Clinical Steps for Bone Health Optimization

Welcome to Everyday Wellness Podcast. I'm your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. This is the start of a new Thursday series called The Midlife Minute that is really designed to address listeners questions in a little bit longer length of time and or deeper dive into topics . Ideally we're going to keep these podcasts under twenty minutes. Occasionally we make over to thirty , but I'm trying to reinforce some key concepts and ensure that I'm addressing listeners' questions in a way that's really helpful. So the questions that I will be addressing topics are going to be items that I'm being asked over and over and over again . I hope you enjoy this series. Please share it with your friends. And as you know, you can always send your questions to support at cynthiatherlo. com. I appreciate each and every listener . Okay friends , this is the latest Midlife Minute and given the viral nature of a recent combined joint post that Dr. Darshan Shaw and I did together highlighting some of the content that we talked about on our most recent podcast together . It is clear to me that my community wants to learn more about the interrelations between oral contraceptives, depop era , and how this impacts bone health over time. And I'm going to be referencing some research that will be research in the show notes that you are more than welcome to just click on and you can read more about this. We know that one in two menopausal females will experience a fracture due to osteoporosis in her lifetime . And the medical community at large continues to treat osteoporosis as a disease of aging rather than a disease with decades long roots. I said it, your bones that you make or don't make as a child and young adult have a huge net impact on the quality of your bone throughout your lifetime. For millions of women, the bone health story begins in our teens and twenties when we are prescribed hormonal contraceptives during the most critical window of skeletal development that our bodies will ever experience . Again , we aren't talking about this enough. My generation , all my Gen X women , we were put on oral contraceptives more than likely not for contraception, but to address irregular periods, heavy periods, spotting periods, painful periods , everything that you can imagine under the sun, including skin . So many of my friends, many of the women that write into the podcast tell me about they were started on oral contraceptives because they had terrible acne . These drugs can be life changing. I want to be really clear. I am not anticontraception. I am pro female fully informed consent, which none of us got because I don't even think our prescribing physicians probably knew the long term net effect of some of these drugs. We're going to cover the research around oral contraceptives and depravera and bone development , the prescribing trends that put millions of girls, millions of girls and young women on these medications during geek bone mass accrual , the immune system and autoimmune risks which I, talk about all of this in my book, but we're going to dive a little bit more deeply into it right now . And these risks are under discussed. They're not mentioned. There's no fully informed consent. I know because I have colleagues that are still prescribing oral contracept ives, and they're mentioning they weren't even aware of some of these risks. I mean, this research has been brewing, but it has not been an area of focus . And the other side of that is the gut microbiome consequ ences that connect everything to my book. My book The Menopause Gut, we spent an entire chapter talking about bone health. And this is definitely one of those areas in the book where when podcsaster or the media would ask what was something that you found really surprising while you're writing the book? It's the bone stuff, and it's the trauma stuff, aging the ovaries. Those two things completely shocked me. I learned so much while writing the book. And I want to be really, really clear young women, women in general need good access to contraception. That is not what this discussion is about. I'm not demonizing it. I just want women to think and I want them to think about the duration of therapy that they're choosing . This is all about giving women they deserve to have had decades ago and were never given. And how many of you have mentioned to me you have children the same age as my own . Of course if they're your daughters, they're females female daughters and how you are trying to navigate having conversations with your children , I think first and foremost, if they need contraception, they need contraception. But I just think I want us to be thoughtful about understanding the long term ramific ations of young women being kept in a low hormone state. Okay . So let's talk about peak bone mass, the window that determines lifetime fracture risk. This is really . Up to ninety five percent of peak bone mass is achieved by age eighteen and females. And the teen years are a critical period for acquiring peak bone strength, with the most rapid accrual of bone mineral density happening six months after peak height velocity . So I stopped growing heightwise when I was twelve . So at the age of twelve, I was the height I have been my entire adult life or teen and preteen life . So at that point , my peak bone neural denserly occurred six months after my peak height and continues even after final height is achieved. So understanding that young women are going to hit their peak bone mass accrual within that next six to twelve months after they are done growing heightwise. What this means clinically is anything that interferes with bone accrual during adolescence and young adulthood does not just affect bone at that moment . It potentially determines the ceiling of skeletal strength for the rest of a woman's life. I know that sounds a little dramatic, but I want to be really clear . I want everyone to think about bone differently. It is not just about a skeleton. It is a living organ and just like the use of GLP Ones is on the rise, and I think these drugs in many instances are giving patients and prescribers a newfound freedom that maybe they've never had before. But when we lose fat and we lose muscle, we are also losing bone . An increase in peak bone mass by one standard deviation would reduce fracture risk by fifty percent . Making peak bone mass acquisition one of the most important consequential health outcomes of adolesc ence in young adulthood, full stop . The hormonal architecture of bone building , which includes the estrogen that our bodies make endogenously and progesterone work together during the normal menstrual cycle to support bone formation. So estrogen drives the calcium reabsorption and mineralization process while progesterone stimulates osteoblast activity on the bone building site of the remodeling equation. So they are constantly working . Estrogen builds bone , progesterone is really working focused on bone breakdown, but they're designed to work synergistically . We know that other hormones and growth hormone and IGF one interact throughout puberty to modulate bone size, our mineral content and micro architecture . And this is why it's important for young women and I'm talking about young women six to twelve that they are physically active . We have a generation in many instances where kids are just not as active. My generation, we were kicked outside and expected to stay outside until we had lunch and dinner . At least that's how my parents felt. That we were expected to be outside, playing, being physically active. That's not always the case. I think it's extreme. We have kids that are probably very sedentary and then we have kids that are probably very physically active, whether it's gymnastics, soccer, volleyball, law, whatever it is that they're doing. And there's three mechanisms through which these hormonal contraceptives, oral contraceptives and depot affect developing bone . So I'm going to get a little bit sciencey, but bear with me , suppression of our internal estrogen , which is endogenous through hypothalamus pituitary ovarian axis inhibition. So this is what prevents pregnancy. Oral contraceptives replace natural synthetic estrogen . A lot of times it's ethanol estradial, which is structurally different from the estrogen our body makes and does not produce the same bone building signal. This is important . So yes, oral contraceptives can suppress ovulation , but that type of estrogen is not body identical to estrodial, which is the predominant form of estrogen our bodies make until we go into menopause . Suppression of progesterone, the type our body makes endogenous, removing the natural luteal phase progesterone pulse eliminates one of the primary osteoblast stimulating signals in the developing skeleton. This is important . Something I hear constantly from women in our community and something I understand personally is this nothing about your effort has changed and yet our bodies are responding differently. Your mid section feels different, your blood sugar is much less stable , and your cravings may have shifted . And let's be honest, your energy probably isn't what it used to be. As a nurse practitioner with over twenty five years of experience , I want to be completely transparent with you about why . Estrogen is one of the body's master regulators of metabolic health. It influences how we store fat, how our tissues respond to blood sugar changes, and how eff iciently our metabolism functions at the cellular level. As estrogen shifts during perimenopause and menopause, the same lifestyle choices, diet, exercise, sleep genuinely do not produce the same result s. This isn't a failure of effort. It's a precise biological transition , and most solutions don't address the root causes. That's why I want to tell you about mighty acute hormonal metabolic control. It's formul ated with SEQL, which is a highly bioavailable phytoestrogen that supports healthy estrogen signaling. We know that eighty percent of women cannot produce SEQL naturally because it requires specific gut bacteria most of us just do not have. This formula bypasses this entirely. It also includes a particular bacterial strain Breva, which works via the gut hormone access to support estrogen pathways and help ease occasional bloating and chromium to support healthy blood sugar balance. This is a targeted cellular support for the transition we are all in and is designed specifically for women in perimenopause and menopause and built around what actually is effective . Go to w ww dot myoQ dot com slash cynthia and get ten percent off your first order . Again, that's MIT OQ . com slash cynthia to get ten percent off your first order. When we talk about perimenopause and menopause, the conversation often focuses on hormones. And let me be clear, hormones absolutely matter . But one thing I think we don't speak enough about is muscle . Women can lose significant muscle mass and strength during the perimenopause to menopause transition and that loss impacts far more than just our appearance. Muscle influences metabolic health, insulin sensitivity, mobility, health y aging, and more. And the good news is there's so much we can do about it. Strength training and adequate protein intake are critically important . And increasingly, we're learning about the role mitochondrial health plays in maintaining muscle quality as we age . That's why I've been paying attention to the science behind Mitopure from Timeline. Mitopure contains Uralithina, a clinically studied nutrient that supports mitochondrial renewal through a process called mitophagy. Think of it as supporting the energy systems that help keep your muscles functioning at their best . For women who want to remain strong, capable , and resilient for decades to come, this is an essential area of research worth knowing about . Visit timeline dot com and use code Cynthia for twenty percent off your order. Again, that's timeline . com and use code Cynthia for twenty percent off your order. This is one of my foundational supplements that I never miss. As I mentioned , estrogen's really important for building up and progesterone generally is responsible for osteoclastic activity where it's breaking bone down, but they work together synergistically . We also know that while taking oral contraceptives and using depot that we get suppression of IGF one . And this can compromise the expected gains in adolescence by altering estrogen and IGF concentr ations, and the use of these medications have been associated with slower accrual of bone mineral density and increased fracture risk in some studies. Okay, that's the sciencey stuff. Let's talk about prescribing trends because this is actually what I found really interesting. What are the prescribing trends over the past thirty years? This really impacts my generation , my generation that we've started on oral contraceptives in our thirties nineties , and beyond . So nearly twelve million US women use oral contraceptives and oral contraceptive use is highest in women under the ages of thirty. Not surprisingly, right? A critical time for bone mass accrual . According to US data, forty point five percent of female teenagers aged fifteen to nineteen years are sexually active. And of those, fifty two percent had at least some point used to birth control pill and eighteen percent an injectable contraceptive agent, probably something like Depop Prevera. The prescribing trend over three decades pill use among teenage women declined in the early nineties, rose between nineteen ninety five and two thousand two and continued rising through the two thousands. A Thompson Rooter study found the number of commercially insured teens filling birth control prescriptions from two thousand two to two thousand nine increased sixty three percent while prescriptions for those with Medicaid rode thirty eight percent. It's estimated that eighty percent of all women in the US have used oral contraceptives. I'm shocked it's not higher, and the use may prevent attainment of maxim al peak bone mass in young women, thus increasing the risk of osteoporosis later in life. I think this is on a case by case basis. I think this is also highly dependent on how long you are on oral contraceptives. I want to be really clear. Someone taking oral contraceptives for six, twelve months is very different than someone that was taking it for ten, fifteen, twenty years . The non contraceptive prescribed in reality is that hormonal contraception is prescribed commonly to adolesc for many reasons from pregnancy prevention to treatment for acne , painful periods, heavy periods, meaning millions of young women are prescribed these medications for reasons entirely unrelated to contraception with bone health consequences that were rarely if ever discussed. If you are listening to this podcast and your prescriber talk to you about these bone health issues before they gave you a prescription, please let me know. I haven't met anyone yet. And I don't even want to sound like I'm being critical of my peers. I'm just saying that I think we didn't know enough earlier and I think that just like many things in medicine , it's not studied well enough. So in nineteen ninety three, when women started being able to participate in research again , they didn't by then, most of us had been on oral contraceptives for many years before that even happened. I think I started probably in gosh nineteen eighty nine, so long, long time ago. Okay , here's the critical nuance as it pertains this conversation . Adolescent women are prescribed combined oral contraceptives for non contraceptive indications. As I mentioned, acne, cramps, heavy cycles, irregular cycles , and there's a need to understand the potential relationship of combined hormonal contraceptives with adolescent women's peak bone mineral density . Full stop . We need to be thinking about what it's like keeping a young woman in a low estrogen state. Okay , so depot priva was something that came out when I was in college. It's been prescribed to over a million adolescent girls. Its main use is for contraception . Although some people are using it for menstrual cycle manage ment, it's been on the market since nineteen ninety two, which was when I was in college, meaning an entire generation of women received it during their peak bone building years before the FDA issued its black box warning in two thousand . From nineteen ninety two to two thousand four , that black box warning was not available . So I was always taught that this was a great option for people who are not to remember to take an oral contraceptive, for people that want to set it and forget it. They get an injection several times a year . You're talking about twelve years of existence before we got a black box warning about the bone effects, which we know if it's used for less than two years, that's supposed to be reversible . The FDA in two thousand four placed a black box warning on depot, stating the that woman who uses it may lose significant bone rinal density. Bone loss is greater with increasing duration of use and may not be completely reversible . And it is unknown if the use of depot during adolescence or early adulthood , again a critical period of bone acquisition will result in reduced peak bone mass and increased risk of future osteoporosis . That's pretty significant . The Blackbox Morning was expanded in May of two thousand six to specifically include young adults aged eighteen to twenty four , acknowledging that the bone risk extended beyond adolescence into the young adult critical window . Wow , right. Like that blows your mind. Okay , let's talk about oral contraceptives and bone and what the research says. If you're watching the live video, you'll see me looking down and it's because I organized, I've taken a couple days to organize all the research beyond what I did in my book, which when you're writing a chapter for a book, you have to be very concise and succinct. Whereas when I'm doing a podcast specific to this topic, I can expand upon what we're talking about . Okay , the research on oral contraceptives and bone is nuanced and dose dependent . This is where the honest complexity lies and where most clinical decisions either oversimplify or avoid the conversation entirely. Let's be honest. The vast majority of reviewed studies showed oral contraceptives containing twenty to thirty microgariums of ethanol estradol. Remember that's synthetic , interfere with acquisition of peak bone mineral density in adolescence in young adults, maximizing bone math in youth. Youth is touted as the best strategy to offset the natural losses of aging and the malenopaus transition , and not achieving maximal peak, bone, mineral density is an independent risk factor for osteoporosis. Again, I'm going to keep touting the same horn. My generation was never talked to about these things . The other thing is, it's interesting there's this low dose pill issue . There was been a trend towards lower dose formulations driven by concerns about clot risk or cardiovascular risk may have inadvertently created a greater bone risk for young women. So it's always this kind of very delicate balance between risk reduction and also wanting to keep symptoms at bay . We know prolonged use of today's oral contraceptives , particularly those containing less than thirty micrograms of ethanol estradal may adversely impact young adult women's bone density. nineteen to thirty year old women peak bone mineral density was lower with longer oral contraceptive use for spine and whole body and was lowest for more than twelve months of low dose oral contrace ptives for the hip, spine and whole body. So this means if you're taking long , many years of oral contraceptives, you miss out on those peak bone mass years . When looking at an adolescent versus young adult distinction at twelve to twenty four months after stopping oral contraceptives, teens who had taken thirty to thirty five milligram pills still gained less bone density in the spine than female teenagers that did not use the pill, and young adult women, both oral contraceptive use and discontinuation were associated with bone mineral density losses or smaller gains relative to non users . Research from Purdue University found that young women who take oral contraceptives in exercise may actually have increased risk of bone loss in the hip and spine compared to women who take the pill and are sedentary . Suggesting oral contraceptives may cancel some of the bone building benefits of exercise , which is a finding with profound implications , right ? For how we counsel active young women . Interestingly enough, women who take oral contraceptives can counteract bone loss by making sure they have enough calcium in their diet, not supplements, but calcium rich foods, especially early in life. The results suggest that the loss for this group can be prevented by increasing calcium intake, again from calcium rich food . This is clinically significant, oftentimes not discussed because no prescribers are counseling young women on calcium adequacy when initiating oral contraceptives . If your practitioner or prescriber did, please let me know because I feel like we need to do a shout out for them. Okay . The recovery question. This is what I keep thinking about inevitably , I do not want this podcast episode to cause stress . There's nothing we can do about what happened in the past, right ? I just want us to be aware of this and be talking about it so that our younger women are aware and so that we can counsel them on what they should be doing to help offset this . Okay . One of the most common clinical reassurances women receive is that any bone effects from hormonal contraceptives are reversible after stopping . The research is less reassuring than that framing suggests. This is interesting. Both oral contraceptive use and discontinuation were associated with bone mineral density losses or smaller gains relative to non users with the clinical significance of these results regarding future fracture risk remaining unknown . The permanent question is, if a young woman's peak bone mass was lower than her genetic potential because of years of oral contraceptive use during critical bone building, no amount of recovery after stopping can raise her above the ceiling that she never reached. This is where I think the lifestyle piece really becomes important . We're going to shift gears and talk about Depot because many of you have shared that you took depot at some point . Depot is more bone damaging than oral contraceptives and I'm going to explain why. Depot works by suppressing ovulation through sustained high dose proges in. So progesterin, it's medroxy progesterone acetate or MPA. This is synthetic progesterone that suppresses the hypothalamus pituitary ovari aantxis so effectively that it creates a pharmacological state resembling no ovulation . The profound estrogen suppression that results from depot , it's more complete than the produced by combined or al contraceptives is the primary driver of its bone consequences . Unlike combined oral contraceptives, which provides some ethanol estradol as a partial estrogen signal, Depot provides virtually no estrogen ic activity. Remember we talked about estrogen as bone building, leaving developing bone without the primary hormonal driver of mineral accrual . In two thousand four, as I mentioned, the FDA required a black that box war ning be placed on the depot labeling , stating that women who used it may lose significant bone mineral density. Bone loss is greater with increasing duration of use and may not be completely reversible This is an injection. For anyone that's not familiar, I apologize that I didn't disclose that. Oral contraceptives are obviously an oral pill, depot purveyor is an injectable contraceptive . The FDA recommends that depot should be used as a long term birth control method only if other birth control methods are inadequate. The fracture data is actually alarming . A retrospective cohort study to assess the association between depot and the incidence of bone fract ures was conducted in three hundred twelve thousand female contraceptive users in the UK . The incident rate ratio for any fracture during the follow up period was one point four one meaning, that depoters us had a forty one percent higher fracture risk than non depot contraceptive users . Here's the reversibility question for Depot. Although the use of depos ciated with a loss of bone m eral density, current longitudinal and cross sectional evidence suggests that recovery of bone mineral density occurs after discontinuation. This is certainly reassuring , right? However, no high quality data answers the important clinical question of whether depot affects fracture risk and adolescents and adults later in life . Again, really important to think about this from the perspective of a developing skeleton in a younger person . Okay, ACOG, which is the American College of Ghnecology on Mic iology and its limitations, their position is that bone race should not prevent practitioners from prescribing it or continuing use beyond two years is a based on a partial recovery data, but it does not address the peak bone mass ceiling question for adolescents who use depot during critical developmental windows. All right, we're going to pivot and talk about the immune system and autoimmune disease risk. Really important conversation why do hormonal contraceptives affect our immune function? I spent a whole chapter in my book talking about the immune system. Immune system is complicated. I'll be the first person to say, as I was writing the book, I was whiteboarding the immune system, reminding myself, reaclimating myself to it . We know that our sex hormones are profound modulators of the immune system, especially estradiol. There are receptors throughout every immune tissue, including our thymus, our spleen, our lymph nodes, and virtually every class of immune cell. Oral contraceptives create a pharmacolog ic state that maintains sustained hormone levels resembling the post ovulatory luteal phase . This sustained environment has measurable effects on immune cell populations, cytokine, which can be inflammatory production, and the TH one to TH two immune balance . I talk about this a little bit in the book . With the aging process, we get changes in immune system function, which makes us more susceptible to certain types of infections, less vaccine efficacy, etc . Hormonal contraceptives disrupt typical monthly rhythms by maintaining elevated hormone levels , consequently sustain the associated peak and continuous window of vulnerability for infection characterized by suppression of specific immune globulins and lactopherin . When we're talking specifically about autoimmune disease risk, we know women are at greatest risk because of our sex or gender. We're four to five times more likely to develop autoimmune conditions in midlife. And based on a comprehensive lit review examining over one thousand eight hundred titles and three hundred fifty two papers, substantial evidence exists linking the use of combined oral contraceptives to a lower incidence of hyperthyroidism but an increase in multiple sclerosis , ulcerative colitis, crohns , systemic lupus and interstitial systitis . Women who take hormonal birth control are found to be approximately thirty five percent more likely to develop MS, fifty percent more likely to develop lupus and faced up to three times the risk of developing crons compared to women who never took hormonal contraception . Combined oral contraceptives have complex, sometimes contradictory effects on autoimmune disease, they can worsen the situation in women with systemic lupus and with antiphospholipids syndrome, conditions in which they are contraindicated . Evidence of effects on multiple sclerosis is conflicting and risks may vary depending on the progestin use, so progestin being the synthetic type of progesterone . Interestingly enough, not all progestins are equivalent in their immune effects. So again, synthetic progesterone Several lines of investigation indicate progesterone and synthetic progesters impact the risk of autoimmune disease and immune mediated injury in different ways depending on their concentrations . Because progesterone respect receptors are on different immune cells, organs and tissues , in the progesterone only contraceptive picture , progesterone only contraceptives are linked to progesterone dermatitis and in one large developing world concurrent cohort study, that's a bit of a mouthful, are studied with increases in eczema, contact dermatitis, and related conditions alope,cia , acne, and urticaria, which are hives. Now, I mentioned in the book I talk a little bit about the semantics with the immune system. I'm just going to talk about this real quickly and then we're going to dive into the gut microbiome . The TH so TH one to TH two immune shift. So it's THE THELEPER cells. Synthetic hormones and oral contraceptives promote a TH two dominant immune environment . This is associated with reduced cellular immunity but enhanced humoral immunity, creating conditions that may increase susceptibility to certain autoimmune conditions with a sustained ludial phase immune suppression, the natural menstrual cycle creates a variation in immune competence . Oral contraceptives completely obliterate this rhythm. Maintaining a continuous immune state that removes the natural protective effects, the immune system has evolved to operate within. We also know that oral contraceptives alter gut microbial composition and gut barrier integrity and since seventy percent of the immune system resides in around the and gut, the gut dysbiosis from oral contraceptive use is also an immune dysregulation story . So how many of us were on long term oral contraceptives to fix a myriad of menstrual cycle issues or skin issues or plus or minus also contraception , and then we didn't even know that this was also dysregulating our immune system and putting us at greater risk for developing autoimmune conditions. Let's touch briefly about the gut microbiome consequences . Okay . The gut microbiome, as I've talked about in my book, is a central mediator between the hormonal effects of oral contraceptives and their downstream immune, inflammatory, and systemic health consequences . Oral contraceptives reduce gut microbial diversity, kind of like what happens in menopause and perimenopause. They disrupt the aestrobolum , just like perimenopausa menopause. They increase leaky gut, just like perimenopausa menopause. They alter bile acid metabolism just like perimenopausa menopause, and create conditions that favor candida and bacterial overgrowth . Wow, right? So imagine you're on oral contraceptives for twenty years and then you slide into perimenopause, you're already at a disadvantage. I certainly was. I had no idea until I started writing this book. The Stanford Medication Microbiome Research published in twenty twenty five confirms that drug induced microbiome disruption follows predictable ecological rules and hormonal contraception are among the medications with the most significant and consistent microbiome effects . There is also an IBD connection revisited. There was a study in Gut found that oral contraceptive use was associated with a significantly increased risk of Crohn's. The mechanism involves oral contraceptive driven changes in the gut microbiome . Composition increased intestinal permeability, which is leaky gut and alter mucosal immune system function , which leads to inflammatory bowel disease. Interestingly enough, Depot's microbiome picture, the effects on the vaginal microbiome are well documented. It alters the vagin al microbiome community in ways that reduce protective lactob that I'm going to say that over again, edit that out. It alters the vaginal microbial community in ways that it reduces protective lactobacilli and increases susceptibility to bacterial vaginosis and other infections . The gut microbiome effects from depot are less steady than its vaginal microbiome effects, but the profound estrogen suppression produces and removes one of the primary hormonal signals that signals gut microbial diversity and asterobulum function . So again, it's a trade off. You take these drugs and it has a large net effect on the microbiome . And then we talk about the intersection with bone. The gut microbiome, as I talked about in my book, is the regulator of bone metabolism. Butyrite producing bacteria support bone formation through parathyroid hormone signaling and calcium absorption efficiency through short tame fatty acid production and gut pH. So all you people , not my listeners, of course, you know better, all the people out there that say that fibers are relevant , it's very important because it is instrumental in creating short chain fatty acids, including butyrate, and butyrate is involved in osteosupportive mechanisms to avo id as much bone breakdown . So getting back to what I was saying , we know that taking depot drives gut dysbiosis, compounds the direct bone effects of estrogen suppression through a second gut mediated pathway . So it's speaking to it from two different directions . The multi gener ational gut consequence of taking oral contraceptives and depot during adolescence . We're all in perimenopause and menopause now, and we're experiencing the natural microbial diversity decline of the menopausal transition on top of a gut ecosystem that may have been dysbiotic for years or decades. That is what I see clinically. I think if we had understood this information many years ago, we probably could have intervened at an earlier time . But most women that are getting stool studies done or are being diagnosed with autoimmune conditions, they're in their thirties, forties, and fifties, and beyond. Interestingly enough al contraceptive driven dysbiosis lay,ered on top of the natural microbial decline that we see in menopause, layered on top of the estrobum disruption from declining endogenous estrogen, and the bone health consequences of each of these reinforce the breakdown of bone . So what does this all mean clinically? Because the biggest thing that I want to make sure we talk about is what are the things we can do? If we know that we took oral contraceptives or depot as younger women , we can't do anything about that now. But what we can do is make sure that we are getting DEXA scan evaluations. Do not wait until you're sixty five . This test is fairly inexpensive, even if your insurance does not cover it , I think women should be getting their bone mineral density tested in their thirties, especially if you breastfed babies because you do lose bone mineral density during and after lactation . Request a tribicular bone score alongside the Standard Dexa. This provides information about bone micro architecture and quality that Standard Dexa miss and it can reveal bone quality impairment even in women whose T scores appear reassuring . I also want you to be asking about key labs. If you follow me on Substack, I've been talking a lot about bone, gut bone, you want to order a CT which is a bone resorption marker and a P one NP, which is a bone formation marker along with a twenty five OH Vitamin D . You want your target vitamin D levelsop greater than fifty nanograms per ML. You want to look at calcium, magnesium, parathyroid hormone, and zinc . And you want to make sure that you're getting nutrient support. You want calcium from food based sources first. You want vitamin D three with K two. You want to think about magnesium glycinate, zinc, collagen peptides . These are oftentimes the raw materials for bone mineralization that oral contraceptive use may have depleted or impaired the absorption of if you're currently taking oral contraceptives or depot , calcium adequacy is non negotiable, so you want to make sure you're getting enough from your diet. You want to make sure your vitamin D levels are optimized. Resistance training is critically important. That's for everyone. Like that's a given for everyone. Consider the duration of therap y for Depot, the FDA recommendation that Depot use beyond two years requires documentation that no other adequate contraceptive option exist deserves genuine clinical discussion rather than routine prescription renewal That's from the FDA . Whether women used hormonal contraceptives in the past or is on them currently , my book is a great reference. The gut bone access means that restoring butyrate , producing bacterial populations , supporting short chain fatty acid production, and maintaining gut barrier integrity are bone health interventions as much as they are gut health interventions . The thirty plant varieties a week, fermented foods daily, targeted probiotic support, depending on what your microbiome analysis shows . I want you to think whatever you're doing for your gut is also going to benefit your bone. So think about leaky gut, lehi bone, the health of your microbiome is largely a reflection of what's going on with your bones . And I want you to think about if you are the parent of an adolescent or young adult oral contraceptives or dep ot are part of the conversation . We have to be talking about bone health implications. We have to talk about alpatinizing vitamin D, calcium . And you should feel empowered to ask these questions. What is my current bone density baseline . What calcium and vitamin D intake do you recommend while I'm on this contraceptive? Boy, well that blows some people's minds. And what monitor change do you recommend for long term use? I think at a bare minimum, if you've been on long term oral contracept ives or end or depot, you need bone marrow density . And if you're a woman who's been prescribed oral contraceptives for acne , for endometriosis for painful periods, the question of whether there are other options available to you that have less bone effects . Okay , so a couple things to kind of hone in on as we finish this conversation. The gut and immune consequences add further dimensions to a risk profile that millions of women were never informed about when these medications were prescribed . My generation, for sure, and every subsequent generation . This is not about regret. We can't look backwards. We can only look forwards. I want you to be thinking about baseline dexas. I want you to optimize your nutrient status. I want you to think a lot about your gut microbiome. You could certainly use my book as a great resource . This is an episode we should be sharing with our mothers, our daughters, our sisters, our friends , because it's all about education , empowerment, and inspiration . We want our young women to have access to when they decide if they want to choose to become parents, but I also want them to be aware of the risk of choices that they make in terms of contraceptive use . And the other thing is there's some nuance around the research that I mentioned . The research around oral contraceptives and depot is genuinely mixed . Some studies find no significant effect. That was certainly the case as I was writing the book, particularly with higher dose formulations and shorter duration of use. Obviously, the longer the duration of use, the lower the dosing of hormones, the greater the risk . Evidence shows concern with low dose formulations used for greater than twelve months in duration during peak bone mass accrual . Not all hormonal contraceptives definitely cause bone loss in all young women . Similarly, on autoimmune disease risk, there was a Williams review in twenty seventeen that provides the strongest synthesis, but the individual study data is heterogeneous and the causal mechanis ms are not fully established . The honest framing for this conversation is to say that substantial evidence exists for a signal . The mechanistic rationale is sound and women deserve to have this in their informed consent discussion , not that hormonal contraceptive definitively causes autoimmune diseases, but I know that the women that interacted with the post that Dr. Shaw did and we were in combination