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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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

Member Spotlight: Alex Ladan on Finding Personalized Health Support After Competitive Athletics

In this Member Spotlight, we talk with Alex Ladan, former gymnast and current clinical researcher in women's health, about her journey with Bionic Health and how personalized health coaching has transformed her approach to nutrition, stress management, and overall wellness.

From Competitive Athlete to Health Researcher

Alex Ladan's relationship with health and fitness began early. As a former gymnast, she was accustomed to being considered "healthy" simply because she was athletic. "Growing up as an athlete, I was always just considered healthy," Alex explains. "I was never given true information about anything. It was like checking the box—you went to your physical, great job, how's gymnastics going? And that was it."

This experience ultimately led Alex to pursue kinesiology in undergrad, followed by a master's degree in sports science at UNC Chapel Hill. Now working in clinical research focused on women's health, Alex brings a unique perspective to her own health journey.

Why Bionic Health?

When Alex moved to North Carolina for her master's program, she faced challenges many young adults encounter: managing her own healthcare appointments for the first time while balancing a rigorous academic schedule.

"It was my first time moving away from home, which came with making my own doctor's appointments and keeping up with my health," Alex shares. "I really liked the flexibility of Bionic, but I also really liked the advisor portion of it."

What particularly appealed to Alex was Bionic's comprehensive approach that went beyond what traditional providers typically addressed: "It brought in the body composition piece, the exercise piece, all of the things that I feel like my traditional provider was never asking me about or never really understood because I was a gymnast and I was active, so that was good enough."

Evolving Goals and Personalized Support

One of the most valuable aspects of Alex's Bionic Health experience has been working with her advisor, Anna. Their relationship has allowed Alex to address changing priorities over time—from managing nerve pain and anxiety to developing sustainable nutrition practices and preparing for her upcoming wedding.

"I feel like my goals change every time I meet with her," Alex laughs. "I think originally I was experiencing some nerve pain, and I wasn't sure if it was related to physical activity or high anxiety levels."

Through regular check-ins with Anna, Alex gained important insights about stress management. "She helped me a lot with recognizing that from an outsider's perspective, like, 'Yeah, actually, this is not a normal level of stress.'"

Making Nutrition Personal

For Alex, nutrition was a complicated area due to her gymnastics background. "I was hyper-fixated on food for my entire upbringing," she explains. After years of not thinking consciously about nutrition during college, Anna helped her develop practical approaches to meal planning.

"She helped me a lot with understanding the importance of planning my meals before work...things that are maybe so small and mundane but ended up being really impactful for me."

Rather than following a one-size-fits-all approach, Alex and Anna crafted strategies that worked for her specific preferences. For instance, with meal prep, Alex notes: "I don't like to feel like I'm eating the same thing over and over again. I can prep fruits, vegetables, and starches, but I have to prepare my protein each day. Otherwise, mentally, I just don't feel like it's fresh."

Meaningful Progress Beyond Numbers

The true value of Alex's Bionic membership has been in the gradual, sustainable changes that have significantly improved her quality of life:

• Improved Energy Levels: By tracking her sleep and adjusting her alcohol consumption, Alex noticed dramatic improvements in her energy throughout the week. "I used to feel like I'm dragging my feet on Monday and Tuesday. But now I actually look forward to Sundays because I look forward to prepping my meals, and then I feel more energized going into the week."
• Better Work-Life Boundaries: With Anna's guidance, Alex transformed her morning routine. "I would wake up and immediately start mentally clocking into my job. Now I take more time in the morning for restorative activities, listening to a podcast during my commute instead of thinking about work."
• Personalized Approach to Protein: Rather than tracking all macronutrients, Alex focused specifically on protein intake. "It's actually funny that you asked specifically about protein because that is really the only thing that I keep track of each day."

Working Through Barriers, Not Around Them

One of the most valuable aspects of Alex's experience has been identifying and addressing barriers to her goals. For example, when discussing resistance training: "I remember myself being like, 'Well, this is the reason why that's not going to work.' And then we talk through it...recognizing what the barriers are is so, so key."

Alex appreciates the collaborative approach: "It's never just Anna being like, 'You need to do this, and if you don't do it by the next time we meet, then you failed.' It's more fluid and a conversation."

Advice for Health Professionals

As someone with a background in health and fitness, Alex offers valuable insight for other professionals who might think they already know enough:

"It is so hard for me to stay consistent with a routine of exercise and nutrition when I get really busy. This helps to have something consistent. Maybe in the periods where I'm falling through the cracks with my own nutrition and exercise, I have somebody there consistently."

Looking Forward

As Alex approaches her one-year anniversary with Bionic Health, she reflects on how her goals and motivations have evolved: "What I would have said at the beginning and what I would say now is so different—why I'm still a member has changed so much across time."

With her wedding approaching later this year, Alex continues to work with Anna on maintaining a healthy perspective amidst wedding culture pressures. "I told her upfront, 'I feel like this is going to become an issue, and it hasn't yet, but I can feel it starting.' And just having her to talk through that and talk through the things that maybe I'm seeing on the internet and to help get ahead of it has been really helpful."

Interested in learning how Bionic Health can support your health journey? Contact us today to learn more about our personalized approach to optimal health.

Interview Timestamps:

• 0:00 - Introduction
• 0:56 - Why Alex joined Bionic Health
• 3:02 - Initial health goals and expectations
• 5:54 - Meeting frequency with health advisor
• 8:02 - Stress management and physical symptoms
• 11:33 - Perspective changes as a Bionic member
• 15:08 - Insights from lab testing and body composition
• 16:50 - How Alex feels different since starting
• 24:34 - Advice for health professionals
• 34:15 - Conclusion

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