Dr Louise Newson [00:00:00] On my podcast today, I'm with Dr Doug Lucas, who's from the US. He's anorthopaedic surgeon and a bone and hormone specialist, and we really talk a lotabout osteoporosis, what it is, what it means to have it, the risks of havingit, and how we can prevent it. We talk about hormones. We talk about exercise.It's so important, because osteoporosis really is common as we age. So have alisten, and hope you learn.

Dr Louise Newson [00:00:31] So Doug, we're here to talk about bones mainly, and I've been quitevocal in the past saying that one of the reasons that I take hormones isbecause I'm really scared of osteoporosis, but lots of people don't even knowwhat osteoporosis is, and I'm actually, I'm less scared of having a fracturedhip, but I'm more scared about osteoporosis of my spine. And I've doctoredhundreds of women in the past with osteoporosis of their spine, and they'vebeen very disabled. They've been deformed in their shape, but they've also beenin lot of pain. They're on morphine, they're on laxatives, they're onanti-sickness. Every time they cough and sneeze, it could be another littlemicro fracture. So, osteoporosis is a real condition, but it's, I think, quitea scary diagnosis that people just like are brushing under the carpet. It's notsensationalised enough, really. So, you are a bone expert. I'm really keen justto really unpick and go back to the basics, like our bones are more than just askeleton that hold up our body, aren't they?

Dr Doug Lucas [00:01:41] Oh my gosh, absolutely. Yeah. So my my journey as an orthopedic surgeonreally taught me a lot about bones, what they are, how they heal, I meanliterally, how they feel, right. But as I exited out of orthopedics, I got intothe space of prevention, integrative medicine, hormone optimisation, and then Ireally realised that we're looking at osteoporosis in totally the wrong way. Weget so wrapped up in this idea of the DEXA, the T-score, the diagnosis ofosteoporosis, and you're absolutely right. It is an anxiety provoking diagnosisfor a lot of people, and unfortunately, a lot of times unnecessarily. But itcomes down to me,  from a definitionperspective, we need to look at it absolutely another way. We need to look atit as an imbalance of bone metabolism. We're all taught in medical school thatthere's cells that break down bone and there's cells that build up bone, and wecan talk about how hormones have an impact on those but if you think about itin the simplest way, which is, your bones are always turning over. You have anew skeleton every 10 years, the dynamic nature of that organ system isremarkable. And you're right. Nobody talks about it. So I like to look atosteoporosis now as not just a T-score, not bone density or even fracture risk.It's really just an imbalance of bone metabolism over time, depending on whereyou start and how fast you break down, eventually you will developosteoporosis. It's just a math equation. So the cool thing about looking at itlike that, though, is that if you think it's an imbalance of bone metabolism,then all we have to do to improve it, to reverse osteoporosis, is change theimbalance of bone metabolism. Do more build up, do less breakdown. And there'sa ton of tools we can use to do that.

Dr Louise Newson [00:03:22] Yeah, and that is so important looking at, you know, how these cells,the osteoclasts, the osteoblasts, work, because we've got to look after ourbones, our bodies, all our tissues and organs, because we want to keep themhealthy. And like you say, the bones are so dynamic. They're repairing theirbuilding. We're getting new cells all the time, new bone, but we want them tobe as good as possible. But we also, there's this thing, isn't there? I think that people think if it'sreally stiff and hard, then it's very strong. But we want a bit of flexibilityin our bones as well, don't we?

Dr Doug Lucas [00:03:58] Yeah, so it's a really interesting thing in the space of orthopedics,you know, we, I think we all think of our structure as this just rigid thing,but actually, bones are pretty flexible in the way that they are actually, youknow, laying down the new bone, laying down the actual, like spicules of boneon the inside. It's all based off of load. Your bones are always responding toyour load, in your femur, that big thigh bone, you can actually bend it. If yougrab onto each side of it, you can actually bend it and see it flex. So everytime we walk, everything we do, Your bones are bending and flexing, and they'reresponding to that stress.

Dr Louise Newson [00:04:34] And you know, there's so many factors that we can talk about that affectour bones, but even very basic. Lots of people think about calcium in theirbones, but vitamin D, the sunlight vitamin, people sort of know it probably hasan effect on bones, but it's really important, isn't it?

Dr Doug Lucas [00:04:53]

Yes, it's one of the strongest associations. When you look at theliterature, it's interesting. We talk a lot about calcium, but it's not, Imean, calcium deficiency is pretty rare in the Western world, and you see it inchildren who are malnourished. We don't see this in adults and in children,it's the different disease, right? Like, this is rickets. This is vitamin Ddeficiency, right? This is bone metabolism dysfunction, disorder in adults.It's not a calcium deficiency for the vast majority of people, but it can be avitamin D deficiency, because without vitamin D, your body can't utilise theminerals. And it's not just calcium either. It's the calcium, it's themagnesium, it's the vitamin K, it's the boron. I mean, it's all of it, right. VitaminD is the gateway to a lot of that. So if you're vitamin D deficient, yeah,you're gonna have a really hard time building bone.

Dr Louise Newson [00:05:40] Yeah, and that's really important, because, you know, I'm veryinterested in preventing diseases, I know you are, and I'm very interested ininflammation in the body, and I know you are as well. And there's a lot of talkabout osteoporosis being associated with all these other disorders anddiseases. And of course, they are, but the root cause is often, you know,increased inflammation in the body, but also a lot of the root cause can bevitamin D deficiency. And I was taught many years ago by a hospital doctor Louise,people with chronic disease, it's an association, not a cause. It's like amarker of poor health is low vitamin D. And I'm like, Well, hang on, maybe it'smore than an association. Maybe there is, it is related. I might. I spoke to myhusband recently, and I said, Do you ever measure vitamin D levels in hospital?He said, No, because it's always low. What's the point? What? But it's it's socheap and it's so easy, like we should all be thinking about vitamin D as ananti-inflammatory hormone, really, which is what it is.

Dr Doug Lucas [00:06:43] Yeah, yeah, yeah. It's funny. So then, did you ask him the follow upquestion, which is, well, if you know that it's universally low, are youuniversally treating it?

Dr Louise Newson [00:06:51] Of course I did, and you can guess the answer! But that's because inmedicine, you become very rigid in the way you think. Because he's not aorthopedic surgeon, he's not a general physician, he's a urologist. So it'slike, oh, that's not my area of medicine. Of course, it is. Paul. We should belooking very holistically, and it's very easy to do, but as a GP, we weren'tallowed to prescribe vitamin D for our patients, and I worked in quite adeprived area, so people would prioritise the food for their kids rather thanvitamin D, and I get that, but I think as we should be looking at ways tokeeping our bones really healthy well.

Dr Doug Lucas [00:07:32]  So I did a little research on this recently,because I remember back in an orthopedic residency, some of my mentors werestudying vitamin D deficiency, and it was clear as day, if you're vitamin Ddeficient, you're not going to heal your bones very well, if at all. But yet,there's the guidelines, the recommendations. I just read this yesterday, TheEndocrine Society here in the US still says the the benefit of testing vitaminD does not outweigh the, you know, the financial burden of doing so. It's a $5test. I mean, it's wild!

Dr Louise Newson [00: 08:01]  It’s bad, because how much is a hip fractureto be repaired? You know, it's more than $5 isn't it?

Dr Doug Lucas [00:08:07] Yeah, oh, it's $100,000, you know. And you know, you mentioned at thestart, you know, you're worried about spine more than hip, having treated bothspine and hip fractures, I know you see it clinically. There's the burden thatcomes with spine fractures, and that's very real. But if you break a hip youhave a 30% mortality rate in the next 12 months, you have a 60% chance oflosing your independence. Was a big deal that 10% that's sort of sitting there,that I didn't talk about, that 10% is not the same either. I remember onepatient of all the hip fractures that I treated, and we're talking 1000s, onepatient that seemed to bounce back. One.

Dr Louise Newson [00:08:42] Yeah, I said this to someone recently, if I was choosing with differentdiagnosis. You know, I sometimes play in my mind. How would I feel if I had Xor Y condition and if I had breast cancer or if I had osteoporosis with a hipfracture due to osteoporosis, my prognosis would be worse with the osteoporotichip fracture, but if I said to my friends, oh, I've just been diagnosed, I justhad a hip fracture, oh, what a shame. Hope you get better, if I say I've hadbreast cancer, this is just catastrophic, and I'm not belittling either, but Ijust think the sort of word on the street is, oh, never mind. It's fixable, butit affects all our bones in different ways. It loses independence, and like yousay, there's, there's a high mortality from an osteoporotic hip fracture. Sothere's not just vitamin D. We've said vitamin D is a hormone, which it is, butthere are other hormones in men and women that are really important for ourbones, aren't there

Dr Doug Lucas [00:09:43]  Absolutely yes, let's get into this.

Dr Louise Newson [00:09:46]  So, I'm very interested in the history ofmedicine and the history of hormones. And I was reading a book recently, and itwas they were describing Professor Albright in 1941. There's a great picture ofthis spine that just you can see through it. Basically, I'm sure you've seenthis the same picture. And he wrote about it. Was a very eminent doctor, and hewrote about osteoporosis and estrogen. And they knew that there was anassociation with menopausal women not having estrogen, having osteoporosis. Andnot long after, they realised that women who took HRT had stronger bones, andnow HRT is licensed as a preventative treatment for osteoporosis, isn't it?

Dr Doug Lucas [00:10:31] Right. Yeah. I mean, this is such an interesting space when you read theliterature, and this is one of the reasons why, when I left the conventionalmodel and I started my own practice, I very quickly niched down into bonehealth, and I very quickly started talking a lot about HRT, because when youread the literature, what we do in practice does not follow the literature, atleast over the last 20 years. And so you hear, I hear all these stories,because I have a clinical practice, I've got a community, an internationalcommunity, of people improving their bones. And then I have a YouTube channel, YouTubechannel that is global. We get 1000s of comments every month, so I have apretty good pulse on what's happening in the in the bone health community. AndI heard over and over again out of the gate. You know, my doctor won'tprescribe this for me. I'm worried about my bones. They say we don't use it forbones. But as you said, in Europe, in the UK, in the US, it is FDA approved,licensed for use to prevent osteoporosis, because we know that it very clearlyhas a powerful impact, not only on slowing down breakdown, which is what peopletalk about, but also on the build up side. It's one of the rare things thatworks on both sides of that equation in a positive way. It is extremelypowerful, and if you look at it compared to the bone drugs, the pharmaceuticals,right? When you compare estrogen to the pharmaceuticals, it is night and day,the potential benefit that estrogen, specifically, estradiol, can have for thebones. And yet, we don't use it for treatment. And most women who go to theirdoctors and say, I'm interested in this because I have osteoporosis, are toldthat we don't use it for that.

Dr Louise Newson [00:12:04] Yeah, and I can't work that out in some ways, because as a GP, for manyyears, I was encouraged to prescribe blood pressure lowering treatment, becauseif we reduce blood pressure, it reduces risk of a heart attack and stroke.That's great. I was encouraged to prescribe statins if people had a higher riskof developing heart disease, so but often the cut off, it varied on theguidelines, but usually, if someone's got about a 20% risk of a heart attack,then you look at their blood pressure, you look at their glucose, you look attheir cholesterol. In women, primary prevention with statins is very scantydata, because the studies haven't really been done, but we would still do it.So on average, people say one in two women who are menopausal will developosteoporosis. So that's 50% isn't it? So we've got a drug. You can see whereI'm going here, can't you? And it's cheap, but then, like, people have beenscared for the wrong reasons. Now, the WHI study that scared the whole world offHRT and still is the Women's Health Initiative study, actually, one of the goodthings it showed was that women who took hormones, even when they started themin their 60s, guess what? You know, it showed that they had a lower incidenceof osteoporosis, didn't it?

Dr Doug Lucas [00:13:22 – 13:41]  Yeah. I mean, it actually showed fracturereduction. I mean, this is actually hard to do in studies, because it was largeenough, yes, and they followed them long enough. The oral, you know, conjugatedequine estrogen Premarin, used in the Women's Health Initiative, showed a 41%reduction in risk of hip fracture, specifically, which is a big drop.

Dr Louise Newson [00:13:42]  So say that again, 41%?

Dr Doug Lucas [00:13:45] Yeah, 41%, and this is with Premarin, which is conjugated equineestrogen, which has very little estradiol, and it is losing market sharebecause it's not a great product, but yet, even that not so great form ofestrogen had a tremendous impact on hip fracture risk.

Dr Louise Newson [00:13:59] And that, I think, is really, really important. And you know, a lot ofmy work is about choice and education, but if I knew there was a medicine Icould take that had a 41% risk reduction of a disease, I've got one in twochance of getting and one in three chance of an osteoporotic hip fracture, likesurely as a patient, that we don't need to know anything else about hormones.You know, it's and it's basic physiology, because we've already said thesehormones work in our bones. We're just replacing them, aren't we?

Dr Doug Lucas [00:14:29]  Yeah, let me play devil's advocate, becausethis is what the doctors who treat, you know, the fracture liaison doctors, andthe doctors that use the bisphosphonates and the Prolia, this is their counterto that. If you look at even like, let's call the newest, the newest, thegreatest drug for bone health, Evenity, in the US. I don't know what it'scalled in the UK, if it's the same, but romosozumab is the generic, and thisdrug is has a, I think it's 70, like a 74% reduction in fracture, right? So youcould say, oh, well, it's better. But the thing about the drugs compared tousing estrogen specifically, is that estradiol you can continue to take, Imean, potentially indefinitely. We can talk about what happens if you ever stopit, but potentially for the rest of your life. Whereas the drugs that arehaving an impact on bone metabolism, you can only take Evenity for one year,you can take the bisphosphonates for three to five years, in Prolia we havesafety data to 10 years. But even then, those drugs do not work with bonemetabolism. They don't work with your dietary changes, your exercise changes,you know, any of the things that you're doing that are good for your bones,they work against it because they're shutting down bone metabolism. Estradiolactually enhances bone metabolism.

Dr Louise Newson [00:15:41] And I think this is really important, because I was reading the historyof the bisphosphonates in these drugs, because I'm very interested in, youknow, how do you decide? How do you make these drugs? And they were draincleaners, actually, weren't they? And, like, I don't know how someone decided,initially, it was the foam from soap, wasn't it? They realised that, and thenthey made them as drain cleaners, and then they converted them to a drug. Butthey hang around in the bone and the blood, don't they, even when you'vestopped using them. But I was looking at the risks of them, because there arerisks of medication, especially when it's a synthetic chemical that's notdesigned for our body, and there is risks of heart failure, there's risks ofatrial fibrillation, it's irregular heartbeat. There's risks of stroke, butthat seems to be ignored, and those risks are greater than any risks of eventhe synthetic hormones, aren't they?

Dr Doug Lucas [00:16:36]  Right? Yeah. I mean, we always, if we'regoing to use the benchmark of the WHI which is, you know, like we could talkabout all the negatives of this study, right? But the medical community seemedto accept that an incidence or a risk, an increased risk of eight out of 10,000patient years seems to be important enough for women, right? So if we're goingto use that as the benchmark, then, yeah, everything that you just said iswildly higher than that in these studies, and you didn't even mention the twothat I really worry about, which is the atypical femur fractures and theosteonecrosis of the jaw, because those are around 1% of users, depending onthe study you look at. If you combine it with steroids like or corticosteroidsprednisone, it goes up by 10x I mean, these are real risks, right? These areabsolutely frightening risks. And if you have osteonecrosis of the jaw, and youcan't heal, you know, a fracture of your jaw, talk about a life changer, right?You can't eat. So, yeah. I mean, there are real risks to the drugs, but I'm notanti-drug either. There is a time and a place for these drugs, but myperspective is, wow, if we can have a conversation about hormones and aboutlifestyle and prevent fracture that way, why aren't we having thatconversation?

Dr Louise Newson [00:17:39] I totally agree. I mean, the drugs in general, are quite expensive aswell, whereas hormones are cheap, so that, in my mind, as a patient, is good.But the other thing is, I often say to patients, I don't know whether youagree, but I hope you do, is that when people are taking HRT to protect theirbones, and they have a fall, the bones are like a plastic tumbler. They'llprobably bounce on the floor, and then they'll, you know, shouldn't slash it.But when they're taking, often, the bisphosphonates, if they have a fall, it'sa bit like a champagne glass. It just shatters because the bone becomes veryhard and rigid, and that is a real problem if you're trying to operate on thatbroken, stiff bone. I mean, you know, more than me, it's very different.

Dr Doug Lucas [00:18:25] So this is the way I look at bisphosphonates. Because, you know, if youmentioned that they they stick around in the blood and then the bone, and theydo, these drugs go into the bone. They poison osteoclasts, the cells that breakdown bone, and they prevent them from working. And they, but they bind to thatmaterial, so then in order to get them out, you have to turn over that bone.But I already said this about the antiresorptive drugs. They shut down bonemetabolism. So when we use bone turnover markers to look at how quickly are webreaking down and building up, they're both very suppressed. You have verylittle bone turnover. So what happens over time is all of the collagen that waslaid down before you started the drug does go through the calcification andmineralisation process, it becomes bone. But just like clearing out an old roadbefore you put in a new road, you have to do the work to clear. That's what theosteoclasts do before you can build. So then you end up just building,building, building, not clearing, and that becomes a dense so it looks betteron DEXA, a dense but fragile bone, and that's why we see these weird fractures,like atypical femur fractures, these other fractures that normally wouldn'thappen in places where they wouldn't happen, and then surgically, this is a bigdeal, because you go in there and it feels like chalk. I mean it literally,like just scraping it, drilling in it. It has a totally different feel to itfor people that have been on bisphosphonates for too long.

Dr Louise Newson [00:19:43] And that is a real problem, because it's not going to be good whenyou're thinking about recovery as well. You know, if you've fractured yourwrist, you want to be getting back home. If you've fractured your hip, you wantto be able to walk independently. And a lot of people, men and women, it canreally be. At the end of like you say, their independence, and it will takelonger to heal if you have these fractures, won't it?

Dr Doug Lucas [00:20:07] That's right.

Dr Louise Newson [00:20:09] So, when we talk about HRT, a lot of people think about estrogen,estradiol, really important, progesterone, the natural progesterone, which arevery different to the synthetic progesterone, like medroxyprogesterone acetatethat was used in the WHI study, because progesterone has really positiveeffects on the bone as well. So we see a lot of women who've had ahysterectomy, and their gynecologists say you don't need progesterone becauseyou've had a hysterectomy, you don't have a womb to protect. But I sort of say,well, you've got bones and brain and cardiovascular system.

Dr Doug Lucas [00:20:42] Yeah, and nerves.

Dr Louise Newson [00:20:44]  Yeah, precisely. So progesterone is importantfor our musculoskeletal system, isn't it?

Dr Doug Lucas [00:20:49]  Yeah, this is a toughy, because I run upagainst the same wall, right? So many women come in, they've had a hysterectomyfor whatever reason, and they're not offered progesterone or any type ofprogesterone. And I agree, same thing. I'm actually setting up - my smallpractice was acquired by a bigger practice - and I'm setting up all these newprotocols. We're setting up the Women's Health protocols. And I just passed bythe board. I said, Look, we are going to have a discussion and recommendmicronised progesterone for all women going on HRT, because of the benefits tothe brain, to the bones, to the nerves, right to the arteries, because thatliterature is pretty clear. Now, unfortunately, progesterone is rarely studiedalone, right? It's always the co-captain to estradiol. And studies, there aresome, but there's not a lot. So I can't say, you know, for a woman, let's say awoman off label, using progesterone without estrogen for bone health, because Isee this frequently, because I talk about it a lot. I can't say how much that'sgoing to help. I don't know. It's never been studied alone. It makes sense.Physiologically. We know that progesterone, or osteoblast the building cells,have receptors for progesterone. It should have a positive effect, and we seeit clinically, but I can't attribute, you know, how much is coming from theprogesterone versus anything else that we're doing. So I think progesterone isreally important for a lot of things. Again, sleep, brain, nerves, but I can't,I can't put a number on it. I can't say, oh yeah, 10% improvement.

Dr Louise Newson [00:22:11] Yeah. And, but we know we've got progesterone receptors in the bones, inthe osteoclasts, osteoplasts. There's a reason that they're there. So we itmakes sense, really, doesn't it, but also the other hormone that is oftenforgotten about, especially in women, but I think also in men, is testosterone.But you don't have an FDA approved for women testosterone preparation, but evenso, testosterone is branded as a hormone that will help with libido, but yes,it will help with libido for many women, but it really can help with the bonestrength. And again, we've known this for a long time, but that data seems tojust be ignored the whole time, doesn't it?

Dr Doug Lucas [00:22:51] Yeah, this has been really frustrating for me, because I practice allthrough telehealth. At this point, after I left orthopedics, the beginning ofthe pandemic, we started the practice. We didn't need a brick and mortarlocation. So we got licensed in all 50 states in the US, and then once you dothat like a brick and mortar, does you no good. So we've maintained telehealth,the company that bought my company, Life MD, is all telehealth, but we'rerestricted in the United States because testosterone is as a controlledsubstance. So it is controlled, just like you would control benzodiazepines,narcotics, you know, all of the things that should be controlled. Testosteroneis the same way. So we can only prescribe in about 30 out of 50 states throughtelehealth. And even then, we're probably pushing pretty hard. It's reallyunfortunate, because when you look at the data around testosterone, and therewas a study that was just published last month, when you look at the dataaround testosterone, it does so much more than improved sexual function inlibido in women, but we run into the same issue because it's only it's actuallynot even FDA approved, but it's recommended for use only with the diagnosis ofHSDD, hypoactive sexual desire disorder, right? That's the only thing thatdoctors are allowed to write down in the chart. If we say we're concerned aboutyour muscle mass. We're concerned about your brain fog, your sleep, yourenergy, we're concerned about your vitality, and we want to consider off labeltestosterone use. They get crucified, and so it has really put up like a bigshadow over testosterone use. But fortunately, you've got some big, big voicesthat are coming out talking about the use of testosterone, what it's good for.I don't know if you listen to the FDA panel in the US, the expert panel?

Dr Louise Newson [00:24:26] Yeah of course, it was brilliant.

Dr Doug Lucas [00:24:27] Oh, it was great. Oh my gosh, so many great comments around the use oftestosterone and how ridiculous some of these restrictions are when it comes tobone you know, there are studies in men. There's two studies I can talk aboutin women, but there are studies in men that show that it increases bone mineraldensity. It doesn't. This is the again, devil's advocate side, as they say, Ohwell, the studies didn't show a reduction in fracture risk, but they weren'tbig enough to show a reduction in fracture risk, right? They weren't big enoughstudies. And whenever researchers use testosterone in studies, they always usethese tiny like, not. They're just trying to go take a guy who's hypogonadal,so total testosterone under 300 and then push him up to like, now, like 350 400you know. But this is not eugonadal. This is not optimised testosterone. So youget these tiny little doses and they say, Oh, well, the effect wasn't thatgreat. It's like, well, the testosterone wasn't that great either, you know.So, like, we're not doing great studies, but even then, they do show increasedbone mineral density in women. There's only one study that I've found wherethey use testosterone, and this was a pellet study. So it was estradiol pelletsand micronised progesterone with and without testosterone. The testosteronegroup had better bone density at the end of the study, but it was small. It wasa pellet study. And so, you know, okay, this is helpful, but we need betterdata. The study that I mentioned, that was just published last month, was a bigretrospective view, so it actually looked at an older population, looked at therate of fracture, and who was on testosterone, which is actually kind of hardto do. It's not a lot of women in that age group are on testosterone, but theywere able to show that if you were on testosterone, there was a significantreduction in hip fracture risk. So it's very real, and we have to get aroundthe stigma of testosterone is bad. It's dangerous. It needs to be controlled,  just like any drug, if it's usedappropriately, we can expect it to have the benefit that it should have, whichis improved bone health, reduced fracture risk, improved muscle mass, you know,improved cognitive function, likely improved vitality overall. We see this inmen. Like all of the symptoms of aging get better with testosterone, and it'strue in women as well. And then, oh yeah, also, it might have an impact on yourlibido and your sexual function. And that's a great side effect, right? Butthat's not the big picture. We need to be using it for what it is known for,which is really like the lifeblood of energy, the lifeblood of vitality.

Dr Louise Newson [00:26:50] Absolutely. And I think also, you know, you're the same as a doctor, asme, you often try medication in people, and you give them options, and if itdoesn't work or doesn't help, then they can have something else. But there's noreason why people can't have HRT testosterone and a bisphosphonate or anotherbone drug if they need it. So there's always options for people. And I feelit's sad when people are just given the bone drugs without thinking abouthormones.

Dr Doug Lucas [00:27:20] Yeah, I may comment on that real quickly, because I hear a lot ofdoctors who are prescribing the bisphosphonate drugs, again, the fractureliaison clinics, which have value, but they're not hormone experts. And so Ihear this a lot, which is, well, we can't use HRT and bisphosphonates, becausethe HRT will make the bisphosphonates less effective. And I know, I know wherethey're getting it from. I do because if you look at studies where they havecombined the two, the bisphosphonate doesn't seem to do as well. But they'retaking the data the way that, the way that they want to, which is, oh, well, Iwant to use the drug, so I shouldn't use HRT. But what they're missing is that,no, actually, the HRT made the osteoclast function better, therefore they hadbetter bone turnover, therefore the bisphosphonate didn't do what you expectedit to do, because their bone function is better and their outcomes ultimatelyare better too. So yes, you can absolutely use them together, but there are alot of doctors saying no, no, it makes the bisphosphonates less effective.

Dr Louise Newson [00:28:16] So at the end of the day, it comes down to patient choice as well. But Ijust sit here feeling really frustrated. I'm really grateful for your time. Butyou know, it's 2025 it was 1941 Professor Albright talked about hormones. SoI'm just keen, I always ask for three take home tips, I'm just keen for threethings Doug, that you think are going to make a difference for women and menthinking about hormones and bones, so that in another 80 years, we're nothaving this still ridiculous conversation.

Dr Doug Lucas [00:28:52] Yeah, let's not make it to a century from that, right? Let's not make itto 2041, before this is resolved. Yeah, so I'm on a mission to go around theglobe talking about bone health in a different way. We need to look at bonehealth as a biomarker of health span. So I'll try to make this into threepoints. So one would be, if you are a perimenopause or post-menopausal woman,and you are considering some kind of hormone optimisation replacement, and youdon't know what your bone density and quality is, you have to get thatinformation before you have that discussion with your provider, because you aremissing a massive piece of the puzzle. So I'd say that's number one. Number twowould be if you are, this one for number two. So we need to image our bones.DEXA is available, it's around. There are other new devices that you canmeasure with as well. There's an ultrasound device called REMS that measuresboth density and quality. I would actually encourage you to get both. So what Iwould say here, for number two, is get all the data that you need. Get both aDEXA, get a REMS. This is more available in the UK than it is in the US. Butget both so that you can have as much information about your bones and then.Follow it over time. If you're losing bone, something's wrong, and that's whatI mean by saying bone health is a biomarker of health span. If you're losingbone, something's off. I can't tell you what it is. Could be hormones, could bediet, could be a lot of things, but if you're losing bone, something's wrong.So that's number two. And then number three is, don't lose sight of this. Ifyou're measuring, if you're imaging, if you're optimising, you can use thesethings called bone turnover markers, which I know are available in the UK, butnot broadly, P1NP and CTX are out there. Those are the bone turnover markersthat we can use to understand what's happening with bone metabolism as we'redoing the things in between our imaging modalities, which are going to be everysix months for REMS, every 12 months for DEXA, we can use the bone turnovermarkers in between to make sure we're headed in the right direction.

Dr Louise Newson [00:30:46] So lots to think about, but the most important thing is getting themessage out that hormones have a role on bones. So thank you so much for yourtime. Doug, it's been great.

Dr Doug Lucas [30:56 – 31:02]  Yeah. Thank you Louise, Thank you.

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