevent it, in terms of screening for it, and the initial treatment. And I think a lot of women find that surprising because they assume it’s gonna be, you know, an endocrinologist, or an internist. And maybe some of them are doing it, but I find that it’s really something that’s on our minds a lot. And I don’t know what your experience has been. Again, I don’t do general gynecology anymore, so I’m not really seeing women post-menopausal, unless, you know, they’re pregnant. But have you noticed that women are really unaware of this other than seeing you or are you finding that lot of women are already on top of this with their other primary care doctors?
Dr. Silverstein: I think it’s made a lot of progress in the 25 years that I’m practicing. The ratio of women to men with osteoporosis is greater than 10 to 1. So it’s the capture. We’re the ones that see the women. Three-quarters of my GYN patients who are otherwise healthy don’t have a regular medical doctor. I send them for their mammograms, I do their pap smears, bone density when necessary, if they need to see a specialist, a cardiologist, an endocrinologist, they go. And so, since the women are coming to me for annual visits incumbent upon me to order the appropriate age-appropriate screening test. I send them for colonoscopy when they reach 50. We talk about bone density after menopause. And women are very compliant with their gynecologists. Often it’s a long-standing relationship that they built, whether as a teen or in their 20s or 30s having children, and that continuity of care, that longitudinal care, there are some patients I’m seeing now who I treated as teenagers who are now going through menopause. There are people I’m seeing now who I’ve personally delivered who are coming to us pregnant or for routine GYN care. And that longitudinal care keeps the patients coming back on an annual basis. And it’s the capture technique. If you’re gonna see the patient on an annual basis, as a primary care provider, it’s incumbent upon you to order the appropriate age-related test.
Dr. Fox: Right. I think a lot of people find that surprising. They go to the gynecologist every year, but they don’t, you know, realize that, you know, he or she is now my primary provider and they’re gonna be ordering things or talking about things that have nothing to do with “gynecology.” But it is important because, unless someone is seeing a different doctor also every year, you’re the one they’re gonna see. You’re their person.
Dr. Silverstein: It’s actually a lot of fun when I have a patient who perhaps had a couple of babies with the practice and she’s 39 coming in for her annual visit. We look at pictures of the kids and do all that kind of stuff. And I say, “And next year I want you to get a mammogram.” And they look at me in shock and say, “A mammogram.” “Wait, in 10 years I’m gonna want a colonoscopy, in 15 years I’m gonna want a bone density.” You know, so we kind of lay it out and we try to make light of it, but we point out that these are very, very helpful tests. And the average patient is not seeing their regular medical doctor on an annual basis.
Dr. Fox: Wow. I think this is a really good review of osteoporosis. Again, it’s one of the things that’s more common than people think it is. And, again, the fact that there is a screening test and there is a treatment that could help stop that bone loss and hopefully prevent fractures as a woman get older is really important. Mike, thanks for coming on to talk about it and to explain it to our listeners. I appreciate it.
Dr. Silverstein: My pleasure. You do a fantastic job with these, asking me these softball questions, a little gentle lob and I get to run with it.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.