The EngagED Midwife
The EngagED Midwife
Osteoporosis Unmasked: Midwives on Screening, Risk, and Real Prevention
A fracture rarely starts with drama. It’s often a quiet misstep, a stumble off a curb, or a slip on a throw rug—and that’s exactly why bone health deserves our full attention. We’re taking a clear, practical tour through osteoporosis and osteopenia: what they are, why they’re “silent,” and how to get ahead of them with smart screening, daily habits, and targeted treatments.
We unpack the biology of bone remodeling—osteoclasts that break down old bone and osteoblasts that build new—and the outsized role estrogen plays as it declines through perimenopause and menopause. You’ll hear exactly who should get a DEXA scan at 65 and who needs it earlier based on risk factors like prior adult fractures, long-term steroid use, low body weight, family history, or conditions like hyperthyroidism, celiac disease, and rheumatoid arthritis. We demystify T-scores versus Z-scores so you can read your results with confidence and know where osteopenia ends and osteoporosis begins.
From there, we get tactical. Nutrition that actually moves the needle, weight-bearing exercise and resistance training you’ll actually do, and when medication is actually warranted. We round it out with fall prevention you can implement today: balance training, better lighting, grab bars, safer footwear, and a clutter-free path through your home. If you care about staying strong, steady, and independent, this conversation gives you the tools.
Welcome to the Engaged Midwife Podcast. This is Kara. And I'm Missy. Hi, Miss. Hi. We are in our 12th season, right? And we're coming close to the end. Yeah, this episode will air like right towards the end of season 12. So crazy. We're it's so much fun though.
SPEAKER_00:Yeah, there are times when we're like, what should we talk about this week?
SPEAKER_02:And I'm gonna tell you, I don't think that this topic is like thrilling, but it's becoming more and more pertinent to my life.
SPEAKER_00:Well, I think what we've noticed is we've been talking a lot more about like things that happen with older women. Right. This season in particular, and maybe last season.
SPEAKER_02:Probably because our aging is becoming more apparent to us. God help us.
SPEAKER_00:God help our husbands, honestly.
SPEAKER_02:Yeah, true. And our families and our friends and everyone around us. But as we mentioned, on our favorite things, we are having better living through estradiol. Yeah, and a little testosterone in my case. Yeah. So today we're gonna talk about bones. Yeah. We're gonna talk about osteoporosis and osteopenia.
SPEAKER_00:Yeah, and it's a thing that I think can get overlooked or that people don't really talk about. I just kind of assume in my life that every older woman is on some sort of something, calcium, a biphosphonate, something. Sure. But honestly, like I also know a lot of people who are not.
SPEAKER_02:Yeah. And you know, the thing that's so interesting about osteoporosis is that it's a really silent disease. And most people don't think about it until they have a fracture. It's usually one of those things that, oh, someone like twists their ankle as they step off of a curb and they break an ankle. And then we realize that they have really low bone density. And um, otherwise, the only other people that really seem concerned about it are people that have a family history.
SPEAKER_00:Yeah, it's often undiagnosed until it's too late. Yeah.
SPEAKER_02:So we're, I think our main message today is going to be when should we screen for it? What are some risk factors? Who should be screened early? How do you diagnose it? And really thinking about really good health promotion, which is what midwives are so good at.
SPEAKER_00:And my one of my key points, especially at this point in my life, and what I've been telling patients, is some of these things are very familial, right? Yeah. And so I'm telling patients, like, how old was your mom? Is your mom still alive? How old was your mom when she went through menopause? How old was your grandmother? Do did was there any breast cancer history? Did anybody have any abnormal bleeding? You have older sisters and all of these same things. Correct. But did anybody have bone issues, right? And that's another question that goes into this. And this is those are great questions for like, I think, as women are approaching perimenopause, right? Um, just to be asking. And honestly, I don't really know because I never did ask my mom. Um, and and now she doesn't have the cognition to be able to answer those questions appropriately. Um, also, I think that those some of those topics are a little taboo in older generations of people, they don't want to talk about bleeding and bones and their health.
SPEAKER_02:Yeah. Um, so you talking about familial risk and that sort of thing, but I also think I come, I jokingly say I come from a long people, a long line of round people. And in general, heavier people have stronger bones just because they're doing more weight-bearing exercise every single day, carrying their body around. And so, yeah, bones in my family, I know they're good. Um, not so much. Yeah, I mean, hearts, hearts aren't so good. But bones are great. Bones are great. But this we're gonna talk more about this and we're gonna talk about assessing risk. But let's give um a little bit of a background about osteoporosis and osteopenia and then talk about some of the pathophysiology around that, if that sounds okay.
SPEAKER_00:Yeah. So osteoporosis is often called a silent disease. And that's because there's really no obvious symptoms. That's why screening is so important, right? Um, whereas, like if you have a musculoskeletal injury or you've like like me on my shoulder, like I hurt my shoulder, my shoulder hurts, I know there's a problem, right? With your bones, you don't really know. And till and until you have a fracture.
SPEAKER_02:Right. I'm saying yeah, there's not really like pain symptoms. There's not, you know, it it really happens gradually over time. So it is very silent in that you don't experience a change, but you can have a pretty significant loss of your bone density over time, and it is pretty um significant for some people, again, diagnosed once they have a fracture.
SPEAKER_00:Yeah. So here's a few key points as to why it's sort of the quietest of the things, right? So one is like we said, no pain or discomfort. So bone loss doesn't cause pain, right? You only get pain when you have a fracture. Yep. It does have a gradual onset. So we hit peak bone density at 25. For me, that was half of a lifetime ago. Yeah. Which is wild, right? Right. Um, and your bone weaken, your your the weakening of the bones happens, right? Over a like slowly, just like a gradual thing that happens. Right. Um, and then the other thing is is that sometimes you can have a fracture that you don't even know you had. Right. And so that some of that can be like you're losing height, right? Right. Um, and when we talk about bone health, some people are like, oh, this is just a natural part of aging, but really there could be some underlying pathophysiology.
SPEAKER_02:Right. And it's really crucial for midwives to understand that we are primary care providers. And this is a really important aspect of how we can help our patients. And it really becomes about prevention of the problem in the first place and really making early detection um possible. And so we're gonna talk a little bit about the pathophys, and that's gonna help us better understand who it is that we need to screen and why we need to screen them. So think about your bones as you know, kind of the building materials of your body. They're they're the structure, they're the you know, wooden frame kind of idea. And our bones are constantly being rebuilt. Um, like a house when you're renovating it, you're constantly rebuilding your bones, are doing that as well. And so we have two types of cells in our bones, and they have very different actions. Osteoclasts with a C are those that break down old bone. And osteoblasts with a B are those that build new bone. So osteoblasts, think about a blastocyst, think about young, that is building new bone, where osteoclasts come later, C comes after B, that is the breakdown of old bone.
SPEAKER_00:Yeah, and I think like when we talk about that, it's so important to understand that that differentiation.
SPEAKER_02:Right. And to understand that generally we want that to be in balance. You're wanting to break down bone as you're building new bone. You know, you you don't want there to be a differentiation of your breaking down more bone than you're building. And that is what happens as we age. We don't have estrogen that is protective of our bones because as that estrogen level declines, the demolition crew, those osteoclasts, start working faster than the construction crew can build it, which is our osteoblast. So estrogen is protective as it declines, especially in early menopause, we start to have more osteoclast activity rather than osteoblast activity. And that leads to a loss of bone density.
SPEAKER_00:Girl, we have been talking about this estrogen thing for a couple of episodes. We have. I'm mad that my ovaries have decided to be like, I'm done.
SPEAKER_02:But they're doing what they're supposed to do. I mean, this is a natural process. I still don't have to like it. You don't have to like it. I agree.
SPEAKER_00:I couldn't have liked my ovaries to work until I was like 55. I'm not even 50 yet.
SPEAKER_02:I hear you. But there are, we're gonna talk in a bit about things that people can do to help slow that process and to protect their bones. Fine. And you've been doing it. I know you.
SPEAKER_00:Yes, yeah. When we get there, you're gonna be like, oh yeah, this is why your bones are gonna be fine, miss.
SPEAKER_02:Yeah. So now let's make sure we understand the difference between osteopenia and osteoporosis. So osteopenia usually comes before osteoporosis. Osteopenia is low bone mass, and then osteoporosis is porous bone. Osteo being bone, porosis being porous. So low, low bone density before we get to the point that our bones are so low in density that they're porous.
SPEAKER_00:And you're saying too that estrogen plays such a critical role in bone protection because it helps to maintain that balance, right, between the osteoclast and the osteoblasts to prevent right osteopenia slash osteoporosis. And we'll get into a little bit more about how we diagnose osteopenia and osteoporosis a little later.
SPEAKER_02:Yeah. So we mentioned that the estrogen helps like kind of hold off that osteoclast activity and keeps it in check. But as that estrogen level decreases, then we lose that protection. So now let's talk about some risk factors.
SPEAKER_00:Well, I I meet I resemble some of these risk factors. So let's talk about the non-modifiable things. There's not there's these are things you can't do a single thing about. Right. That would be your age, your anybody who's female, gendered, Caucasian or Asian ethnicity, family history, small body frame. I am so screwed.
SPEAKER_02:These are not my people. These aren't my people. I know, yeah, absolutely. So again, those are non-modifiable. But then we do have some things that are modifiable. So low calcium and vitamin D intake can be modifiable. A sedentary lifestyle or smoking or excessive alcohol consumption. The excessive alcohol consumption is because it's competing for those nutritional stores. And so it can be problematic. And then there are some certain medications which, with long-term use, can really impact the bones. Oh, you mean like medications for asthma? Yes, corticosteroids. Absolutely. I mean, there's another major medication that we use um in family planning that has an impact on bone density. And it actually has a black box warning because of that impact on bone density. What is it, Missy?
SPEAKER_00:It's depot provera.
SPEAKER_02:That's right. The black box warning tells us we shouldn't use it for more than two years without taking a break from it because it does have such an impact on bone density. But while that's modifiable in that we could stop the corticosteroids, we can stop the depot. Some people need those, obviously. And we just need to know that they're at increased risk.
SPEAKER_00:Amazing. I mean, not amazing, but amazing. Like I think it's so important to know the things you can do for me, to know the things you can do to prevent something, right? Right. Or slow it down. Right. Versus the things I can't do a thing about. Right. Absolutely. That conversation for me also goes back to that whole idea of like familial hypercholesterolemia. Like, there's not one thing I can do about that genetic predisposition. Thanks, mom. Thanks, dad. And grandma and grandpa, right?
SPEAKER_02:Thanks so much. Yeah. To all of you. Yeah, that's the gift that keeps on giving. That's right. So before we talk about what we can do to prevent it, let's talk about how we can screen for bone density issues and what kind of testing we can do. So, as primary care providers, again, as midwives, we're the front lines of screening for this disease. And the gold standard test is dual energy x-ray absorptiometry or DXA or DEXA. I've also seen it as D E X A. And that is a bone scan. It's pretty easy, simple, quick scan that you can do on bone density. When I was in my private practice, we had a DEXA scanner in our office. That's so nice. Yeah, it is. Um, I think it was overused. So we're gonna talk about who should be screened. The people that should be screened are women that are postmenopausal and age 65. Yeah. Not 50, not 50. 55, 65. Yeah. Now, if they have increased risk, then we would screen sooner. And so let's talk about what that increased risk is. It has to do with some of those risk factors that we talked about earlier. So if they've had a previous fracture as an adult, not a childhood fracture, but they are an adult and they have had a fracture, they're at increased risk and should have earlier screening if they've been on long-term steroids. I don't know what you're talking about. And I couldn't find as we were looking for this, if it was inhaled or systemic. I would say I would be concerned about any long-term steroid use. Yep. And then low body weight. Again, what the crab. Yeah.
SPEAKER_00:How low? Is it like an underweight category? I think it would be underweight.
SPEAKER_02:Okay, I'm not there. You're not underweight, but you are very small in your frame. And then if you have a family history of osteoporosis, that would also indicate a reason for earlier screening.
SPEAKER_00:Okay, so my gram, I have to tell you this funny story. It's a good interlude. Um, my gram was taking a biphosphenate that was made by Lily, and my grandfather worked for Lily for a million years, and she used to just be like, they just put me on this medication, but it's okay because it's helping my stock options. Oh, and then she stops taking it all of a sudden. She's like, I don't know, I had some weird side effects. It's fine. I'm an old lady. If I break something, it's fine. She's gonna be 90 soon.
SPEAKER_02:Except for that breaking something can be like the start of a downhill, like yes.
SPEAKER_00:But listen to me, my gram was on a biphosphonate. You just told me I'm skinny and have a little frame. I also take steroids because of my asthma. You should probably have earlier screening. And I did break my leg at 38, remember? Oh, yeah. I broke my leg.
SPEAKER_02:I think you were being athletic. I was being athletic, yeah, but still. I know, I hear you. So, yes, I think you meet the criteria. So, now let's talk about what is the difference and how do we make a diagnosis when we use that DEXA scan. So, when we have a DEXA, we get a T-score, and the T-score is comparing your bone density against people with good bone, basically young people is comparing your bone against people that are around 20 to 25 and saying it's it's you know, it's a standard deviation measure, but it's telling us, are your bones weaker than people with good strong bone, or is it really weak and porous and you have osteoporosis? So that T-score number is how we diagnose osteopenia and osteoporosis.
SPEAKER_00:So tell our listeners about the Z-score really quick, because people are going to get confused, and I want you to tell them the knowledge that you have acquired because then they will be able to go forth and be because I was how many years old when I learned this?
SPEAKER_02:You were today years old. Today minus one. I was today minus one when I learned this. Okay, so a Z-score compares your bone density against other people of your similar age, ethnicity, gender, so forth. It is sometimes mentioned when we talk about osteopenia and osteoporosis, but it is much more rare to see someone's Z-score. It is much more common to talk about the T-score where we're comparing your bone against good, healthy, strong bone.
SPEAKER_00:Yeah. So Z-score is kind of crap. Kind of, but I don't want to know what my score is versus your score because we're just different. We are different.
SPEAKER_02:We're similar age, we're similar gender, yeah, ethnicity, but we are very different people. Different. Yeah, yeah. So osteopenia. Osteopenia is when the T-score is between negative one and negative 2.5. So when I think of this, you'll see people draw an up and down line and they'll go from negative numbers to positive numbers, or you I always think of it as like horizontal. Either way, the main thing to know is that if your T-score is negative one or higher, meaning it's negative one, it's negative 0.5, it's zero, it's one, it's two, your bones are really nice and strong. Uh, if it is above negative one, you're good on your T-score. But if your T-score is between negative one and negative 2.5, negative 2.5 going lower, that is osteopenia. And when your level reaches negative 2.5 or less, more negative, more negative, then you have osteoporosis.
SPEAKER_00:Right. And so osteopenia reminder that that's nor that's normal lower, lower than normal bone density, right? It's low bone mass that puts you actually at a risk for developing osteoporosis later.
SPEAKER_02:Right. And it's that T-score between negative one and negative 2.5. And if we identify things early, we can intervene with different lifestyle modifications and so forth to slow down that bone loss. And we can prevent the progression to osteoporosis.
SPEAKER_00:So then osteoporosis is a more advanced progression of this bone loss, right? Yes. Where the bone density has actually gotten critically low and the internal structure of the bone has become more porous and therefore more fragile.
SPEAKER_02:Right. And so then these people are more susceptible to fracture from even just a minor incident, like I said, tripping over something, catching yourself as you stumble a little bit, that kind of idea.
SPEAKER_00:Oh, like when my mom fell off the porch last year and shattered her arm. Yeah, absolutely. Um, so the goal then for people, so let's go to T-score, right? That's the next part. So, like you said, the T-score for osteoporosis is when the DEXA is less than negative 2.5. So if you're on that horizontal continuum and you're on the left side of it at negative 2.5, you keep going left, yes, you are osteoporotic. And so what's the goal with osteoporosis? And that's really to prevent fractures, right? Right. And so this often involves doing some lifestyle changes, adding weight-bearing exercise, adding things like calcium and vitamin D to your diet, as well as pharmacological therapy that helps to reduce the risk of fracture.
SPEAKER_02:Yeah. So as we're taking care of people and we're preparing to screen and those sorts of things, let's talk about how taking a really, really thorough history can be so important. And we'll start off with personal and family history of fractures. So you want to ask, has the patient ever had a fracture as an adult? And if so, what was the circumstance? Um, have they had a fracture from a fall from a standing height? Like they weren't up on a ladder, but they were literally just standing and had a fall, then that's a fragility fracture, and that's a significant red flag. Um, do they have a family history of osteoporosis? And specifically, has a parent experienced a hip fracture? And that's a really strong predictor of increased risk.
SPEAKER_00:Well, we've talked about medications, right? So, what kinds of medications are in their history? Long-term terms, so more than three months of these medications that are known to affect bone density. So corticosteroids, prednisone, right? Um, and some anti-seizure medications, and then then some hormone therapies, right? So especially if they're like estrogen blockers, correct. Or that would be like your GNRH agonists, like lupron, depolepron, right? Those kinds of things, um, and depoprovera, like we talked about causing bone loss. Yeah.
SPEAKER_02:In addition to medication, when you're thinking about health history, do they have any chronic diseases that can impact their bone health? So do they have thyroid disorder or hyperparathyroidism? Have they had rheumatoid arthritis, celiac disease, or chronic kidney disease? All of these can put somewhat at increased risk because it has to do with their absorption of calcium and vitamin D and sometimes to the exposures to some of these medications.
SPEAKER_00:I think I didn't know about the celiac thing. These poor celiac people, man.
SPEAKER_02:Yeah. Um yeah, it's it's problematic. It's bad when our bodies want to attack themselves. Autoimmune in general is just not great. It's a bad, it's a bad, it's a bad gig. Yeah.
SPEAKER_00:So we talked some about calcium and vitamin D, but when you're doing your health history, how much calcium and vitamin D do you get? Do you eat or drink dairy products? Do you eat or drink fortified foods? Do you take supplements? And those are important things. I think when people ask me what I like medications I take, I oftentimes leave out all of the supplements that I take.
SPEAKER_02:I feel like that is what my medicine box is full of now is different supplements. And sometimes there's supplements to help take care of the side effects from other medications I'm taking.
SPEAKER_00:Yeah. Yeah. That sounds wild. Yeah. Um, so here's the exercise thing too in your history. Um, what kind of exercise do you do if you do any? And um, and how often, right? Is it weight bearing? Is it walking, dancing, running, or muscle strengthening, like lifting weights, right?
SPEAKER_02:What is the best, the best exercise that someone can do to prevent bone loss?
SPEAKER_00:Uh anything that's weight bearing. But walking. Walking. I mean, like we all walk, right? But it's also like what you said about if you have a high BMI, yeah, even better.
SPEAKER_02:You're carrying around more weight, more weight. You're bearing more weight.
SPEAKER_00:Yeah. So me who is, you know, has a normal BMI, I wear a weighted vest when I walk because it gives me a little extra weight bearing. Good for my bones. Yeah, yeah.
SPEAKER_02:So but I love that they add in their dancing is weight bearing. Yeah. That's so great. Swimming, swimming is not good for your heart.
SPEAKER_00:Buoyancy, not good for your bones. Not good for your bones. Right. I think too, again, back to this health history thing, substance use, yes, right. So specifically smoking or excessive alcohol consumption. So um with alcohol, more than two drinks a day, both smoking and alcohol can negatively impact bone density. Um, and so we need to be considering that. And then you and I have also talked a lot in already about body weight, right? So low BMI has a is a significant risk factor. So very thin, or someone who may have experienced um a significant weight loss.
SPEAKER_02:And I have I've had weight loss journeys throughout my life, but have recently been in the last year or so on a GLP medication. And my physician was like, Because of your age, I really need you to do a good job of getting calcium. I need you to get good protein. I'm worried about muscle wasting, but I'm also really worried about your bones. And I was a little bit offended, but I'm really glad that she was so thoughtful about it and helped me think about that because I don't know that I would have thought of that as a problem. Yeah.
SPEAKER_00:Uh, another um assessment component is about reproductive and menstrual history. So, in terms of um menstrual history, for anyone who's pre-menopausal, right? How regular is their cycle? Did they have any history of amenorrhea, right? So anything that gets you to a place where you have decreased the amount of estrogen in your body. Right. Right. And then for people who are menopausal, how old were you when you went through menopause? Did they have early menopause? So that's before age 45, because that can significantly increase risk, um, uh fracture risk.
SPEAKER_02:Yeah. So now we've talked about screening, we've talked about diagnosis. Let's talk about some of our management strategies and how we can really empower patients because our management approach is multifaceted. And the good news is that we have a lot of tools at our disposal that can really help our patients. And the first step is always about lifestyle. It's the foundation of our health, it's health promoting, and it can really prevent so many problems, but it can also be part of managing a problem so that it doesn't progress further.
SPEAKER_00:Yeah. And when we talk about like nutrition, we've said all of the things, right? Right. We've said calcium, right? Yogurt, milk, cheese. And some a lot of people now though are don't eat, like don't ingest dairy. Yeah. And so that's a huge thing. But um, other things like fortified foods. So plant-based milks, if you do almond milk, soy, oat milk, right? Some juices and cereals, those things also have calcium in them.
SPEAKER_02:Yeah, you know what's so fascinating? I know that you and I both are yogurt lovers, but a one cup of milk or an eight-ounce serving of plain yogurt can give you 30% of your daily needs for calcium.
SPEAKER_00:So don't tell my family, but I have been blending up cottage cheese and putting it in so many of their foods.
SPEAKER_02:I know you make a really yummy um egg uh casserole that has uh a lot of cottage cheese. Yeah.
SPEAKER_00:Yeah, because an egg has some protein in it, but you add a cup of cottage cheese to like your egg situation, and then you've like doubled or tripled the amount of protein.
SPEAKER_02:Yeah. And you're getting calcium. Absolutely. So, other than dairy, there are other things that we can do and take in to get good calcium. And some of that is plant-based or other sources. So our leafy green vegetables, um, certain greens are really, really good as fantastic sources of calcium, things like collard greens or kale or bok choy. Um, spinach does contain calcium, but it also has high levels of a compound that can like block that calcium absorption. So it's not as effective as other greens, but it can be helpful. And then fish that has edible bones.
SPEAKER_00:I cannot tell you that I'm gonna that I've eaten a fish with edible bones.
SPEAKER_02:Yeah, um, so things that are canned, like sardines or salmon that has the bones in it, is high, very high in calcium. Um, and the soft edible bones are actually where the calcium is concentrated. I'm not sure this is a big source for most people.
SPEAKER_00:No, no, but my vegetarian friends are doing beans, right? And um, legumes and nuts and seeds, tofu. Yeah, right. All of those things um will give you calcium. But let me highlight something that I think we cannot forget, which is the vitamin D component, right? Right. And so a good dose of vitamin D to go along with your calcium. And that is for absorption, right? We need to have the vitamin D for calcium and absorption. I love the sun. You do not love the sun. It does not love me either. It's correct. So I am like, oh, I get plenty of vitamin D because except for in the winter where I live in the Midwest and it's nothing but gray, on a sunny day. I am like a sunflower. I just turn towards the sun and absorb it for people who don't love the sun. Yeah.
SPEAKER_02:You want to get 600 to 800 international units a day of vitamin D. And that can come um through dietary sources if you don't have a lot of sun exposure. And so things like fortified milk or fatty fishes have good vitamin D in them.
SPEAKER_00:Well, and I think the last part of this is like we have been talking a lot about exercise already, right? Adding some sort of exercise into your regimen will also help your bones.
SPEAKER_02:And it's that weight lifting and body weight, like resistance training that can really help as well. It's not just cardio. Yeah. Absolutely. Okay, so now let's talk about some pharmacologic intervention. And this is usually this is reserved for people that have a diagnosis of osteoporosis or they have a very high fracture risk. And there are a couple of different classes of medications, things like bisphosphanates. Um, and we're going to talk a little bit about each of these so that you better understand their mechanism of action.
SPEAKER_00:Well, I mentioned biphosphonids earlier, right? And what biphosphanids, these are things like phosmax, do is they slow down the osteoclasts. The ones that are breaking down the bone, it slows those down. Yeah. So, like you were saying earlier, the osteoclasts are like little tiny demolition crews. Right. Right. And they're always working, but phosmax basically tells the those little demolition crews to go on break.
SPEAKER_02:Yeah, absolutely. And this is generally the first line treatment for most people with osteoporosis, and they're really effective. It's very important though, this is a major teaching point for anyone that is prescribing a bisphosphonate, or you have patients taking it, is you want to make sure that they take it correctly. So they need to take it with a full glass of water and they need to take it on an empty stomach. And most importantly, as well, they need to remain upright for at least 30 minutes because it can cause a lot of irritation of the esophagus. And so you want to make sure empty stomach, full glass of water, sit upright for 30 minutes.
SPEAKER_00:This is why my gram stopped taking it.
SPEAKER_02:Yeah. She said it was a pain in the ass. Yeah. And I remember back, it was right as I was finishing midwifery school. So, or right new in practice, there was a lot of stuff that came out about jaw necrosis with people that were on bisphestiphenate. So you just want to make sure that you're doing really good education about it. But again, this is still generally first-line treatment for most people with osteoporosis.
SPEAKER_00:So another class of drugs is the anabolic agents. And those are the ones that are the gas pedals for the osteoblasts. Right. Yep. So they give this is um drugs like um terepitide, which is Forteo, that um it's different than the reabsorption ones, but because these ones actually help to build new bone.
SPEAKER_02:Right. So they directly simulate bone-building cells or the osteoblasts, and they are building that new bone. They don't just slow down the bone loss like the bisphosphonase, but they are building new bone. And these are really great for people with severe osteoporosis or those who have already had fractures and they need to rebuild that bone mass quickly. And they are generally taken by a daily injection. That kind of stinks. Yeah, that really does.
SPEAKER_00:Um, then let's talk about the rank inhibitors, so R-A-N-K-L inhibitors. Yeah. Um, this again um is an another mechanism, right, where it keeps the osteoclasts from forming, meaning you have less number, right, of osteoclasts.
SPEAKER_02:Yeah, so it's not just slowing them down, it's just they're not even being created in the first place as a type of cell. Correct. Okay, and these are um they are particularly working to target again that specific protein that is R A N K L. And it is essential for the formation and function of bone-breaking osteoclasts. And when we will we block this protein, they decrease bone resorption. These are long-acting injections and are typically given like every six months or so. They could be a good option for people that can't take something weekly or can't do something daily. Um, but a pretty major option that is out there for people with more severe disease.
SPEAKER_00:Yeah. And then I think the last class that we're really talking about is the one that another one that people know a lot about, which is the estrogen agonist antagonist CERMS. Uh-huh. And CERMS are selective estrogen receptor modulators. These are things like Avista, and they act like estrogen in some parts of the body, like in the bones, and then block it in others.
SPEAKER_02:Yeah, it's really interesting. So Avista, which is rhaloxifene, is unique because it provides the bone protective benefits of estrogen without stimulating breast or uterine tissue. So it is sometimes used in people that have had a breast cancer diagnosis in the past, that sort of thing.
SPEAKER_00:Yeah, a good option for people who need bone protection but can't really do estrogen. Right.
SPEAKER_02:Interestingly, though, it does have a pretty significant risk of hot flashes as well as an increased risk of blood clots. I don't need any more hot flashes. No, so it acts like estrogen in some ways, it blocks estrogen in others. And so you can have, you know, the increased clotting like people that are younger and have more estrogen, but it can also cause you to have menopausal symptoms like people that have low estrogen.
SPEAKER_00:Yeah, people may need more than one thing, too, right? Yes, absolutely. And so really working carefully with your physician or advanced practice nurse, right, on which medications do you need? What is the severity of your disease? What are the other things that you can be doing?
SPEAKER_02:Absolutely. So this is not medication that I have typically been prescribing, but certainly caring for people that have been on these medications. So I think it's good to have an understanding of it. And you certainly could be in a practice that is routinely prescribing these types of medications, depending on what population you're caring for.
SPEAKER_00:The next one hits home a little bit for me because I'm kind of klutzy, like not purposely. My husband thinks that I'm klutzy because I'm always in a hurry. Like that I rush to do things and then I like bump into something or I trip or I I do think you have your mind in many, many places at once. So oh yeah. It's and it's not diagnosable ADD. It's just, I think um, mom brain, yeah, like mental load, there's just a lot of things happening. I think sometimes you're like three steps ahead of yourself, but you forgot to take the steps to get there. Yeah, I forgot my body along the way. Yes. So injury prevention is gonna be important for people who have bone potential bone issues.
SPEAKER_02:Yeah. So preventing falls is really, really important, especially in our older adults. And there's different ways that we can do that, but it could be, you know, getting regular exercise, working on balance. So things like Tai Chi and yoga and those sorts of things and strength training, uh, flexibility, but also making sure that people get in for their vision checks and hearing assessment, because that can also impact um their fall risk.
SPEAKER_00:Yay for my yoga and my balance ball.
SPEAKER_02:Yeah, absolutely. I love it but you also want to think about what kind of medications could increase fall risk because maybe they cause dizziness or drowsiness or changes in blood pressure. So if your older patients are on antihypertensive, some of those different things, even some um over-the-counter medications can make people feel a little bit dizzy. So you want to talk about side effects of medications, you want to think about a pharmacist consultation, potentially for older patients that are on multi, um multiple different medications and really thinking about moving slowly, changing positions slowly, doing good activities that will help so that we're not dropping the blood pressure too quickly.
SPEAKER_00:Now you have been to my house. We don't have a lot of clutter. Clutter is not something that I that I believe in. Right. But I also grew up in a house with my grandparents that did not have a lot of clutter either. Yeah. However, how many times have you walked into a family member's house or somebody's house and been like, oh my gosh, there's so much stuff I would trip? Yes. Like that is uh environmental safety.
SPEAKER_02:But also just like throw rugs. Like I I have always lived in, grew up in a house that didn't have carpeting. We had wood floors, we had tile, we had whatever um laminate floors now. And so we have a lot of area rugs and throw rugs. You have to be really careful with that as you age so that you're not tripping on those things, and then not having cords, um, you know, charging cords for all of our devices.
SPEAKER_00:I had um, I had a charger plugged in at my standing desk in the basement, and then my computer was on my sitting desk. Yeah, and it like the cord went across, and Bob went downstairs and didn't turn the lights on, and he came upstairs and he's like, a charging cord across the place where people walk through, probably not a good idea, miss.
SPEAKER_02:Um, well, that leads right into our next thing of making sure you have really good lighting. Um, my husband would love to live in a cave, and I am always wanting things light and bright. So I need to let him know that um he is putting me at risk. It's for our safety. Yes, absolutely. So good lighting, thinking about handrails or grab bars or those sorts of things, especially in um the bathroom, because gosh, there are so many injuries that happen in people's homes when they're in the bathroom.
SPEAKER_00:Yeah, non-slip surfaces, right? I hate to say this about getting old, but like maybe your shower needs to have something in it that's not slippery, right? Or your bathtub. We did add a bench into our shower as well, which I'm really thankful for.
SPEAKER_02:Yeah, I mean for shaving your legs at minimum. That's really truly what I wanted it for. But it's also like, oh, if one of us got injured.
SPEAKER_00:I have other ideas about the bench in the shower, but we won't go there today. Oh goodness, I knew you were gonna do that.
SPEAKER_02:Okay, so I knew you were gonna say that. But don't forget your home safety checks, vision checks, and then thinking about balance issues because fall prevention is so, so important.
SPEAKER_00:Um I used to call them old old orthopedic shoes. And I'm not saying I will not, I'm never gonna wear like an orthopedic shoe as I get older. I'm always gonna have cute shoes on, but shoes matter. They do, um, not only for your comfort, but also just for safety. This says that slippers increase your um fall risk. So uh, madam slipper wearer. I love slippers. What if they have that grippy? I know. I have Ug slippers, I should have put that on my favorite things list. Yeah, and the Ug slippers are like literally the treads in them is so thick. I think it's the idea that your foot can slip out of it.
SPEAKER_02:That and then I will also say I actually most of my slippers now have a back on them because I like that, but also so many slippers now are indoor-outdoor. So you can, you know, run out to check the mail, you can, you know, lounge in them. And if you run to the store or something, you don't look like an idiot. Or maybe you do, I don't care. Um, but they're not as slippery because they've got that rubber bottom on them.
SPEAKER_00:Bob's deck is like Mr. Rogers, though. Mr. Rogers used to come in, take his shoes off, and put his house shoes on. Yeah. Bob wants nothing from outside of the house on the floors inside of the house.
SPEAKER_02:I get that. But I mean, we don't wear shoes at home generally. Um, but he's so particular.
SPEAKER_00:But it's a clean walkingness, it's cleanliness for him. He's like, you don't even know what you've walked through every day. And I was like, okay, that's gross. It's so true.
SPEAKER_02:I don't want to think about it, but I am just helping my immune system.
SPEAKER_00:I get that.
SPEAKER_02:Yeah. We're being grouped in hospitals, so our immune systems are fine. Probably, probably. So, again, this is so important for us as primary care providers to understand that bone health is a core component of primary care. And when we understand the risk factors and we do timely screening and we empower our patients with knowledge about taking care of themselves, lifestyle management, that sort of thing, we help them protect their bones and prevent the devastating effects of fractures and osteoporosis.
SPEAKER_00:Well, and I think if you learned anything today, you learned about the difference between a T-score and a Z score. Yes. What things are diagnostic for osteopenia versus osteoporosis? Yep. Drug classes that could be important and things that patients may be on that if you re-review their med list, you'll be like, oh, I recognize these now. Yeah. Right. And I would say biphosphanates are like the first thing that we generally do outside of calcium and vitamin D for people and their bones.
SPEAKER_02:Yeah, I think I always thought this topic wasn't like sexy and fun, and it wasn't about babies and pregnancy. And so I just didn't really want to think about it. But I think we broke this down to a way that I certainly have learned a lot as I've been preparing for this episode. And I think it's pretty straightforward.
SPEAKER_00:Yeah, and and the things you already knew, like do weight-bearing exercise, right? Eat well, eat the things that you should eat, get some vitamin D, go outside, it's good for your body. Or take a supplement. Right. Yeah, absolutely. So it's been really good. I yeah, I I mean, again, we're we're approaching an age at which these things are important.
SPEAKER_02:And sometimes as we age as midwives, our patients age along with us.
SPEAKER_00:Yeah. Do you remember when we were itty bitty midwives and people would ask us, like, we'd have older women and they wanted to talk about perimenopause or menopause or osteoporosis, and we would be like, I don't know. I know. Yeah. For me, it was even when people pregnant people before I had babies. Yeah, I was like, I don't know anything about common discomforts of pregnancy because I haven't been pregnant. And I'm not saying you can't be good at it without having those experiences. I'm just saying I have learned so much more now that I've experienced some other things.
SPEAKER_02:I will say you knew about them and you knew what to counsel. It's just that you better understood it once you had experienced pregnancy yourself. Correct.
SPEAKER_00:Yeah. I better understand perimenopause and menopause now that I'm there. That's right.
SPEAKER_02:So we hope this has been helpful to you. It's important that as midwives, we're taking care of people all across the lifespan. It's not just pregnant mamas and babies. And so, really thinking about how can we help our young people think about their bones? How can we help people in their reproductive years? How can we help people as they near menopause to think about protecting their bones? And this is such an important key. We don't want fractures. We don't want people to have to take medications that cause icky side effects. So protect your bones now.
SPEAKER_00:Yeah. Our our role prevention, screening, lifestyle management.
SPEAKER_02:Prevention of um disease progression. Treatment. Yeah.
SPEAKER_00:Yeah. All right. Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.