The Musculoskeletal Syndrome of Menopause: A Conversation with Orthopedic Surgeon Dr. Jocelyn Wittstein

"Why do my joints suddenly hurt?" "Is this frozen shoulder connected to my hot flashes?" If you're a woman in your 40s or 50s experiencing mysterious joint pain, you're not alone—and it's not just aging. In this eye-opening episode of Medicine 3.0, host Catherine Isaac delves into the hidden connection between menopause and joint pain with Dr. Jocelyn Wittstein, orthopedic surgeon and sports medicine specialist at Duke Health. They uncover the surprising truth about the "musculoskeletal syndrome of menopause" that affects millions of women but remains largely unrecognized in clinical practice.

Understanding Musculoskeletal Changes During Menopause

As women transition through perimenopause and menopause, the decline in estrogen levels triggers significant changes in the musculoskeletal system that many women—and even healthcare providers—may not recognize as being connected to hormonal shifts.

Dr. Wittstein explains that these changes fall into three main categories:

1. Increased Inflammation: Women experience more painful, inflamed joints and an accelerated rate of arthritis development. A prime example is frozen shoulder (adhesive capsulitis), which almost exclusively affects women aged 40-60.
2. Accelerated Bone Density Loss: During menopause, the rate of bone density loss increases from 1% to 2% annually, significantly raising the risk of osteoporosis and fractures.
3. Muscle Mass Challenges: With declining estrogen levels, it becomes more difficult to maintain and build muscle mass, leading to sarcopenia (muscle loss).

The Menopause-Arthritis Connection

Dr. Wittstein describes what she calls "menopause arthritis" as existing somewhere between mechanical wear-and-tear osteoarthritis and purely inflammatory arthritis. The combination of aging joints and increased inflammation creates a unique scenario where women have a 30% higher risk of developing osteoarthritis around age 50—a risk men don't experience until about age 80.

Estrogen receptors exist in the synovium (the tissue lining joints), and studies show that estrogen withdrawal increases inflammation while estrogen therapy can reduce joint pain and inflammation. Interestingly, Dr. Wittstein notes that even though 77% of women in the Women's Health Initiative reported joint pain, and hormone therapy reduced both the number and severity of painful joints, joint pain is not currently an FDA-approved indication for menopausal hormone therapy.

Frozen Shoulder: The "50-Year Shoulder"

Frozen shoulder deserves special attention as it disproportionately affects women during the menopausal transition. Dr. Wittstein explains that this condition:

• Usually occurs without injury or trauma
• Begins with aching that progresses to significant pain and stiffness
• Can take up to two years to resolve completely
• Is so common in menopausal women that some cultures have termed it the "50-year shoulder"

The condition is so strongly associated with hormonal changes that when Dr. Wittstein sees a man with frozen shoulder, she screens him for diabetes, as that's typically the only context where men develop this condition.

Treatment Approaches

For frozen shoulder, Dr. Wittstein emphasizes early intervention:

• Steroid injections into the joint can be "magical" when administered within the first three months of symptom onset
• Physical therapy may worsen symptoms if attempted during the painful inflammatory phase
• For severely "frozen" shoulders that limit daily activities, surgical intervention may be necessary

Dr. Wittstein also discusses the complex relationship between menopause and musculoskeletal health, emphasizing two factors under individual control:

1. Exercise: A balanced approach that includes:
   • Strength training (resistance exercises) to support muscle and bone health
   • Cardiovascular activity for heart and brain health
   • Impact exercises (like jumping) to stimulate bone density
   • Balance training to prevent falls
2. Diet: An anti-inflammatory approach focusing on:
   • Minimizing red meat, fried foods, and processed foods
   • Including at least 25 grams of fiber daily from whole grains
   • Consuming a variety of fruits and vegetables for their antioxidant properties
   • Incorporating omega-3 fatty acids from fish, walnuts, and chia seeds

Resources for Further Learning

For those looking to learn more about maintaining musculoskeletal health during menopause, Dr. Wittstein recommends:

1. The Complete Bone and Joint Health Plan - Dr. Wittstein's own book co-authored with registered dietician Sydney Nitskorsky, providing comprehensive guidance on nutrition and exercise for bone and joint health.
2. The Musculoskeletal Syndrome of Menopause - A medical paper co-authored by Dr. Wittstein and Dr. Vonda Wright, available through the journal Climacteric.
3. The Science of Joint Health: How to Keep Your Bones Strong for Life - Dr. Wittstein's recent appearance on Gabby Lyon's podcast (Episode 147).
4. The M Factor - A recommended film about menopause that provides additional context and education.
5. Ortho Info - A patient-friendly resource from the American Academy of Orthopedic Surgery offering guidance on various orthopedic conditions.

The Takeaway

This episode highlights how the musculoskeletal impacts of menopause remain underrecognized despite affecting millions of women. Dr. Wittstein's expertise sheds light on why women experience particular joint, bone, and muscle challenges during this life stage and offers practical strategies for maintaining musculoskeletal health through the menopausal transition and beyond.

By understanding these connections and taking proactive steps with exercise, nutrition, and appropriate medical interventions when needed, women can better navigate the musculoskeletal challenges of menopause and maintain mobility and function for years to come.

Episode Timestamps

For easy reference, here are key moments from the conversation:

• 02:33 - Definition of musculoskeletal syndrome of menopause and its three main categories
• 05:27 - Explanation of menopause arthritis vs. other types of arthritis
• 10:07 - Dr. Wittstein's explanation of frozen shoulder
• 12:14 - Why frozen shoulder predominantly affects women
• 24:03 - Treatment options for frozen shoulder (steroid injections)
• 31:41 - Discussion about muscle loss during menopause
• 33:11 - Connection between muscle mass and bone density
• 39:42 - Explanation of hip bursitis and prevention strategies
• 45:21 - Anti-inflammatory diet recommendations
• 48:41 - Resources for further learning about musculoskeletal health

Listen to the full episode of Medicine 3.0 with Dr. Jocelyn Wittstein to learn more about managing musculoskeletal health during menopause.

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Optimize Your Fitness Journey with Performance Testing

In this insightful episode of the Medicine 3.0 podcast, Bionic Health advisors Kelly and Anna dive into the world of performance testing and how it can revolutionize your fitness journey. Whether you're a seasoned athlete or just beginning to incorporate exercise into your routine, establishing a baseline through comprehensive testing provides invaluable data to guide your path toward optimal health.

Why Performance Testing Matters

Performance testing gives you a clear picture of where you stand across multiple fitness domains. As Anna explains, "We recommend it to get a baseline of where our members are at currently in their fitness. They get percentiles, and that's helpful to get a knowledge of where they're at and where they should go."

This data-driven approach transforms abstract fitness goals into tangible metrics that can be tracked and improved over time. By establishing these baselines, your Bionic Health team can create truly personalized recommendations tailored to your specific needs.

What to Expect During Testing

The comprehensive performance testing protocol at Bionic Health includes:

• VO2 Max Testing - The gold standard for measuring cardiorespiratory fitness, conducted on a stationary bike
• Strength Assessments - Including bench press and leg press for maximal strength evaluation
• Muscular Endurance Tests - Push-ups and dead hang measurements
• Hand Grip Strength - An excellent indicator of overall body strength
• Mobility Assessments - Evaluating shoulder, hip, ankle, and knee mobility
• Vertical Jump - Measuring power, which tends to decline most rapidly with age

Many members feel nervous about performance testing or believe they need to "train before they train." Kelly and Anna emphasize there's no need to worry—the purpose is simply to establish a starting point. "There's really no pressure to get any certain score right off the bat," Anna reassures. "It's just getting more information that's valuable for how to improve looking forward."

The Science Behind VO2 Max

The VO2 Max test measures how efficiently your aerobic system uses oxygen during maximal exertion. This data helps determine your personal heart rate zones for training, allowing for more precise workout programming. As Kelly explains, the test also provides insights into metabolic flexibility—your body's ability to switch between different energy sources during exercise.

Tracking Progress Over Time

Most members who return for follow-up testing see significant improvements across multiple metrics, particularly in VO2 Max and bench press strength. The recommended retesting frequency is every 6-12 months, allowing sufficient time for meaningful changes to occur while keeping you accountable to your fitness goals.

Beyond the Numbers

Performance testing isn't just about achieving high percentile rankings—it's about optimizing your health for longevity and quality of life. As Anna notes, "A lot of our members join Bionic with the goal of aging comfortably and being able to do the things that they love long-term."

Even members who regularly strength train often discover opportunities for improvement in their programming. The testing process frequently reveals needs for more strategic progressive overload or better balance between different fitness domains.

Take the First Step

If you've been hesitating to schedule your performance testing session, Kelly and Anna have one clear message: don't wait. The valuable information gained from these assessments will help you work more efficiently toward your goals, whether you're just starting out or looking to optimize an existing routine.

"Performance testing is valuable for all of our members," Anna concludes. "It gives a lot of valuable information on how to improve in all of these different areas... we can really work with you one-on-one to slowly add in training or adjust to your specific goals."

Ready to establish your fitness baseline? Contact your Bionic Health advisor today to schedule your performance testing session.

Podcast Timestamps:

00:08 - Introduction and welcome
00:58 - Overview of performance testing benefits and protocols
03:53 - VO2 Max testing explained
09:53 - Using heart rate data for personalized training zones
12:50 - Strength and grip testing protocols
16:25 - Importance of mobility for healthy aging
18:55 - Vertical jump testing and power assessment
20:06 - Plyometric training discussion
23:55 - Recommended frequency for retesting
25:19 - Balancing different training modalities
26:42 - Final thoughts and encouragement for members
29:05 - Closing remarks

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Fighting Heart Disease Like Cancer: A Conversation with Dr. Mike McConnell

In this episode of the Bionic Health podcast, Dr. Jared Pelo sits down with cardiologist Dr. Mike McConnell to discuss a revolutionary approach to heart disease prevention. Dr. McConnell, who authored the book "Fight Heart Disease Like Cancer," shares his expertise on early detection, risk assessment, and proactive treatment strategies.

Rethinking Heart Disease

Dr. McConnell challenges the traditional view of heart disease as simply a "plumbing problem" where arteries gradually get clogged. Instead, he frames it as an active biological process more similar to cancer, where growths develop in the arteries that supply blood to the heart. These growths can remain asymptomatic until a blood clot forms, potentially causing a sudden and catastrophic event - as happened with Dr. McConnell's own father-in-law.

"We're in this amazing era of tools, both for prevention from a lifestyle perspective and from a medication perspective that we can really stop this," Dr. McConnell explains. "We shouldn't be having people who have blockages and need stents or bypass surgery or having heart attacks."

Early Detection and Screening

The conversation explores various screening methods for heart disease, including:

1. Risk Assessment Scores - Evaluating factors like age, gender, cholesterol levels, blood pressure, diabetes status, and smoking habits
2. Coronary Calcium Scans - A rapid CAT scan that detects calcified plaques in arteries
3. CT Angiograms - More detailed imaging that shows both calcified and soft plaques
4. Retinal Imaging with AI - An innovative approach using eye scans to detect cardiovascular risk

Dr. McConnell highlights the importance of early screening, especially for those with a family history of heart disease. He also discusses how these imaging tools can help motivate patients to take their risk factors seriously and adhere to treatment plans.

The Essential Eight for Heart Health

The American Heart Association's "Life's Essential Eight" provides a framework for heart disease prevention:

1. Blood sugar management
2. Cholesterol control
3. Blood pressure regulation
4. Regular physical activity
5. Healthy diet
6. Avoiding smoking
7. Maintaining healthy weight
8. Getting adequate sleep

Dr. McConnell adds two more important factors to this list: limiting alcohol consumption and managing stress.

Combining Lifestyle and Medication

While lifestyle modifications are important, Dr. McConnell acknowledges their limitations. He advocates for a combined approach:

"The more you can do with lifestyle, the less you need medication. So that's sort of part of the bargaining or discussion that we have," he explains.

Dr. McConnell notes that only about one in three eligible people in the US are taking cholesterol-lowering medication, even though guidelines would recommend it. He sees tremendous opportunity in increasing awareness and proactive treatment.

Looking to the Future

Dr. McConnell shares exciting developments in heart disease prevention, including using AI to analyze retinal images for cardiovascular risk assessment. His company, Toku, is working to bring this technology to market, which could potentially identify at-risk individuals during routine eye exams.

"Not everybody's day to day, unlike me, most people are not thinking about their heart disease risk every day," he says. "Why not when you're making contact with optometry, ophthalmology, getting an eye exam, that there's an opportunity to say, look, your retina looks like you have some increased risk."

For those interested in learning more, Dr. McConnell's book "Fight Heart Disease Like Cancer" and website (FHDLC.info) provide additional resources and guidance.

As Dr. Pelo notes at the conclusion of their conversation, following Dr. McConnell's advice on screening and prevention could save countless lives - perhaps the greatest impact a physician can have.

Timestamps:

00:00 - Introduction and welcome
00:22 - Dr. McConnell's background and career journey
03:09 - How Dr. McConnell decided to become a physician
05:35 - Framework for understanding heart disease
09:18 - Personal stories motivating heart disease prevention
10:30 - Heart disease screening approaches and risk assessment
14:58 - The "Life's Essential Eight" for heart health
19:11 - Retinal imaging for cardiovascular risk assessment
24:03 - Expanding heart health screening through eye exams
27:08 - Using imaging to motivate patients
30:05 - Balancing lifestyle changes and medication
33:39 - Advanced imaging: CT angiograms and soft plaque detection
40:15 - Where to find more information
41:22 - Closing thoughts