unPAUSED with Dr. Mary Claire Haver

Episode Title: Strong Bones, Strong Body, Stronger Second Half with Dr. Jocelyn Wittstein - Part 2
Air Date: January 22, 2026
Host: Dr. Mary Claire Haver
Guest: Dr. Jocelyn Wittstein (Orthopedic Surgeon, Duke University)

Episode Overview

In this second part of their wide-ranging conversation, Dr. Mary Claire Haver and Dr. Jocelyn Wittstein dive deep into the complex interplay between hormones, pain, cartilage health, and joint resilience in women, especially as they move through menopause. The discussion explores the roles of estrogen, progesterone, and testosterone in understanding why women experience higher rates of arthritis and musculoskeletal pain, the realities and misconceptions around fibromyalgia, lifestyle prevention, and the actionable steps both doctors recommend for bone and joint health in midlife. Dr. Wittstein also shares cutting-edge research and gives concrete protocols listeners can use to protect and strengthen their own musculoskeletal health.

Key Discussion Points & Insights

1. Hormones as Pain Modulators

[04:17-07:31]

• Estrogen and Progesterone’s Role:
  • Animal studies show these hormones can trigger cells in the spinal cord to produce natural pain-relieving substances.
  • There are observed links between progesterone levels and pain in women with fibromyalgia.

"Estrogen and progesterone stimulate these cells to create like an endogenous analgesic, basically... suggesting that maybe there's like some central pain modulating effect."
— Dr. Jocelyn Wittstein (04:31)

• Fibromyalgia in Midlife:
  • The classic definition involves pain in myofascial tissue at specific points.
  • Dr. Wittstein speculates that much of fibromyalgia diagnosed in menopausal women might actually reflect musculoskeletal syndrome related to menopause.
  • Notably rare in men.

"A lot of menopausal women get diagnosed with fibromyalgia... Rather than just being this de novo condition, could just be a symptom of menopause."
— Dr. Mary Claire Haver (05:38)

2. Hormones and Arthritis Risk

[07:31-10:52]

• Estrogen Withdrawal:
  • Key driver for increased pain and inflammation.
• Testosterone:
  • Gradually declines with age in women, not as abruptly as estrogen.
  • Emerging research shows lower testosterone in women is linked to increased knee and hand arthritis risk—no similar correlation found in men.

"We're seeing... more research about testosterone in women later in life potentially being also related to knee and hand arthritis, which are of course very common sites."
— Dr. Jocelyn Wittstein (07:42)

• Research Initiatives:
  • Dr. Wittstein describes a new study assessing early changes in cartilage resilience by sex and hormone status, including with and without hormone therapy.

"If anyone is listening... and wants to give me $3 million to solve this arthritis [gap] in men versus women, I have the study."
— Dr. Jocelyn Wittstein (09:32)

3. How Cartilage Recovers: The "Rebound" Study

[09:00-10:55]

• Study Design:
  • Evaluates cartilage's ability to rebound after compression, and how this relates to levels of sex hormones.
  • Hypothesis: Maintaining/supplementing estrogen may help preserve cartilage resilience.

"My hypothesis is that maintaining or supplementing estrogen levels will preserve that resiliency of the cartilage."
— Dr. Jocelyn Wittstein (10:22)

4. Exercise, Bone Density, and Fracture Risk

[12:05-14:43]

• EPHAPS Trial:
  • Long-term exercise program for osteopenic women (~55 years old at start) achieved a 50% reduction in fracture risk over 15 years.
  • While bone density gains leveled off with time, the reduction in fracture risk remained substantial, likely due to improved balance, coordination, and fall prevention, not just bone density improvements.

"What they found was over time the women who participated in the exercise group... had approximately 50% reduction in fracture risk."
— Dr. Jocelyn Wittstein (13:17)

• Key Insight:
  • Prevention isn’t just about bone density, but also balance, flexibility, and fall prevention.

5. Hormone Therapy Dosage: Nuances for Bone Health

[14:43-21:15]

• Optimal Estradiol Levels for Bone Protection:
  • Some evidence: 60 pg/mL+ greatly reduces bone turnover markers.
  • Others: Even levels as low as 20 pg/mL (e.g., with ultra-low dose estrogen like Menostar) confer protective benefits.
  • Response is individualized; some benefit more from lower doses.

"There's also data... showing that using [ultra-low dose estrogen] and even people not even exceeding a level of 20 picograms per milliliter protects bone and reduces bone loss."
— Dr. Jocelyn Wittstein (17:01)

• Measurement of estradiol is nuanced and variable among practitioners:
  • Menopause Society typically recommends treating symptoms, not aiming for a specific lab value.

"Just because you're protecting her from hot flashes does not mean her bones are necessarily protected"
— Dr. Mary Claire Haver (18:11)

6. Lifestyle vs. Medication: Returns on Investment

[23:15-25:26]

• Exercise:

  • 6 months of impact exercise: ~1% hip bone density increase.
  • 8 months of "Liftmore Protocol": ~3% lumbar spine increase.
  • Exercise benefits are multifactorial: insulin resistance, muscle mass, balance, brain health.

• Medications:

  • Bisphosphonates (e.g., Reclast): ~5% hip BD increase, ~7% spine, 70% reduction in spine fracture risk, 40% hip.
  • Hormone therapy: ~5% lumbar spine BD over 3 years, 30-40% reduction in fractures.

"If you just look at the scale of these things, 1% gain is a really big deal, 3% gain is a really big deal."
— Dr. Jocelyn Wittstein (25:05)

7. Dr. Wittstein’s Real-World Prevention Protocol

[27:17-30:17]

• Strength & Impact Training:

  • 2x/week heavier strength for large muscle groups (per LIFTMORE protocols).
  • Daily balance and flexibility.
  • Agility sequences built into cardio.
  • Impact activities (jumping, box jumps, even small step-downs).

• Dietary Focus:

  • High-fiber, high-variety, anti-inflammatory diet: vegetables, fruits, nuts, seeds, legumes.
  • Creatine monohydrate (5g/day) when combined with strength training.

"I recommend... a couple of days a week of heavier strength training, making sure you're doing large muscle groups... The balance work. I do some of that every day."
— Dr. Jocelyn Wittstein (27:33)

• Micronutrients:

  • Calcium: 1200 mg/day
  • Magnesium: 400 mg/day
  • Vitamin K: 100 mcg/day
  • Vitamin D: 600-2000 IU/day (not >4000 without reason)
  • Vitamin D may also help with joint pain, depression, and dementia.

• Supplements:

  • Hydrolyzed type 1 collagen (e.g., "Fortabone"): May provide measurable bone improvements.

8. Role of Vaginal Estrogen in UTI & Hip Fracture Prevention

[32:00-36:16]

• UTIs and Hip Fracture:
  • High rates of postoperative UTIs in women post-hip fracture, contributing to morbidity and mortality.
  • Many UTIs are present prior to falls/fractures.
  • Vaginal estrogen reduces UTI risk by 50%, and should be standard care for postmenopausal women with recurrent UTIs.

"We know that vaginal estrogen prevents urinary tract infections [by] 50%... If we could reduce those, [we] would definitely reduce hip fractures and urosepsis."
— Dr. Jocelyn Wittstein (34:10)

• Breaking News:
  • The boxed warning on vaginal estrogen products has been removed, confirming their safety and broader applicability for prevention.

9. Advocacy, Health Literacy, & Gender Gaps in Care

[37:02-42:51]

• Many women’s musculoskeletal pain is dismissed, especially when imaging appears “normal.”
• Self-advocacy and health literacy is crucial—Dr. Wittstein is active on social media to improve this.
• Dr. Wittstein’s book is pitched as a true “how-to” manual, loaded with exercises and recipes.
• Collaboration between disciplines (e.g., orthopedics and women’s health) is key to addressing health disparities.

"If people have awareness they can be more of an advocate for themselves... People just don’t understand their bodies."
— Dr. Jocelyn Wittstein (37:02)

• Encouragement to seek second opinions and track symptoms in context (joint pain, vasomotor, urinary symptoms may be linked to menopause).

10. Attitude Toward Menopause and Aging

[41:53-42:51]

• Dr. Wittstein shares she’s not fearful of menopause; she feels empowered by knowledge and urges others to seek education and adopt healthy lifestyle changes.
• She notes she’s changed her exercise approach with age but maintains positivity about her “second half.”

"I feel empowered by the knowledge I have. But I have a strange amount of niche knowledge and I love to share it with people."
— Dr. Jocelyn Wittstein (42:51)

Notable Quotes & Memorable Moments

• "We build the life you want by reclaiming your healthspan—not just the number of years you live, but the number of years you live well."
  — Dr. Mary Claire Haver (00:40, Intro context)
• "There is nuance... so if someone is having [side effects at a higher dose], you're probably not doing them a disservice to have them at the best tolerated dose."
  — Dr. Jocelyn Wittstein on estrogen dosing (19:42)
• "If you want to protect your bones, you have to do all the things—which includes the lifestyle."
  — Dr. Mary Claire Haver (21:05)
• "I swear, if we could reduce those [UTIs], we would reduce hip fractures and we would definitely reduce urosepsis."
  — Dr. Jocelyn Wittstein (34:09)
• "Stop siloing women's health to the bikini area."
  — Dr. Mary Claire Haver (41:00)

Key Timestamps (MM:SS)

• 04:17 — Pain modulation by estrogen/progesterone
• 05:19 — Fibromyalgia and menopause
• 07:31 — Role of testosterone in arthritis
• 09:00 — Cartilage rebound study
• 12:05 — EPHAPS trial: Exercise & fracture prevention
• 14:56 — Estradiol levels for bone protection
• 21:05 — Importance of comprehensive lifestyle
• 23:31 — Exercise vs. medication: outcomes
• 27:17 — Dr. Wittstein’s prevention protocol
• 30:25 — Micronutrients & supplements for bone health
• 32:00 — UTI, general urinary syndrome, hip fracture connection
• 36:16 — Removal of boxed warning on vaginal estrogen
• 37:02 — Advocacy for musculoskeletal symptoms
• 41:53 — Dr. Wittstein’s approach to aging and menopause

Resources and Where to Find More

• Dr. Jocelyn Wittstein on Instagram: @JocelynWittsteinMD
• Her Book: The Complete Bone and Joint Health Plan (Available on Amazon)
• Dr. Mary Claire Haver: @rmaryclaire | thepauzelife.com
• Upcoming Book by Dr. Haver: The New Perimenopause (Amazon preorder)

Summary compiled for listeners who missed the episode—actionable, evidence-based, and empowering for women seeking to live better, longer.