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

Summary

Podcast Summary: unPAUSED with Dr. Mary Claire Haver
Episode: Menopause, Frozen Shoulder and the Joint Pain Wake Up Call with Dr. Jocelyn Wittstein – Part 1
Date: January 20, 2026
Host: Dr. Mary Claire Haver
Guest: Dr. Jocelyn Wittstein, Orthopedic Surgeon, Researcher, Associate Professor at Duke University, President of the Forum Women in Sports Medicine

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Overview

In this insightful episode, Dr. Mary Claire Haver sits down with Dr. Jocelyn Wittstein to discuss the musculoskeletal syndrome of menopause—a new term capturing the joint and bone health challenges disproportionately affecting women during and after menopause. The episode dives deep into osteoarthritis, the infamous “frozen shoulder,” the intersection of hormonal changes with bone and joint health, and actionable prevention and treatment strategies. Dr. Wittstein draws upon both pioneering research and her experience as a clinician and female athlete, helping listeners understand and rethink women’s musculoskeletal health for lifelong independence and quality of life.

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Key Discussion Points & Insights

Dr. Wittstein’s Background and Path to Orthopedics

• Grew up on the East Coast; daughter of a physician.
• “I actually thought I would not go into medicine… but somewhere along the line, probably when I was a junior, I decided I wanted to go to medical school.” (05:07, Dr. Wittstein)
• Nutrition undergrad at Cornell shaped her approach to bone and joint health.
• Only about 6% of orthopedic surgeons are women; reflecting on this, Dr. Wittstein notes progress remains slow: “It’s well over 200 years before we will [reach gender parity].” (08:04, Dr. Wittstein)

Athletic Background and Effects on Bone Health

• Former collegiate gymnast; recognizes both injury risks and profound benefits of weight-bearing sports for women.
• “Children who participate in weight bearing sports like gymnastics and soccer, for instance, arrive at the age of 30 with greater bone density than those who don’t.” (09:16, Dr. Wittstein)
• Discusses specialization and early participation in sport—benefits and potential drawbacks.

Musculoskeletal Gender Disparities: ACL Injuries

• Women are 8–10x more likely than men to tear an ACL; root causes remain multifactorial and under investigation.
• “There’s probably some hormonal component related to this.” (14:12, Dr. Wittstein)
• Cutting-edge NIH-funded study in progress, combining hormone level data (estradiol, relaxin) and advanced imaging to map ligament strain during physical tasks.
  • “We’ve developed machine learning so that in just a couple minutes we can create a whole three dimensional model of the knee...We overlay the model on their knee with movement and…actually measure how much strain there is on the ACL.” (17:38, Dr. Wittstein)
• Contraceptive use and ACL injury risk data remains mixed and nuanced.

Siloed Medicine & Need for Collaboration

• Both doctors reflect on the lack of overlap between orthopedics and women’s health, advocating for multidisciplinary approaches to research and care.
  • “We need a less siloed approach to studying musculoskeletal conditions that have this intersection with women’s health.” (20:47, Dr. Wittstein)

Frozen Shoulder: The Forgotten Menopause Symptom

What is Frozen Shoulder?

• Predominantly strikes women aged 40–60.
• “Really, the only men who get frozen shoulder are men with diabetes and usually poorly controlled diabetes.” (25:47, Dr. Wittstein)
• Characterized by phases: initial inflammation and pain, stiff 'frozen' phase, then gradual 'thawing'—can last 1–2 years.
• “Something cannot be idiopathic that almost entirely affects women, but not men, and almost entirely affects women between the age of 40 and 60.” (25:47, Dr. Wittstein)

Hormonal Connections

• Estrogen has an anti-inflammatory action; many estrogen receptors in the joint lining (synovium).
• “There is an inflammatory phase where the shoulder becomes very, very painful… then a frozen phase… then a thawing phase.” (27:55, Dr. Wittstein)
• Dr. Wittstein’s research found that women on systemic estrogen therapy had roughly half the risk of developing frozen shoulder (though needing more data for statistical significance).
  • “Women who used menopausal hormone therapy that included estradiol… had half the risk of developing frozen shoulder.” (31:03, Dr. Wittstein)

Diagnosis, Prevention & Treatment

• Early steroid injection into the joint is highly effective if caught during early phase—“It is not a band aid. It’s like a cure.” (36:04, Dr. Wittstein)
• Physical therapy is useful, but only after the initial pain/inflammation has resolved.
• “If you’re in physical therapy for frozen shoulder, but it’s making you worse, not better… it’s not the right phase.” (37:56, Dr. Wittstein)
• Dr. Wittstein routinely screens for menopausal symptoms and refers to women’s health.

Musculoskeletal Syndrome of Menopause: A New Framework

• Women over 50 are 35% more likely to have arthritis than men; differences persist until age 80.
• Acknowledges pushback—some see these issues as ‘just aging,’ but research shows clear estrogen-related acceleration in bone and joint changes post-menopause.
  • “Some of these things accelerate in a different way at age 50-ish in women versus men.” (44:34, Dr. Wittstein)
• Surgical menopause and premature ovarian failure produce dramatically accelerated symptoms (e.g., joint inflammation, bone loss).

Osteoporosis & Prevention Strategies

• “One of the largest impacts lifelong of estrogen withdrawal is osteoporosis, which largely affects women and is a silent condition.” (50:33, Dr. Wittstein)
• Menopausal hormone therapy approved for osteoporosis prevention, but only part of the strategy.
  • “Hormone therapy alone will not be really enough, probably… certainly isn’t the only way to protect your bones.” (53:39, Dr. Wittstein)
• Strength training (especially heavier lifts), impact/jumping exercises, and balance/agility work all reduce fracture and loss risk.
  • “There is evidence that heavier strength training, higher intensity, does increase your bone density more than moderate and lower intensity. But there’s still benefit to moderate and lower intensity.” (53:41, Dr. Wittstein)
  • Jumping (impact): “30 jumps a few days a week…about a 1% improvement in hip bone density in menopausal women.” (55:16, Dr. Wittstein)
  • Balance training: Single-leg stands, tree pose, daily habits.
• Weighted vests and vibratory plates—useful adjuncts, especially for those with physical limitations, though the evidence varies.
  • “I don’t think weighted vests are the magic cure-all, but I think they’re a nice tool addition.” (61:37, Dr. Wittstein)

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Notable Quotes & Memorable Moments

• "I always take basically a perimenopausal or menopausal history. I always ask them, are you having hot flashes? Are you having night sweats? … And I make a lot of referrals to women's health, probably three to five per day in my orthopedic clinic to women's health because they're having these concomitant symptoms." (00:00, Dr. Wittstein)
• "There are clues as to why women have more arthritis than men, a lot more. And they’re here and there... But if they're not all brought together, they just don't work as well." (33:04, Dr. Wittstein)
• "I think the thing that first sent me down the path was the effect of aromatase inhibitors… This has to be a symptom of menopause." (29:18, Dr. Wittstein)
• "Use is the opposite of disuse." (61:37, Dr. Wittstein)
• On culture and language clues: “There are certain Asian cultures that have their own term for frozen shoulder, which translates to '50-year shoulder'... If you listen to people and... terminology within various cultural groups, they're telling us this is something that happens to women when they’re 50.” (35:10, Dr. Wittstein)

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Important Segment Timestamps

• 04:47 — Dr. Wittstein’s background; motivation for medicine
• 07:00 — Gender disparities in orthopedics
• 09:16 — Advantages and risks of girls' participation in sport
• 14:12 — ACL injury risk in women and cutting-edge research
• 25:47 — Defining and demystifying frozen shoulder
• 31:03 — Research: Hormone therapy and frozen shoulder risk
• 36:04 — Diagnosis and treatment strategies for frozen shoulder
• 44:34 — Introducing 'musculoskeletal syndrome of menopause'
• 50:33 — The silent crisis of osteoporosis in women
• 53:39 — Strength, impact exercise, and bone health
• 55:16 — Jumping for bone density; modifications for all abilities
• 61:37 — Weighted vests, 'use not disuse,' and reframing prevention

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Closing Thoughts

This episode offers a science-backed, action-oriented look at the intersection of menopause, joint health, and movement. Dr. Wittstein’s work is breaking silos, highlighting overlooked female health issues, and equipping women to take charge of midlife wellness with both emerging science and lived expertise.

Next Episode: Dr. Haver teases continued conversation with Dr. Wittstein, promising further exploration of practical steps and hormone-therapy considerations for musculoskeletal health.

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For more resources and support, follow Dr. Jocelyn Wittstein on Instagram @jocelynwittsteinmd, and Dr. Mary Claire Haver @maryclaire, or visit thepause.life. Dr. Wittstein’s “Complete Bone and Joint Health Plan” is available on Amazon.

Transcript

[Dr. Jocelyn Wittstein]

The other thing I always do whenever I have a woman with frozen shoulder, I always take basically a perimenopausal or menopausal history. I always ask them, are you having hot flashes? Are you having night sweats? You know, like, what else is going on with you? And I make a lot of referrals to women's health, probably three to five per day in my orthopedic clinic to women's health because they're having these concomitant symptoms. And do I have proof that initiating, you know, systemic estradiol reverses or makes your shoulder better or makes you not get on the other side? No, but I'm studying that. But does it make sense to me that it would? It does make sense to me that it would. And they need their other symptoms treated anyway.

[Dr. Mary Claire Haver]

The views and opinions expressed unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any.

[Sponsor/Advertisement Voice]

Related materials are intended to be a.

[Dr. Mary Claire Haver]

Substitute for professional medical advice, diagnosis, or treatment.

[Sponsor/Advertisement Voice]

One day I came across a social.

[Dr. Mary Claire Haver]

Media post from an orthopedic surgeon, Dr. Jocelyn Wittstein.

[Sponsor/Advertisement Voice]

She was explaining the key lifestyle strategy.

[Dr. Mary Claire Haver]

She uses to prevent osteoporosis. It caught my eye because I'd been receiving a little bit of flex on social media by the weighted vest haters. Immediately, I shared her post on my page. I know my followers would want to hear this too.

[Sponsor/Advertisement Voice]

I was right.

[Dr. Mary Claire Haver]

It blew up. Tens of thousands of women were tagging their friends saying, why has no one ever told us this before? I quickly Learned more about Dr. Wittstein. She's a practicing orthopedic surgeon, a researcher, and an associate professor of orthopedic surgery at Duke University and a mom of five. She isn't just another expert giving bone health tips. She's lived this science from every angle as an athlete, a clinician, and as a woman navigating midlife herself. I knew I had to invite her to the podcast. Her research interests are female athlete across the lifespan, post traumatic arthritis after knee injuries, frozen shoulder, and the musculoskeletal syndrome of menopause. She's the president of the forum Women in Sports Medicine. She's also a core leadership member of the Duke Female Athlete Program and a member of the Milken Institute Women's Health Initiative. She is the co author of the Complete Bone and joint health plan. Dr. Wittstein's work is changing how we think about musculoskeletal health across the female lifespan, from injury prevention to joint health and how menopause, hormones and movement intersect with our long term independence and quality of life. Today, she and I will talk about osteoarthritis, how it disproportionately affects women, why frozen shoulder loves midlife, and how hormones influence pain and bone strength, and how hormone therapy fits into the bigger picture of prevention versus treatment. This conversation will challenge how you think about movement, hormones and aging and it might just change how you care for your own body. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified Menopause practitioner. I'm also an Adjunct professor of Obstetrics and Gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

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[Dr. Mary Claire Haver]

Well, welcome to Unpaused.

[Dr. Jocelyn Wittstein]

Thank you for having me.

[Dr. Mary Claire Haver]

I am so glad you came in from North Carolina to New York to film. So tell me a little bit about your background. What kind of kid were you? Where did you grow up?

[Dr. Jocelyn Wittstein]

I grew up basically up and down the east coast, In Connecticut, the D.C. area, North Carolina. My dad was an ophthalmologist, so like any child of a medical practitioner, we followed the char chunks of his life. You know, medical school, residency and his first practice. So I'm an east coaster mostly.

[Dr. Mary Claire Haver]

Why did you go into medicine?

[Dr. Jocelyn Wittstein]

I actually thought I would not go into medicine, which I think is also common among children of doctors. And I hear my own kids saying it now like they don't want to be doctors. But when I was an undergraduate I thought I wanted to do something related to nutrition. So I studied nutrition as an undergraduate at Cornell University. And somewhere along the line, probably when I was a junior, I decided I wanted to go to medical school. I think the I had been suppress.

[Dr. Mary Claire Haver]

That and that's exactly what happened to my daughter.

[Dr. Jocelyn Wittstein]

Yeah. And then I had to take all those prerequisites all in a year and catch up and go and you know, I'm. I'm glad I made the decision, but for some reason I saw myself in health adjacent fields, areas I was interested in. But I'm really glad I studied those things as an undergraduate because I apply them now.

[Dr. Mary Claire Haver]

My daughter undergrad ended up being nutrition as well. And then she kind of second year ish decided so she was able to catch up. But she never got to go to Europe or do the fun things, you know, Cause she was like playing catch up to make sure she had all the free rides.

[Dr. Jocelyn Wittstein]

And sometimes you realize you don't want to do anything else, but it comes to you late after you study a lot of the adjacent things.

[Dr. Mary Claire Haver]

Yeah. Did anybody try to talk you out of it?

[Dr. Jocelyn Wittstein]

Did your dad? When I told my dad I wanted to go to medical school, the first thing he said was, are you sure you want to do that? And my youngest, who is now 18, just said to me the other day, you know, do you think I could still study this and still apply to medical school? And I thought to myself, oh my gosh, he's going to tell me he wants to go to medical school and I'm going to have that feeling of I don't want him to have the stress and the sacrifice and the lack of sleep and you know, things like that. But at the same time, if he ultimately decided he wanted to do that, like I know he would be happy with his decision in the end. For example. And it's the question that people ask you all the time, if you could go back in time, would you redo it? Yeah. And that's hard to say, but yes, because I like where I am now, but I wouldn't want to redo it.

[Dr. Mary Claire Haver]

Yeah, exactly. Go through that training all again. So why orthopedics? There's very few women in orthopedic surgery.

[Dr. Jocelyn Wittstein]

Right. About 6% of orthopedic surgeons are women. I was, I've been accused of being naive about many things, but I was actually quite naive about that when I, when I applied. I didn't actually really know that, which is odd. It's very obvious. It should have been obvious. You know, you do a visiting rotation here or there and you don't see many female orthopedic surgeons. But I think I just see people for people. And so I've always had like a lot of male friends. I also have female friends and it's kind of funny why we go on these rotations. I just had a great experience everywhere I was. I really enjoyed the people I was working with. It was fun. I was learning a lot. It didn't really cross my mind that there was, there were like no female attendings or maybe one or two at various places and you know, one female resident. I mean, I of course noticed it, but I didn't kind of think about like, what is the true statistic? Yeah, I mean, I, I, I know it now and, and it's, it, the number is growing. But there's a very interesting study that looked at the rate at which orthopedic surgery will get to parity in terms of, you know, sex in the field. And it's well over 200 years before we will. Oh my God.

[Dr. Mary Claire Haver]

At the current rate of attrition. Yeah.

[Dr. Jocelyn Wittstein]

I think for a lot of people, athletics is a, a gateway to orthopedics. So student athletes are often very aware of nutrition, musculoskeletal health, often have an injury here or there, often have, you know, a chance encounter with someone in the field of orthopedics who then, you know, it just gets you, you thinking about it. And when I originally went to medical school, I thought I wanted to be a pediatrician actually, because I, I love same, I love children same. And I did one block and it was just like, not for me. It was either, I mean, I, I've adore our pediatricians that are children have had over the years and they're amazing. But I couldn't do it because for me it was like either boring or very sad or very. And I just, it was not for me. And I wanted to be in the operating room doing surgery. I really like taking care of people in a way that I can acutely make them better. You know, they have an acute injury and I can solve it. And then I gravitated to sports medicine, which is again, that, that, that is something that a lot of former athletes do. Just sort of an area of interest for many People who have that background.

[Dr. Mary Claire Haver]

Yeah. So you were a collegiate gymnast. Has that really shaped part of like you said, you know, coming from the athlete world, were you injured?

[Dr. Jocelyn Wittstein]

I mean, most, most gymnasts, you know, I had so many teammates that had like an ACL tear. I had multiple teammates who had Achilles ruptures over the years, which are, those are common things that happen in that sport. Stress fractures in the spine. I actually didn't have any of those things. Ankle sprains, a minor disc herniation one time. But you know, nothing too crazy. But yeah, so I think sports have benefits and disadvantages, risks. And every sport has its risk. You know, in soccer it's acl. In baseball it's, you know, shoulder and elbow. In gymnastics there are, you know, there's a variety of random things that can happen. But sports also have major benefits for children. Children who participate in weight bearing sports like gymnastics and soccer, for instance, arrive at the age of 30 with greater bone density than those who don't. You know, they have a better basis for lifelong fitness in terms of regularity and participating, things like strength training and cardiovascular exercise and especially for girls, I mean, Title IX was a huge shift in terms of increasing women in sports and you know, more like lifelong athleticism for women. So, you know, people always talk about risk of sports in young people, but overall there are so many, so many benefits. But each sport does have a certain risk profile.

[Dr. Mary Claire Haver]

My kids definitely have more exposure to sports than I ever did. I danced my whole life, so that was my sport. But it was ballet, tap gymnastics and a little bit of acrobats.

[Dr. Jocelyn Wittstein]

Yeah. And nowadays children do specialize sooner in sport and there are issues with early sports specialization and overuse injuries and things like that. But overarching theme like participating in physical fitness and impact and load bearing activities and things that build muscle are, is very beneficial to people in their youth, you know, for their long term musculoskeletal health.

[Dr. Mary Claire Haver]

I mean it's benefited my kids for sure. And they didn't go to a high school where like if you wanted to be a cheerleader, you pretty much needed a round off and a smile. And if you wanted to play soccer, you just showed up. You know, it wasn't like this huge competition I see in the suburbs around Houston area where these kids have been like kind of groomed from like young childhood to like go into one sport.

[Dr. Jocelyn Wittstein]

And one thing about the sport I did, it is a year, it is a year round. Once you get to a certain level, you don't do other sports, but in that vein, it is a whole body strength, you know, bone muscle building sport. I personally feel like it gave me a really good foundation for strength as an adult, you know, bone health as an adult. And you do live off of that for a while, but then you have to start working harder and maintaining.

[Dr. Mary Claire Haver]

Yeah. Well, do you still talk about.

[Dr. Jocelyn Wittstein]

It still becomes apparent on trampolines. I will do flips, you know, back tucks. Front tucks.

[Dr. Mary Claire Haver]

Do you like impress your children? Are they like, mom, do a back handspring?

[Dr. Jocelyn Wittstein]

I do like an aerial cartwheel probably once a year. But I do it on sand in case. Cause I don't want to rupture my Achilles when I hit the ground.

[Dr. Mary Claire Haver]

Now, five kids. When I read your most impressive resume in your bio and I had to stop at five kids, Holy cow, that is. I'm in awe.

[Dr. Jocelyn Wittstein]

Well, you're able to live your life well. I don't want to seem like too amazing of a human being, but I. Cause there is a caveat to this, which is when I married my husband, he was a widower with three children.

[Dr. Mary Claire Haver]

Okay.

[Dr. Jocelyn Wittstein]

And so I married him, plus a 5, 8 and 11 year old. And then we had two more kids. So I had two kids.

[Dr. Mary Claire Haver]

Do you still have five kids?

[Dr. Jocelyn Wittstein]

Yeah, I had two kids during residency. One at the beginning of my second year of orthopedic residency and one at the beginning of my fourth year. But yes, I have mothered and raised five kids. But the funny thing is, and I just think this is such a funny comment all the time that I get. Cause patients will read my bio or something and say, you have five kids. How do you look like you look? And then I feel funny. Also it's a funny comment for people to say, like, you look amazing after having had five kids. And so I have my little thumbnail story that I say, because first of all, it is a funny comment. But I also, I guess this is a weird thing to say, take credit for having birthed five children. So I. I'm just thinking time management. Yeah, Time management has always been crazy in our house and people think we're nuts. My husband is also an orthopedic surgeon. And there was definitely one year. Yeah, there was. There was one year where we had. Or maybe two where we had one in preschool, one in elementary, one in middle, one in high school, one in college, and just the craziness of, of schedules and things like that.

[Dr. Mary Claire Haver]

Well, let's dive in to musculoskeletal issues in women.

[Dr. Jocelyn Wittstein]

Can you? Of which there are many.

[Dr. Mary Claire Haver]

I wish there Are many. So here you are, orthopedic surgeon, you know, putting bones back together. When in your training did you start realizing, you know, besides the presence of a breast, you know, of larger breasts and uteruses, that there's a difference, you know, the physiologic difference between men and women and how their bones and muscles function, how the musculoskeletal system functions.

[Dr. Jocelyn Wittstein]

I think the first, like, sex disparity that I was most aware of was in younger patients. And part of that is because I chose to specialize in sports medicine. And so, I mean, and I do see patients, I see, you know, teens, adolescents, college age, and, you know, women of all ages. But the first and most glaring disparity you see is in. Is actually in sports medicine. That's the most obvious one because girls are about eight times more likely than boys to tear their acl, which is really a poorly understood phenomenon. There have been many theories and hypotheses tested, but there's probably some hormonal component related to this. So you want to talk about that some more? Eight times, some studies say 10. I mean, yeah, but there's a huge propensity for girls and women to tear the ACL more than boys in sports.

[Dr. Mary Claire Haver]

But girls will tear their ACL more than boys. Like, did you, you know, was this like.

[Dr. Jocelyn Wittstein]

Well, you see it. I mean, it's recognized. It's in studies. If you look at, you know, how many.

[Dr. Mary Claire Haver]

And did anyone try to figure out why?

[Dr. Jocelyn Wittstein]

Oh, people have been trying to figure this out for a long time.

[Dr. Mary Claire Haver]

Every woman who's torn in ACL listening to this is flipping out right now.

[Dr. Jocelyn Wittstein]

People have tried to figure this out for years. I think there's been a lot of focus on this in the world of sports medicine, actually. And so I think credit to that subsection.

[Dr. Mary Claire Haver]

The people who have been trying.

[Dr. Jocelyn Wittstein]

People have been trying to figure this out. People have hypothesized it must be the size of the ACL or the size of the notch, which is the space for the ACL or neuromuscular control, or women have more valgus knees or what?

[Sponsor/Advertisement Voice]

For our listeners, what is a valgus.

[Dr. Jocelyn Wittstein]

Knee being like A little bit more knock kneed. Yeah. And to simplify, you know, you'll get one researchers that shows this, then someone else can't reproduce it. And oh, we find the ACL is smaller because the knee is smaller. It's proportionate to size, you know, so we. There are a lot of theories that have been explored but never really truly figured out. And then people have also Looked at, you know, timing, cyclical timing of injuries. There are some researchers.

[Dr. Mary Claire Haver]

Meaning menstrual cycle.

[Dr. Jocelyn Wittstein]

Yeah. Some researchers have shown like, well, there's more likelihood of knee injury, like in the luteal phase. Is it a lower estrogen state, perhaps with more muscular fatigue or like worse collagen synthesis, something like that. Or is it in a higher estrogen state where perhaps there's more laxative of the ligament? That is something that we are actively studying and we have the most amazing study to look at all of these issues that I am so excited about. But it's not. It's not. But no, it's not. We have done pilot, we've done some early data collection and it's a NIH funded study and we are proceeding with.

[Dr. Mary Claire Haver]

Kind of a big deal right now.

[Dr. Jocelyn Wittstein]

Yeah, yeah.

[Dr. Mary Claire Haver]

Because there's not a lot of NIH funding floating around right now.

[Dr. Jocelyn Wittstein]

So this study, and women especially. Yes, this study, I'll try to explain it in not too boring or complex a way, but it's, I'm so excited about it because no one has ever really been able to study like real time estrogen and relaxin levels with laxity of the acl. And we have a way that we do that.

[Dr. Mary Claire Haver]

Okay, so let's, let's break it down for the audience. So estrogen, everybody knows normal hormone. I know what relaxin is, but what.

[Dr. Jocelyn Wittstein]

Explain what estrogen makes ligaments more stretchy.

[Dr. Mary Claire Haver]

And is it, is it a steady state? Relaxin is a, is, is at a steady state or is it something that kind of ebbs and flows with the menstrual cycle?

[Dr. Jocelyn Wittstein]

You know, I don't actually know the actual ebb and flow of, of relaxin with the menstrual cycle.

[Dr. Mary Claire Haver]

We get a really, a lot of it in pregnancy.

[Dr. Jocelyn Wittstein]

Yes. And pregnancy is very high. Yeah. But we're including it in our study with the estradiol levels. But what we do is we check real time because obviously these things change over the course of a month or um, in women as they get older, you know, they're not steady state. But so we have these hormone levels and then we bake. We basically make these models of knees from MRIs and we've developed machine learning so that in just a couple minutes we can create a whole three dimensional model of the knee that shows traces, the whole acl, all the cartilage surfaces, all the structures of the knee. Then we have women who, we have their blood levels, we can test them with and without fatigue. So we're combining hormone levels plus, plus fatigue as A component. And then we have them do a test where they kind of jump off of a block and land, basically. And then we have this fancy setup with live fluoroscopy or X ray from different angles. It's called Biplanar fluoroscopy. And we overlay the model, the three dimensional model we made of their knee, on their knee with movement, and then we can actually measure in these moments of jump landing how much the ACL stretches or how much strain there is on it. The ACL is the ligament you hear about tearing talk all the time. So we're going to be able to actually measure how much strain there is on the acl. Does it strain more when estrogen or relaxin are higher? Does it strain more with fatigue? Is there a relationship between, you know, fatigue and hormones? So, but every other study that has tried to look at this kind of looks at say, oh, these women tore their ACL and we asked them what part of their cycle they were in.

[Dr. Mary Claire Haver]

Right.

[Dr. Jocelyn Wittstein]

Or they weren't measuring it. Yeah, it's, I mean, it's, it's hard to capture because people have these injuries randomly and it's not like you took a blood test on them that morning or something. And so it's, this is, I think, an amazing study design that's going to answer a lot of questions that people have been asking but not been able to get to the bottom of.

[Dr. Mary Claire Haver]

How, how hard is it to get something like that funded?

[Dr. Jocelyn Wittstein]

Well, you apply round after round and you know, you have to get scored typically in like the top 8%, you know, in order to get funded. And then sometimes there's delay in funding and things like that. But I mean, these studies cost millions of dollars, a few million really. And they, but this study in particular, I feel could really change, could be a very meaningful study. So if we find that there is this relationship, you know, that may impact training or maybe timing of games or events, things like that, that might, you know, put women more at risk for ACL injury. And there's this other body of literature which looks at oral contraceptive pills and risk of ACL injury. And there's some mixed evidence. Some studies show that use of oral contraceptive pills reduces risk of ACL injury. Some studies don't, especially if you control for things like comparing to other women who use IUDs. So you're kind of getting a good control group, things like that. And I think one funny thing is you've got sometimes orthopedic surgeons trying to figure out how to study these things and they're not necessarily maybe differentiating between, you know, phasic or continuous or, you know, just different forms. It's just receptive.

[Dr. Mary Claire Haver]

There's 50 different ones on the market.

[Dr. Jocelyn Wittstein]

And they're all different. They have different thought process about. I just feel like we need less siloed approach to studying musculoskeletal conditions that have this intersection with women's health. Because people really want to answer this question, but they're using insurance databases that pull, oh, these people were on oral contraceptives.

[Dr. Mary Claire Haver]

And it's more nuanced.

[Dr. Jocelyn Wittstein]

Yeah. There's so much nuance in my field that people outside my field are not going to know. And there's so much nuance in women's health that I don't know. And I'm an orthopedic surgeon with a very high interest level in women's health, but I consult all the time with my partner, Anne Ford, who is in Women's health at Duke. I constantly ask her questions to help me clarify things because. And I pull her into studies all the time because I need her expertise in the study to do it right.

[Dr. Mary Claire Haver]

Because we trained in silos.

[Dr. Jocelyn Wittstein]

Yes.

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[Dr. Mary Claire Haver]

I broke my foot when I was pregnant, 25 weeks. Tripped on a curb, you know, had a fifth metatarsal fracture. They brought in a pregnant woman, you know, into the ER with a broken foot. And like, the entire orthopedic team came in and like, I was a space, like, you know, I was an alien. They didn't know what. They were so scared to hurt the baby. I'm like, you can put a cast on me.

[Dr. Jocelyn Wittstein]

Like, you can do what you need to do.

[Dr. Mary Claire Haver]

You know, I just realized I'd never met any of these people. I rarely saw them that we had just. There was no interaction between our two specialties other than when the one pregnant resident comes in with a broken foot.

[Dr. Jocelyn Wittstein]

I mean, I want to get back to orthopedic conditions with sex disparities, but I will tell you, the gateway to my connection to women's health and all this work that I do came from the fact that my mom's favorite doctor over the course of her entire life, my mom's gone now, but was Ann Ford. And so for like 20 years, she'd be like, I just love Ann Ford. Ann Ford is the best doctor. This is her women's health doctor. She was like, she's like, she. Oh, my gosh. She just. My mom raved about her. So one Day, I'm in the break room, and thank goodness my office is directly on the same floor across the hall from Duke Women's Health. And I'm in the break room and I see this woman with a badge on, and it says Anne Ford. And I said, you're Ann Ford. I have heard about you for at least 15 years. And, you know, we started talking and ever since that moment, we have worked together.

[Dr. Mary Claire Haver]

That's awesome.

[Dr. Jocelyn Wittstein]

But because she meant so much to my mom.

[Dr. Mary Claire Haver]

Yeah, no, that's a, that's a great story. I often wondered how the whole frozen shoulder story. We'll get to that. We'll dig into that later. But let's talk about, let's go back.

[Dr. Jocelyn Wittstein]

So we talked about acl, right? So then I think the next most obvious condition, I mean, there are little ones you see here and there, like dequer veins, tenus innovitis, which happens to like new moms, but also like perimenopausal women. So much, so much plantar fasciitis, you see more of. But the one that's really, really obvious to me is frozen shoulder. Like we've talked about. It's just a condition that mostly strikes women. And really the only men who get frozen shoulder are men with diabetes and usually poorly controlled diabetes. So, you know, another inflammatory state. So frozen shoulder is a condition that for many decades was described as idiopathic, which is a fancy word for we don't know what causes this. I hate the word idiopathic because you're an idiot. Yeah. But, you know, something cannot be idiopathic. That almost entirely affects women, but not men, and almost entirely affects women between the age of 40 and 60. That's the typical timeframe. But what frozen shoulder is, is. And it's also called adhesive capsulitis, if you see that term. But it's typically a non traumatic or sometimes minimally traumatic situation where you didn't have a big injury, but your shoulder becomes very painful and then subsequently very stiff. It's a process where the lining of the shoulder joint, you may hear the term capsule or synovium, think of just sort of the lining around the whole ball and socket joint of your shoulder becomes inflamed and thick and fibrotic. And our phases. One of my friends, Johannifan, who is in the forum with me, the women's Sports medicine group, has described this variable over the years, including, you know, looking at the actual, you know, pathophysiology in the capsular tissue. But there is an inflammatory phase where the shoulder becomes very Very painful, you know, like pain at end range of motion. Just like. Okay, with the mid range, we get the end range and Ow. Like super painful leads to guarding, then a frozen phase where it becomes not so painful, but just really stiff. With women can have extreme lack of motion. I mean, I've had women come in who cannot rotate their arm out to the side or lift it up at all. And I just don't know how they can be at home.

[Dr. Mary Claire Haver]

So they can't brush their hair, they can't put their bra on, they can't put their arms behind their girlfriends in a picture.

[Dr. Jocelyn Wittstein]

Oh, yeah. Common things are I can't shave under my opposite armpit, cannot tuck in a shirt or fasten a bra. Yeah, washing your hair, you know, things like that. All very common. And then there's a thawing phase which could take one to two years. And if a woman has diabetes, that is the worst case scenario. Women with diabetes can have a really prolonged course of frozen shoulder. But, you know, we. I really believe this is hormonally related. This happens mostly to women between the age of 40 and 60. There are a lot of estrogen receptors in the synovium, or again, lining of the shoulder joint. And estrogen has been shown to inhibit cells called fibroblasts in the lining of the shoulder joint. So these cells that can like thicken and stiffen the capsule. I think you're aware we presented a study on this at NAMS or now the Menopause Society Menopause study.

[Dr. Mary Claire Haver]

So I want everybody to understand, women have been having this condition forever. And she and her team, you know, the co authors, were the first people to even suggest that this may have something to do with menopause, since it usually happens in women between the ages of 40 and 60.

[Dr. Jocelyn Wittstein]

60.

[Dr. Mary Claire Haver]

And it didn't go over well at first, right?

[Dr. Jocelyn Wittstein]

Yeah. I mean, what made you think of this?

[Dr. Mary Claire Haver]

What made you wait, like, wait a minute.

[Dr. Jocelyn Wittstein]

So I work in a network where I can. It's a closed network. Not a closed network, but the primary care doctors, all the notes, everything are in there. And I can see what's going on with my patients and I can see that they're seeing their doctor for sleep disruption, night sweats, hot flashes, lipids creeping up, things like that, anxiety, you know, all these other symptoms associated with perimenopause and menopause. And I, I just started, I also started asking my patients. So, you know, my. The first clue was like, I have all these women with breast cancer who have this. Then I started thinking, well, I mostly See this in women and then you know, it's in this age group and estrogen is an anti inflammatory hormone. I just, I sort of started just putting these pieces together and then these other situ, you know, complaints that they're having all kind of together. And I just, I think the thing that first sent me down the pack path was the, the effect of aromatase inhibitors. And, and I ended up talking to Ann about this and I was, I, this has to be a symptom of menopause. So this was like actually during COVID I spent hours and hours and hours, days and days and days manually doing chart reviews of like thousands of charts.

[Dr. Mary Claire Haver]

I just, yeah. This is the important part I want our listeners to understand is that the work that goes into getting the scientific proof.

[Dr. Jocelyn Wittstein]

Yeah.

[Dr. Mary Claire Haver]

That this could be correlated. Because the whole world is going to tell you.

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[Dr. Jocelyn Wittstein]

Yeah.

[Dr. Mary Claire Haver]

You know, as being the first person.

[Dr. Jocelyn Wittstein]

To make this correlation as you know, use of menopausal hormone therapy is less than 5% in the United States now in our population. Because I work with women's health doctors who are ahead of the curve. I would say on top of things. Not to say other people aren't on top of things, just they're, they're, I think have a higher percentage. I think it's about 8 or 9%.

[Dr. Mary Claire Haver]

Typically in academics we see that.

[Dr. Jocelyn Wittstein]

Right. So but even so, if you only have 8 or 9% of people on hormone therapy and the rest are not, and you have, you know, several thousand women who, that you're looking at, it's hard to get the numbers you need statistically. So we need to do more research on this. And what we ended up finding in our study was that women who used menopausal hormone therapy that included estradiol, systemic, not just local, had half the risk of developing frozen shoulder as compared to those who didn't. However, we approached statistical significance, reach it. And then our, you know, the other thing is we, when you look at our confidence intervals, they didn't overlap. So you know, if we could have just had more patients, some more patients, I think we would get there. And I mean just the number of cases of frozen shoulder in the hormone therapy group were so small. But again, you know, we need larger numbers. So I did a post hoc power analysis, you know, and I know how many we need, but I can't go back and get more. Cause this was, it had to be. I used patients that were in an enclosed system, meaning they were within our hmo so there's not leakage. I'm not Missing data. But I have ongoing prospective perspective work that I do with our women's health group. We enroll people in something called the, our Musculoskeletal Symptoms of Menopause Registry. We survey, survey them every few months, you know, follow them with timing of onset of hormone therapy or not. So we're doing that prospectively and I have a very large cross sectional study that will be coming out with that. I actually collaborated with Vonda right on in terms of distributing and that was great that she was able to collaborate with us. And we have huge numbers and we'll be coming out with that. And I don't want to say what it shows yet, but it does confirm our suspicions. I have that in submission and so I think it's becoming more and more obvious and people are recognizing this more and more.

[Dr. Mary Claire Haver]

When that paper was presented at the Menopause Society, I talked about it on social media and it was one of the most viral videos that I've ever had.

[Dr. Jocelyn Wittstein]

I remember that. And so many people reached out to me. They're like, are you the doctor she's talking about? Because you're like doctors at Duke University. And I was like, I think I am. But I do want to say there are, I think about this all the time in women's health. If you look hard at older data, there are pieces here or there right there, pointing in these. There are clues that just haven't been brought together because they're, you know, siloed. There are clues. There are clues as to why, you know, women have more arthritis than men, a lot more. And they're here and there. Some of it's in the orthopedic literature, you know, some of it's in women's health literature. But when you, if they're not all brought together, they just don't work as well.

[Dr. Mary Claire Haver]

Have you published in orthopedic journals, any of this data?

[Dr. Jocelyn Wittstein]

No, not the frozen shoulder data. I've tried. I've also tried. I wrote a piece on managing, you know, hormone therapy and oral contraceptives perioperatively. And I sent it to so many orthopedic journals, even got pre approval to write editorials on this. You know, yes, this is approved. Submit it, submit it to JAMA Surgery, all these places. And then they would get it and review it and be like, oh, this isn't, you know, no, just kidding, we're not going to publish this. Or I don't know if this is of interest to our readers and, you know, and 51% of the population. So I Eventually published it in a journal.

[Dr. Mary Claire Haver]

Women's Health is niche.

[Dr. Jocelyn Wittstein]

What on earth? So that paper, for instance, I eventually published in a journal that Miho Tanaka, who's at Harvard, is the lead editor of, which is Journal of Women's Sports Medicine. To give people guidance about how you manage exogenous estradiol perioperatively in orthopedic surgery. You know, oral estradiol has some increased risk. Transdermal much less, little to none. Vaginal zero. You don't have to hold that around the time of surgery. But it's just interesting. Like sometimes these things that are so significant and affect so many people are just, it's just hard to get it to where I, where I want to, you know, get it. Oh, regards to frozen shoulder. This is very interesting in some cultures that are highly prone to frozen shoulder, such as Asian cultures.

[Dr. Mary Claire Haver]

Okay.

[Dr. Jocelyn Wittstein]

Like there are certain Asian cultures that have their own term for frozen shoulder, which translates to 50 year shoulder. Like that is also not a coincidence. Like their term is 50 year shoulder. And some women just full on expect to get 50 year older. Oh yeah, my mom got 50 year shoulder. So again, if you listen to people and it's just, this is not random. So I wanted to share that anecdote because that's actually meaningful to me. Like if you just listen to terminology within various cultural groups, they're telling us this is something that happens to women when they're 50.

[Dr. Mary Claire Haver]

Yeah. Especially since we're talking about frozen shoulder. I am a gynecologist, have zero training in orthopedics, but because it's such a popular theme on social media, and you know, I'm always asked, how do we avoid it? What can I do if I develop it? You know, is there prevention? And then how do we take care of it? What do you do?

[Dr. Jocelyn Wittstein]

Yeah. So one of the most important keys to treating frozen shoulder is if you think you're developing it so you didn't have a traumatic event really, or something very mild, and then you have this new onset severe shoulder pain and you start to notice you're losing range of motion, even just a little bit. Like if you look down and you try to like rotate your arms out to the side and you see even just like a 10 degree difference like that that's not normal. Like normally you, you're gonna have normal range of motion. Yeah, I tell people this all the time, especially when they're in treatment for frozen shoulder. Like just check yourself, make sure you're not losing it after we gain it. But go see someone early this is not who. Ideally, I think an orthopedic surgeon or you could see like a primary care sports medicine doctor, someone who will give you a glenohumeral joint injection. An injection into the ball and socket joint. You're basically trying to combat or reverse as soon as possible. The inflammation of the lining of the joint and frozen shoulder is the best indication for use of a steroid injection, I think, in all of orthopedics, because it is not a band aid. It's like a cure.

[Dr. Mary Claire Haver]

Is it ever too late?

[Dr. Jocelyn Wittstein]

So if you're three or four months into the process and you've already started to lose motion, there is less efficacy of the injection. I'll still give it to people because they're still in pain. It just doesn't work as well. If I catch someone within three months of onset of the symptoms and I give them an injection, it'll often restore their motion, make the pain go away. And I don't. Half of those people, I never see them again. Okay. And they hug me when they come back. If they come back because they're so.

[Dr. Mary Claire Haver]

Happy, what percentage will get the contralateral, the opposite shoulder?

[Dr. Jocelyn Wittstein]

I don't, you know, I don't know an accurate statistic on that. I would say anecdotally in my own patient population, you know, maybe like 20%. Okay. But so some people need a second injection. The idea is you keep the inflammation at bay. You're shortening the course of the inflammatory phase, trying to get them to not freeze up so much or shorten the course of the frozen phase that they can then thaw.

[Dr. Mary Claire Haver]

What about physical therapy?

[Dr. Jocelyn Wittstein]

You will read in textbooks and our, like, examinations, the correct answer is send people physical therapy. But physical therapists. And I will tell you, if I send you to physical therapy in the throes of the inflammatory phase, it is not going to help. So if you're in that very painful phase and I send you to physical therapy or your primary care doctor, whoever send you to physical therapy, oftentimes the physical therapist is gonna recognize you have frozen shoulder and be like, I can't help you right now and send you for an injection. Because if you have pain and end range of motion and someone is trying to help you move it and you move it. And at the end of each end range, you're like, ow, ow, ow. By the end of the session, it's inflamed and you guard more. It's kind of exacerbating. Okay, so if you're in physical therapy for frozen shoulder, but it's making you worse, not better. It's not that your therapist is doing something wrong, it's just that that's the nature of the condition. It's not the right phase. I think you don't get as much out of physical therapy, so doing the injection early is helpful once we get you out of the painful phase. And I will like bring people back usually six weeks later and check them if I can rotate them. And at the end of the arc of motion, they're not painful, they're just still a little limited. Then we do physical therapy and it's more helpful then. And then. Rarely people need surgery for this. I mean, I don't operate on many of these because it is a self limited course and people do get better. And most people don't need like we call lysis of adhesions or manipulation, but some people do. You know, I think certainly less than 10% of people. So I think using physical therapy at the right time or phase is important, so we don't exacerbate things. And then the other thing I always do, whenever I have a woman with a frozen shoulder, I always take basically a perimenopausal or menopausal history. I always ask them, are you having hot flushes, are you having night sweats? You know, like, what else is going on with you? And I make a lot of referrals to women's health, probably three to five per day in my orthopedic clinic to women's health because they're having these concomitant symptoms. And do I have proof that initiating, you know, systemic estradiol reverses or makes your shoulder better or makes you not get on the other side? No, but I'm studying that. But does it make sense to me that it would? It does make sense to me that it would. And they need their other symptoms treated anyway.

[Dr. Mary Claire Haver]

And that your data so far suggests that HRT could be preventative. Is that a correct statement?

[Dr. Jocelyn Wittstein]

Yeah, our evolving data that I. Yeah, that I, I don't want to, like, I gotta get it out there in the right way. But yes, that's what I'm seeing. I, I wanna do this the right way, get it accepted and reviewed and everything. But yeah, that's, that is my feeling.

[Dr. Mary Claire Haver]

Okay.

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[Dr. Mary Claire Haver]

So frozen shoulder is part of the musculoskeletal syndrome of menopause, which is a new term. Is everyone like arms open wide accepting this term? Is it, Are you, is the terminology receiving pushback in certain organizations?

[Dr. Jocelyn Wittstein]

I mean, I think people question, is menopause arthritis just. Do you just have arthritis because you're aging? There are a lot of things that we can attribute to just aging. Progression of arthritis, loss of bone density. But some of these things accelerate in a different way. At age 50 ish in women versus.

[Dr. Mary Claire Haver]

Men and women, we see as the premature. What really stands out to us is some of these conditions in the people with premature ovarian failure, you see this rapid, rapid, you know, in their metabolic health.

[Dr. Jocelyn Wittstein]

Or surgical menopause.

[Dr. Mary Claire Haver]

Yeah, or surgical menopause.

[Dr. Jocelyn Wittstein]

Which is again, like, takes me back to the aromatase in Revelation. You know, it's like, yes, these people have the most exaggerated version. Surgical menopause is the human equivalent of the studies on the oophorectomized rats. Rat. I'm in no way comparing my lovely female patients to rat. No, but we don't have a perimenopause model. It's the parallel animals.

[Dr. Mary Claire Haver]

There's no perimenopause model. They either take out the ovaries and they're so surgically menopausal. And then they do the experiments or we don't have. There's no transition in the rodents.

[Dr. Jocelyn Wittstein]

Yeah, there's not a mouse perimenopausal model.

[Dr. Mary Claire Haver]

They're trying, but it's so complicated. We are so complicated.

[Dr. Jocelyn Wittstein]

Yeah, the, you know, musculoskeletal effects of menopause are are multiple and some are more silent than others. So, you know, more accelerated loss of bone density, increased joint inflammation, and risk of arthritis. Women over 50 are 35% more likely to have arthritis than men. And that difference doesn't equilibrate until age 80. So that is a disparate aging of joints. And so that's just not normal aging. Well, I guess it is normal aging for women because women do normally go through menopause. But I'm saying it's is a probably a modifiable thing. Right. As is osteoporosis.

[Dr. Mary Claire Haver]

We know that. I mean, we're at. Is FDA approved for the prevention of osteoporosis.

[Dr. Jocelyn Wittstein]

So and then getting back to the mouse versus human situation, you know, the. We talk about muscle mass and maintenance of muscle mass as we age, both men and women do lose muscle mass. Now, there are some studies that show that men and women don't have different rates of muscle mass loss over 50. There are. There was a recent systematic review that looked at hormone therapy that included estradiol and showed like in this meta analysis, that it didn't actually make a difference in terms of helping women maintain muscle mass. On the other hand, some of these studies use like, older forms and older ways of assessing for sarcopenia.

[Dr. Mary Claire Haver]

Right.

[Dr. Jocelyn Wittstein]

And then there are some new studies coming out that I want. I read one recently out of Thailand where there was a positive effect of, of hormone therapy with estradiol on. On muscle mass. There's a very interesting Finnish study where they followed these sets of monozygotic twins, like, for years and years and years. And that's a small study, but they had these 15 twins sets where one woman was on hormone therapy and one wasn't. Oh my gosh. And they've followed them for years and they show that they're in. Again, this is a small study, but so niche. And how would you get this group? Because they have such good studies in Scandinavian countries and they show a positive effect of hormone therapy on maintenance of muscle mass. So I think that is evolving. And I think in terms of the whole muscle mass aspect of thing, I would like to see more research on. And it's possible I just haven't found it because I read a lot of research, but I also have a full clinical and surgical schedule, so I could easily. I could miss something, but I don't.

[Dr. Mary Claire Haver]

Don't be shocked. We have so many listeners. Someone is gonna do a deep dive for you and you're gonna get an email.

[Dr. Jocelyn Wittstein]

I would love this.

[Dr. Mary Claire Haver]

I haven't seen or Some researchers are.

[Dr. Jocelyn Wittstein]

Gonna be listening to this and being like data. If someone is doing research and has data on more like muscular endurance or fatigue with or without hormone therapy, I don't know the data on that. And I wonder about that. And I think about that because we think about it in sports medicine sometimes in terms of, and that's one of the hypotheses about maybe potentially having increased ACL risk during luteal phase is they're more muscular, fatigue at a lower estrogen state. And we know that estrogen relates to, you know, glucose utilization and, and metabolism in muscle. So it would make sense to me that there could be some effect on, you know, fatigue. But any case, so we have potential effects on muscle. Some of that thought process comes from what we know about mice, o fructorized mice having less, you know, satellite muscle cells, loss of muscle mass. Now, like you said, we don't really have a perimenopause or menopause model necessarily with mice. It's more like an equivalent of surgical menopause. And there is some data that suggests that women with surgical menopause maybe are more at risk for sarcopenia as compared to just regular.

[Dr. Mary Claire Haver]

And we've talked about it previously on the podcast. But sarcopenia for new listeners is the loss of muscle mass to the point where you lose function. So if you want to explain what sarcopenia is.

[Dr. Jocelyn Wittstein]

Yeah, obviously a more extreme version is you're having so much weakness that you, you're frail. You're frail. I mean like grip strength less than 17 kg or something like that for women. But in general, obviously everything is on a continuum from a large amount of muscle mass to less and weakness. But there's some data suggests that surgical menopause would put people more at risk for having some loss of muscle mass.

[Dr. Mary Claire Haver]

Than someone who had natural menopause. Yeah.

[Dr. Jocelyn Wittstein]

Or more at risk for completing a survey that indicates your strength and muscle function being more at risk for sarcopenia than natural menopause. So I think we need more information about. There are basic science things that make sense and mice models. I think maybe we'll learn more going forward about actual, you know, what actually happens to muscle mass with some of the more, you know, modern day utilizations. But those are kind of the components.

[Dr. Mary Claire Haver]

So you've said that musculoskeletal health might be the most overlooked dimension of women's health. Why do you say that?

[Dr. Jocelyn Wittstein]

For multiple reasons. So the most, one of the largest impacts lifelong of estrogen withdrawal is osteoporosis, which largely affects women and is a silent condition. So it's easy to overlook it until so late in life that you have a hip fracture or, you know, a vertebral compression fracture. And then who are you seeing at that point? Usually a male surgeon.

[Dr. Mary Claire Haver]

Yeah.

[Dr. Jocelyn Wittstein]

And at that point, you know. Yes. You know, for instance, where I work, we have a fracture a fragility clinic that we send people to after a hip fracture, vertebral fracture. And we, you know, many of these people haven't been tested for the bone density or haven't ever had like a zelenronate infusion or something like that. And we're getting them down that path, but it's so late. And so I think there's this weird thing that happens where women are obviously receiving life, a lot of lifelong healthcare through their women's health providers. There's a silent disease which, you know, prevention of osteoporosis is and has been for a long time an FDA approved indication of menopausal hormone therapy for protecting your bone density. But the end result of declining estrogen levels and more bone resorption than bone building is this progression to osteoporosis, then fracture. The end result is so far down the line that the people seeing at the end of the line were not there at the beginning of the process. And so again, it's this siloed approach. And I'm on our fracture fragility committee and I'm pushing really hard to get our distal radius fractures, your wrist bone fractures, which peak for the first time in women between the age of 50 and 60. I want that group to go to the fragility clinic. The silver lining of if you fall and break your wrist, I mean, there's good and bad things to this. If you're a 50 something old woman and you fall, same level fall and break your wrist. Depending on the study you read, you have a nearly 50% or maybe 200% greater risk of eventually breaking your hip as compared to a woman who never had a distal radius fracture. But this group of people, if you had a distal radius fracture, you were the group I want to focus on. Because if I get you to a fragility fracture clinic and I get you a DEXA before the age of 65 and you're diagnosed with osteopenia and you make your hormone therapy decision about potentially bone health as the driving factor, maybe, and you're in the window where you can safely start. You're in the window of opportunity. Because again, these are happening in women in their 50s. This would inform you and you may say, okay, I don't want to have a hip fracture. I am at increased risk for a hip fracture. Maybe you have osteopenia, not osteoporosis. And we know that hormone therapy that includes estradiol will increase your bone density over time and protect you against fractures, you know, quite significantly. So I think we need to shift our thought process towards obviously earlier prevention. But in my world, we get a.

[Dr. Mary Claire Haver]

We ask, we try to get a bone density on everybody.

[Dr. Jocelyn Wittstein]

Yeah, in my world, I think we need to focus, like capture these wrist fractures because at least we're not so far down the line. So bone health is silent. Some of the other things are less silent.

[Dr. Mary Claire Haver]

What else can a woman do to prevent osteoporosis?

[Dr. Jocelyn Wittstein]

So many lifestyle choices.

[Dr. Mary Claire Haver]

That's how I found you.

[Dr. Jocelyn Wittstein]

Yeah, yeah, yeah, yeah. Many lifestyle choices will help you protect your bone density. And so many people, as you know, are not candidates for hormone therapy. So hormone therapy alone will not be really enough, probably or certainly isn't the only way to protect your bones. So lots of data and, you know, you've talked about a lot of times about strength training and everyone hears the saying, you have to lift heavy. And I do want to say, because I'm an orthopedic surgeon and I see people, not everyone can lift heavy, and that's okay. But there is evidence that heavier strength training, higher intensity, does increase your bone density more than moderate and lower intensity. But there's still benefit to moderate and lower intensity. They both, they both will, can help you increase bone density. And of course, the classic trial that everyone knows, which is an amazing trial, Lyftmore trial, you know, a great trial that used women who were menopausal with some of the osteopenic, some of them osteoporotic, and they did back squats, deadlifts, overhead presses, and jumping chin ups. And they kind of ramped them up to high intensity over eight months and they gained 3% in their lumbar spine and also significant gains in their hip. Strength training is very effective. But for people who cannot do that high intensity, you know, 85% single rep max type lifting, like, don't give up and just be like, I can't do that. There's definitely benefit to moderate and low intensity. So I just want to say that, yeah, jumping or impact, you know, is also a great way to improve your hip bone density. The most of the, like, load bearing strength training exercises will have a larger effect on your lumbar spine than the hip region.

[Dr. Mary Claire Haver]

So that's your back.

[Dr. Jocelyn Wittstein]

Yeah, your back. There is still some benefit with strength training to your, to your hip region, to your hips. But there is a specific effect with jumping and impact. This mechanical load, or this process called mechano transduction, which basically creates like a biochemical reaction in your bones and stimulates bone formation, is more effective in perimenopausal women than menopausal women. But there's still benefit for menopausal women. So one study showed over a six month period that included jumping a few days a week, maybe 30 jumps each time that there was about a 1% improvement in hip bone density in menopausal women. But if you look at similar studies of perimenopausal women, you may see gains of, you know, 2% in the hip region with these interventions. That could be. One study compared 10 versus 20 jumps a day, another did 50 jumps a day. And that study in perimenopausal women actually showed an increase of like 3% in the hip region. So impact is very effective. And we know that from studies of children, you know, participating in exercise. With impact they have, they accumulate more bone mass. So impact is great. Now there are people who cannot do impact because again, I'm an orthopedic surgeon, I have so many patients, like, that's great, I would love to do that. And I get tons of messages from people that's ridiculous, I can't do that. You know, and I'm like, I'm sorry, I'm just trying to share information about what jumping can do. But there are lots of modifications. And so if you have terrible knee arthritis and every time you jump, your knee swells, that is not going to be a good option for you. You can do heel drops, you can do jumping on a rebounder, which doesn't do as much as land based jumping. You can do jumping in a pool, again, not as much as land based jumping, but better than sedentary. And so impact, that's a broad category.

[Dr. Mary Claire Haver]

What about vibratory plates?

[Dr. Jocelyn Wittstein]

Yes, so those have mixed results. If you look at meta analyses of these, you know, you're certainly going to see like half of studies that had no effect, half of them had some effect. The most effective, I would say, like formulation, if you're trying to think about using a vibratory plate, uses a 30 Hz speed. So that's high speed vibration or frequency, I should say low magnitude. So you don't want the big magnitude of vibration, you want it to be this. The studies show 0.3g. So that's called low magnitude, not like 1g, which is like a larger vibration. Actually. Interestingly, there's something about vibration that seems to be beneficial at this point, like low magnitude. And then the exposure time matters. So the downside of using vibration plates is the studies that show benefit. You're basically having to do this 20 minutes every day.

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Okay.

[Dr. Jocelyn Wittstein]

And that's probably. Most people aren't going to do that.

[Dr. Mary Claire Haver]

Yeah.

[Dr. Jocelyn Wittstein]

But I do tell people who are. You know, there's so many people like, I can't do this, I can't do that. I have all these limitations. And that's probably a reasonable thing for you to add if you can do that. You know, 20 minutes a day. And then other components people need to include, because it's not all about just bone density for fracture prevention, balance, some agility work.

[Dr. Mary Claire Haver]

So when we talk about fracture prevention, we talk about limiting your chance of falling.

[Dr. Jocelyn Wittstein]

Right. You want to reduce balls.

[Dr. Mary Claire Haver]

So balance is key here. So what do you do for balance?

[Dr. Jocelyn Wittstein]

I. I was a gymnast. I literally love standing on one leg. I mean, I. It is the most natural. I love standing in tree pose. I sometimes I just stand on one leg. Just if I'm waiting for an instrument or I just stand on one leg. It's just.

[Dr. Mary Claire Haver]

I do it without thinking.

[Dr. Jocelyn Wittstein]

It's so comfortable to me. And I think. But I have patience. I'm even teenagers. I ask them to stand on one leg and they're wobbling. That's not good. So, you know, single leg balance is a really easy thing to practice. You can brush your teeth standing on one leg and switch. You know, when you switch, I don't know, your top and bottom teeth or whatever, that's easy to do. But, yeah, I think tree pose is a very easy thing to recommend. And you can try to do other things while you're standing, but it's such an easy thing to do. If you're waiting in a line, you can stand on one leg. You can practice, you know, like bending over and picking something up standing on one leg. It's like a little mini single leg deadlift, things like that. If you have balance issues or inner ear issues or, you know, you fall frequently, like maybe like keep yourself near a. A wall or something. But so, yeah, I think it's important to just practice balancing and agility work is just sort of anything that makes you move your feet kind of quickly. That's another thing. When I recommend it to people, like, I can't do that. And you can do less intense forms of agility where it's just a matter of helping yourself respond to your external environment so you're less likely to fall.

[Dr. Mary Claire Haver]

What about the weighted vest? There's a lot of weighted vests.

[Dr. Jocelyn Wittstein]

Misinformation.

[Dr. Mary Claire Haver]

I have one and I love mine.

[Dr. Jocelyn Wittstein]

Yeah. So the funny thing is like rucksacks have been around for years. Exactly. The military uses them to train their. They're members, they're athletes. So the data on weighted vest is, it's, it's the, the problem with it is that some of the studies are very small and then some of the follow up studies are on even a smaller portion of the original study and they're usually using mixed methods. So they're not only wearing the weighted vest, the subjects are also doing some strength training and some other things. So we can't attribute necessarily improvements in bone density to just using a weighted vest. But there are some studies that indicate there are improved parameters of balance and strength and things like that. And I like it for cardiovascular exercise. It adds to my walk. If I walk my dog, I put on that or a rucksack. If I wear a rucksack, I feel like I get a little bit more maybe core work. But so it's, they're certainly not harming people.

[Dr. Mary Claire Haver]

I like it for balance training too.

[Dr. Jocelyn Wittstein]

And there's so many things that I like to tell people are the opposite of disuse. And now we think about data on things that simulate bone density and jumping. You know, we, we want to create a big impact, something that's going to create a force than three times your body weight to stimulate bone formation. But if you think about the opposite extreme of thing, like if you're an astronaut and you're in microgravity and you're not putting any weight on your bones, just the absence of standing or having like your body weight on your legs will make you lose 1% of your bone density per month. So in contrast to that, what if I were on crutches? If you're on crutches for like six weeks, you get diminished bone density in your whole leg and loss of muscle mass. And it may take one or two years for your bone density to return to normal. Like in your, in all parts of your femur, for example, from just not walking. So then what about walking? Does walking, you know, put a load three times your body weight with every step? No, but it is the opposite of disuse. And it does slow bone loss over time. And people who walk regularly have less risk of fracture. And the end point isn't always bone density.

[Dr. Mary Claire Haver]

It's not fracturing.

[Dr. Jocelyn Wittstein]

Not fracturing, yeah.

[Dr. Mary Claire Haver]

Which is different than your bone density.

[Dr. Jocelyn Wittstein]

And so I really like to tell people use is the opposite of disuse. It's not like everything you have to do has to like make new bone or. And it's worthless. Like if you're not. These other activities are beneficial too. And so you know, you're adding a little bit to your, to your walk. So I, I don't think weighted vests are like the magic cure all, but I think they're a nice tool addition or tool and, and they get people excited about going out and walking and getting a little extra workout in. I always feel a little breathier if I'm out walking.

[Dr. Mary Claire Haver]

And my followers tell me it's like the perimenopausal, like badge of honor, you know, like you're like when you see someone walking.

[Dr. Jocelyn Wittstein]

So I think there's nothing wrong with. I don't want to like exaggerate what they'll do for you, but I think they're a nice addition. Now, if you have terrible knee arthritis, the funny thing is, right, they're not for everyone. Yeah, any exercise can be, you know, because we know if you lose like 10 pounds, your knee is going to feel a lot better. You're taking some load off your knee. So I have patients have terrible knee arthritis. I mean, that might not be for you, especially downhill walking with weighted vests. That's going to. You might make your knee hurt some more. But if your joints are tolerating it, I think it's fine.

[Dr. Mary Claire Haver]

It's fine.

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As a reminder to our audience, you.

[Dr. Mary Claire Haver]

Can follow Dr. Wittstein on Instagram at jocelynwitsteinmd. Her book, the Complete Bone and Joint Health Plan is available on Amazon. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram rmaryclaire and get honest and accurate information on health, fitness and navigating [e-mail] My upcoming book, the New Perimenopause is available for pre order on Amazon. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also follow full episodes on YouTube at Dr. Maryclaire UNPAUSED is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver.

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The views and opinions expressed on UNPAUSED are those of the talent and guests.

[Dr. Mary Claire Haver]

Alone and are provided for informational and entertainment purposes only. No part of this podcast or any.

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Related materials are intended to be a.

[Dr. Mary Claire Haver]

Substitute for professional medical advice, diagnosis or treatment.