Dexa Scans, 
Bone Loss & 
What Most Doctors Miss

Brent: So Dexa scans, why are these not commonly recommended?

Gina: I think that this is something more primary care physicians should be doing. But of course we're limited by time insurance reimbursement, and muscle health is really not on the radar very much, unfortunately, because there's no pharmacologic treatments for it.

Brent: Welcome to Deathlok. I am your host, Brent. Friends. Today we speak with Doctor Gina Woods about Dexa scans. Doctor woods is an associate professor of medicine at UC San Diego. She's a board certified endocrinologist that focuses on osteoporosis and bone metabolism. So this was a really interesting episode. We dive in to talk about Dexa scans, which are scans that are most commonly used to understand bone density and the health of bones, and people who are middle aged and tend to be a little bit older, but they are increasingly being used for longevity.

Brent: So to understand how much muscle we have, how much fat we have. And then we also talk about bone health and some new medications that are out for preventatively, reducing the risk of bone deterioration of bone density decreasing over time. She's a great guest. I hope you enjoy.

Brent: Doctor Gina Woods, welcome to the show.

Gina: Thank you for having me.

Brent: Today we're going to talk about Dexa scans. Which is interesting. This is this is one of those I've done all of the scans. But I have I guess I haven't done them all, but I've done lots of scanning of my body, but I haven't done a Dexa scan. And I got excited as I was preparing for this episode because I'm, I've convinced myself I need to go get one.

Gina: Maybe I should get one.

Brent: Okay, wonderful. So. But before we get into Dexa scanning, what is it? Why do we do it? How do we read the results? Give us a sense of your background, your day job.

Gina: Thanks again for having me. I'm an endocrinologist at UC San Diego. My clinical interest is bone health, so I, director osteoporosis and Metabolic bone Disease Clinic, and I got into bone bone disease. I chose endocrinology because I liked the intersection of, you know, lifestyle factors and physiology. You know, I thought I was going to go more into obesity and metabolism, but got really intrigued by the bone because it's such an interesting tissue.

Gina: We think it's just a static tissue, but it's really dynamic. It produces hormones and responds to hormones. And I found that really interesting.

Brent: And is it common that an endocrinologist is is focused on bone health? I mean, I just immediately think of diabetes and so is it. Would that be a common path for endocrinology or do I just not know what I'm talking about?

Gina: Diabetes, thyroid and bone are the most common, conditions that endocrinologists will see. Although that being said, in some places osteoporosis is managed by rheumatologists. But a fair number of it is managed by endocrinologists.

Brent: I want to touch on the Dexa scan from the perspective. I think we will obviously touch on on bone health, but it seems it's being used more or more broadly for longevity and understanding the muscle and and fat in the body. And so can you just tell us like what what is it, what kind of scan is it?

Brent: How long does it take? What does Dexa stand for?

Gina: Dexa stands for a dual energy x ray absorb geometry. So it's a low radiation dose x ray that when we're talking about bone, the sites that we standardly measure are the lumbar spine, the lower back and the hip. When one of those sites cannot be evaluated, we may evaluate the wrist as an additional site. And then a total body.

Gina: Dexa can tell you things like your body composition so your, you know, percent lean mass, versus fat mass. It's the gold standard. So it's very accurate. It's very safe. It's an extremely low dose of radiation. It's the same amount of radiation as just spending a day out in the sun. Readily available, inexpensive. So yeah, there's no reason to not get one.

Brent: And is that a common misconception that it's there's some danger. There's there's radiation that I shouldn't be getting a Dexa scan. Do you find yourself working against a misconception like that.

Gina: Occasionally, but most patients are pretty comfortable getting them.

Brent: And how is it different than an x ray? If I broke my arm.

Gina: Because it's a lower radiation dose than a standard x ray, it's not going to give you the same resolution. But it's used to measure the amount of bone mineral, so it doesn't need to be a high resolution scan. So we're not using it to diagnose hip arthritis, for example. We're not using it to identify a fracture. We're just using it to measure the amount of bone.

Brent: And then it seems it's it's most common use is in understanding bone density, particularly in understanding bone health for women and older men, but older and in both cases, but that it's increasingly being used in the, in the context of longevity in middle age to understand how much fat I have, how much muscle I have, and then in particular, visceral fat.

Brent: So the amount of fat that sits around my organs and, it's not subcutaneous like not the fat we think of on the outside of the body. How how new is that? Like, when did that start happening? How common is that? And and what you're saying.

Gina: So it's not new. It's been around for a long time. I think it's just become more, widely available and, you know, given kind of the interest in longevity, people are more interested in looking at these variables. So, yes, you can it'll it will tell you your, percent of Android fat, which is that metabolically unhealthy fat versus gyno fat Dexa is available without a doctor's order in a lot of places.

Gina: But the Dexa in that situation, you would get your body composition, analysis, and a total body bone density score, so you wouldn't get the hip and spine scans that I usually get in my patients who are being evaluated for osteoporosis. So there is a difference between the kind that you can just walk in off the street and get, and one that your doctor would order for you.

Brent: And there are two different types of fat. There's basically a good fat and a bad fat.

Gina: Yes.

Brent: And what are those like? What's the difference and how would I know?

Gina: The Android fat is the, the visceral fat that's the fat in, in the organs in the abdomen, you know, fat in the liver, for example. That's metabolically unhealthy, that's associated with diabetes and, insulin resistance. Whereas the glenoid fat is the subcutaneous fat. So, people talk about the apple versus the pear. The pear is more of the kind of fat that's, metabolically friendlier compared to the android.

Brent: Okay. So when we think about fat and we think about somebody who is overweight, who carries a lot of subcutaneous fat, actually, that fat would be considered the good fat and the the scary fat is the fat that is inside my body and sits around my organs. And I might be overweight and have a lot of the quote unquote bad fat, or I might not I might not appear overweight on the outside, but I might have a lot of unhealthy fat on the inside.

Gina: Correct.

Brent: Is it that people who are overweight tend to have a lot of both, because it's obviously unhealthy to be overweight? And, you know, obesity carries all sorts of, chronic health risks. And so is it that those people, it's not necessarily the subcutaneous fat that's impacting their health, it's that they're carrying good fat and bad fat.

Gina: They can go together and you could have more of both or less of both, but it's the ratio, you know, if you have a high ratio of, Android to Glenoid, that it's more likely that you would have insulin resistance and, and metabolic, disease.

Brent: But is there a is there somebody and maybe it's edge, but are there people who would appear very overweight on the outside but like it's all good fat and they're perfectly healthy?

Gina: Yes. We've seen this. I can recall, for a patient in particular who had a very high BMI over 40, who his, fat was all subcutaneous and his, you know, oral glucose tolerance test with stone cold, normal. I remember seeing this patient in my training, and it was I was surprised we don't see those cases all the time, but it is possible.

Gina: And then, you know, I would say very commonly I see people who appear very lean and have abnormal glucose tolerance tests.

Brent: The OG at the oral glucose tolerance test being the gold standard and understanding, basically the risk of type two diabetes and, and how you're tolerated, how you're managing your blood sugar. This is what was really piquing my interest for myself, because I'm somebody who has, I'm a little bit on the high end on an A1. See, I'm like A56.

Brent: I'm higher than I want to be, and I have a little bit too much dessert with my wife. My cholesterol is a little bit high, total and LDL bad cholesterol. My apob is a little bit high, but I'm just genetically skinny. Like I'm just not. I'm tall and I've always I'm insecure about not looking strong. I'm just kind of bony.

Brent: It strikes me that I might have a lot of visceral fat and not know it. It's not something where I'd have a lot of symptoms.

Gina: Right? Correct. You wouldn't have any symptoms? Probably. Yeah.

Brent: So Dexa scans, it seems from a bone health perspective. And just a I should understand, what's happening in my body in terms of fat. What kind of fat? Muscle? I probably want to see those things over time. Why are these not commonly recommended by primary care physicians? Like what? Like what is the downside of getting a Dexa scanner?

Brent: Their incidental findings. Are there false positives like we might see in a full body scan? Like why wouldn't I, starting at age 40, get Dexa scans regularly?

Gina: And that is a great question. And in my opinion, there's no reason to not start getting them regularly. I do get Dexa with body composition whenever, whenever I can, so it is not something that the body composition portion of the Dexa scan is not, covered by insurance. I do have, facility. We have a Dexa school, at UC San Diego, where we train Dexa technologist.

Gina: And as part of that training, they do body comp. I can refer patients who are willing to pay cash who want this additional scan. So many of my patients do get these yearly, and I'm able to track their lean mass. And when they're doing a comprehensive treatment that includes not only medications for their posture process, for example, but also doing strength training, hitting protein targets, etc. we see nice improvements in their lean mass.

Gina: I also do physical strength measurements in my clinic. I have, you know, a dynamometer where I can check their grip strength, which is, you know, not necessarily the most important or only strength test you want to use, but it's something I can easily do in the office for my older patients, I have them. Do you know the 32nd chair stand?

Gina: We can track their progress on that. I think that this is something more primary care physicians should be doing. But of course, we're limited by time insurance reimbursement. And the fact that right now, you know, muscle health is really not on the radar very much, unfortunately, because there's no pharmacologic treatments for it. And in our medical training, we're heavily biased towards pharmacotherapy.

Gina: And so if there's not a drug to treat something, it's not going to receive as much attention in our in our training.

Brent: It feels maybe that that's part of the problem where some people are losing trust. I mean, one of the things we talk a lot about is I personally don't. I think the docs get into it because they want to help people, and then it's just a tough system. And so you're you're operating within the confines of, of a system that has just a bunch of different restrictions.

Brent: And so, but, but it does seem there's this unhealthy habit in among primary care physicians of saying, well, if something does cost anything out of pocket, then I'm not going to recommend it, and I'm not going to talk about it because and I get that in some cases, like a colonoscopy, if it's not covered by insurance, I it's going to cost me $20,000 or something.

Brent: That would be very expensive, but something like a Dexa scan. I mean, these these scans are what that's a 150, $200. It's not zero, but it's not it's not going to put me in debt for the rest of my life. Is that right?

Gina: Yeah. I mean, it depends where you're practicing, who your population is, what resources they have. You know, I'm fortunate to that many of my patients are able and willing to pay for these scans out of pocket, because they're interested in their health and they're they're interested in the information.

Brent: Yeah. I always wonder about that answer. Not not your answer specifically, but I wonder if sometimes we do too much of well, the patient might not be able to afford it, so I'm not going to mention it. And I wonder if it's like, hey, what the patient figured out. So surely it relate to health. I mean, I could imagine there are people who have very low incomes statistically, but they say, well, I'll definitely spend $150 on the Dexa scan or on preventative health or whatever.

Brent: Or maybe they won't, but it feels like, hey, let's make sure we give them the information. But then again, these primary care physicians, they've got 15 minutes per visit and they're just cranking through people. And it's very reactive. It's like, okay, fix what's wrong. It's hard to do preventative health. And I bet if I were a primary care doc, I'd say, hey, it's it's really tough to focus in on on sleep, diet and exercise.

Brent: And then with your focus on, bone health, do you think that the longevity community maybe has over rotated on visceral fat and what you're calling body composition? Because there's the scans to look at bone health, they are more likely to be covered by insurance. Not always, but you need a referral in either case from a doc. And then there's the walk in off the street body composition scan that's going to look more at fat and muscle.

Brent: And so do you think the primary reason to do these is more related to bone health or more related to body composition or both? Like what are they most valuable for?

Gina: It just to be clear, the the Dexa scan that you could get from a physician that would be covered by insurance does not include the body composition portion. It's only the.

Brent: Bone that's never going to be covered by insurance.

Gina: Well, I can't say never, but currently, it is not.

Brent: But now it's rare. So it's like, hey, even if I get a referral, it's that's very specific to a, a part of a bone in the body. Yeah.

Gina: If I so if I order it through my EMR and send the patient upstairs to my radiology department, it will be a lumbar spine, hip and maybe a wrist if I order that, it will not include the body comp or imaging or radiology department at UCSD doesn't offer that and it's not covered by insurance. I have to go to a special different site to get the body comp.

Gina: So I guess your question about how important is it to get the body cam? I guess I would say it depends on what you're going to do with the information. You know, if you are trying to make lifestyle changes and you want something to measure, I think it's a great, it's a great piece of data to have, you know, using it in combination with your agency or your oral glucose tolerance test or your CGM that you may be wearing and how much you're lifting.

Gina: You know, these are all data points. I have patients that are engaged in a, supervised structured strength training program for part of their bone health. So they bring me body comp scans, and they're also telling me how much weight they're lifting and how much they've, you know, increased compared to their last visit. So all of these are data points.

Brent: And are you seeing any false positives or incidental findings with your patients? So you're sending them upstairs to get the scans of this of their, lumbar or their wrist? You know, this can be a concern with other types of scans. Are you are you finding other things that there's a nodule or there's a lump and something that gets referred somewhere else, or these are pretty specific scans that are like, they go in and look at something and they're not they're not catching these incidentals.

Gina: No, because it's a low radiation dose and a low resolution scan. They are not finding incidental as on these know.

Brent: And then for yourself personally are like, could you tell me about your visceral fat. I mean, you have to actually tell me, but like, could you do you know that information as a professional who's spends a lot of time or on Dexa scans or you're like, yeah, no, I don't really think about that for myself. I can tell you about my bone health.

Gina: Yeah, I can, I can pull up my, body comp if you want to see it. Let's see, what was my, my Android adenoid ratio was 0.36, then.

Brent: Is that good? Is that in range? Out of range. What's the output of those reports.

Gina: That's favorable I mean it doesn't give a normal range, but, you know, it means I have less Android relative to gyno. So, it's considered to be metabolically a better ratio. But I will also tell you that when I wear a CGM, my better metabolic health is not perfect. So.

Brent: Well, those glucose monitors, they're there funky because they spike and you think spikes are bad, but actually it's a that's a normal part of processing food or you know, it's but is your A1 C high or do you is your CRP high your inflammation markers, your metabolic health markers. Are they are they high.

Gina: What is you know, I honestly don't know my A1 c I want to say it's around 5.4.

Brent: Yeah. Because the reason I ask is, is one of the questions I'm asking myself is, is proactively getting a body comp dexus scan. Is that going to give us information that we might not get from a good, you know, a good set of labs of their just the right bloodwork, which is, okay, I've got a healthy hemoglobin A1, C I've got healthy fasting glucose.

Brent: You know, I've got normal levels of C-reactive protein as measured by an CRP. So I'm not the, the the lights are not blinking on inflammation. But then I go get a Dexa and I've got really high visceral body fat. Or is it, hey, you're going to see those lights blinking that you get from typical bloodwork. And then, yeah, you're probably going to see the visceral fat isn't great as well, but it's not telling us anything new.

Gina: That is a good question. It might depend on factors like age and I'm not sure what would go up first. Would it be these markers on the blood, or would you see an increase in visceral fat opacity on your Dexa scan? I actually don't know that, but I'm just thinking that maybe like a younger person who maybe they're A1.

Gina: See, we know all of these things get worse as we age, so you might be able to pick something up sooner with a deck somebody. But, you know, they're all just different data points. Often they're going to be congruent, but sometimes not like, you know, like my deck, somebody's comp might have been very reassuring, but then my, you know, my, my CGM report reveals, you know, things are not quite as great as I was hoping.

Gina: So yeah. Yeah, I think, you know, each test tells you something different and you have to look at them all, you know, take each piece of data together to kind of look at the full picture.

Brent: Yeah. Well and that's the reason I ask I have I saw as I mentioned, I've got high cholesterol in different ways and high LDL high total. And I was really concerned about heart disease. And I had these feelings at night of my heart pounding. I wonder if I'm going to have a heart attack. You know, I was just getting in my head.

Brent: And then I went and had a CT to a coronary CT and geography. And then there's this analysis called clearly on top of it. And you're able to look at the amount of plaque in your heart, right. Like high cholesterol is not disease in and of itself. You're able to actually see is there plaque in my arteries and I don't have plaque anywhere.

Brent: I do I did it did identify this coronary anomaly that I might have to get open heart surgery for, but I don't have any plaque. And so that's where I'm wondering, does the role of is the role of the Dexa scan related to body comp or even bone health? Is it similar in that way, where we have these canaries in the coal mine that aren't their surrogate markers?

Brent: They're not necessarily disease in and of themselves, and the Dexa is actually giving us the phenotype. It's actually giving us a sense of whether or not we have disease, because in my case, it was because of that CT scan that I've chosen not to take stats. I well, I don't actually have any disease and statins have some side effects.

Brent: And so it changed the way I think about treatment for myself. Do you think Dexa plays a similar role related to bone health or body comp, or it's more an additional surrogate marker if that question makes sense?

Gina: Well, I think with the with the body comp, it's more of a surrogate marker. You know, often there's you're going to know from your family history or your lab work if you're prone to, you know, metabolic disease. But the bone is that one is the thing that is often the surprise, because many times people are very surprised to see how low their bone density is.

Gina: And like every day I patients in here saying, I can't believe I have osteoporosis. I've done everything right my whole life, you know, and it's there's no science, there's no symptoms. So that is often the big surprise.

Brent: And is it is it what they haven't done right their whole life is strength training basically resistance training. And they've done everything. I eat all my veggies and I went to bed early and I don't drink and yeah, well, you got to do resistance training probably.

Gina: You know, I think the majority of my patients are women, and I think women are coming around to recognize the importance of strength training, but perhaps that hasn't always been as popular or as common for women to engage in, in strength training. And it needs to be moderate or high in intensity. So, you know, it can't just be light.

Gina: But I do think that, you know, genetics are a big. So the most common causes of osteoporosis and bone loss are, you know, just your genetic predisposition simply getting older. And for women going through menopause, that explains by and large the majority of osteoporosis. Then there are other, you know, health conditions and lifestyle factors that can play into it, of course, but oftentimes it's just simply having certain genes and getting older and going through menopause.

Gina: That is, though, the sole explanation.

Brent: Okay. So the Dexa scan for body composition, there are other ways you might measure it. And if, you know, if you've got a lot of visceral fat, there's some likelihood that your blood based biomarkers are going to be telling you something about your metabolic health or your cardiovascular health, that the visceral health that the visceral fat would also tell you about the the unhealthy fat on the inside of the body.

Brent: But in the case of bone health, there's just no replacement for the Dexa scan. Everything. You can have great biomarkers and you can feel good, and you can have lived what anyone would consider a healthy life. And then we do a Dexa scan and you're you're bone density is in a concerning place.

Gina: Absolutely.

Brent: And then what is your prescriptions in that case what are you what are you saying to do. Are there are there meds or it's just it's hey, we got a that's resistance training.

Gina: And well the basis is nutrition and exercise. So we talk about calcium. Most people are not getting enough calcium. So 1000mg for adults. For women over 52,000 hundred is the target. Dairy you know, swings in popularity. I think it's a little bit on the upswing again. But for a while there, you know, people were really avoiding it.

Gina: And from my perspective, if you don't have any allergies or intolerances, it's a great source of calcium and protein in a beneficial food matrix that's well absorbed. So, you know, making sure to get enough calcium, you want to be getting it throughout the day. You can't absorb it all in one bolus and then protein. And, you know, I'm sure you've talked about protein and protein targets.

Gina: We know we need more as we age for our muscle health. We don't know exactly how much protein we need for bone health. So we use them up the skeletal muscle targets. I use the 1 to 1 point 2g/kg. At a minimum, more is okay. And then the strength training at least twice a week, at least moderate in intensity, moderate or high intensity, and impact exercises.

Gina: So in addition to strength training you need impact on the bone. So the bone likes that force to be applied to it. And when we look at athletes to see which athletes have the best bone density, the top of the list are gymnasts because they're like tumbling and landing with so much force. Soccer players, bone Lakes novel forces not just like a runner who's doing the same motion over and over.

Gina: It isn't as good as a soccer player or a basketball player, or someone who's had has novel forces applied to the bone. So those are the types of exercise. And then, of course, I recommend balanced training because there's such a high level of evidence for fall prevention. Falls are a major source of injury and mortality in older adults.

Gina: So we really want to prevent falls. And then we do have five different classes of FDA approved medications for treatment of osteoporosis and three FDA approved classes for prevention of osteoporosis. And I would like to get the word out that osteoporosis is preventable. And we are these drugs are vastly underutilized for prevention. So, you know, if we did a better job of prevention, I wouldn't have my clinics overflowing with people who are deep in the hole with terribly low bone density, and we're trying to dig our way out.

Brent: Oh, so the drugs themselves. So if I, if I get a Dexa scan early and the trajectory, like, I might not be in a terrible position in that moment, but the trajectory is not good. I don't know bone density based on my age or something. Then the meds can actually slow down the deterioration of the bone.

Gina: Yes. These are approved for women. So because we know that women, you know, women build smaller bones and muscles than men to begin with due to differences in our sex steroid hormones. So our bones are not as strong as men supposed to begin with. And then when we go through menopause, we lose 10% of our bone mass in a in a very short period of time.

Gina: It's a huge amount of bone loss. And so, there are three approved classes of drugs to prevent osteoporosis in women. Menopause hormone therapy being one serves, which are selective estrogen receptor modulators being a second, and this phosphatase being the third. And in fact, I would just like to plug this one study that came out in January of this year because it was such a terrific study.

Gina: So it was done in New Zealand. It was a ten year long study. They took women between the ages of 50 and 60 just up and all comers. Didn't matter what the bone density was. Three groups. One group got two doses of a medicine called request over ten years, one dose every five years. The second group got one dose at the beginning, and then the third group got just placebo.

Gina: They didn't get any treatment. The group that got just the two doses totally maintain their bone for a decade, no bone loss whatsoever. Whereas the group that couple Sibo lost 10% as we expect. So it's completely preventable with two doses of a medication, but it's completely underutilized.

Brent: And what what are the side effects like why aren't we putting it in the water?

Gina: Right, exactly. I mean, it can cause flu like symptoms for about 24 to 48 hours. Pretty common, but it goes away. Otherwise, it has a great safety profile. It's in the class of this phosphate. So these medicines got a bad reputation because they came on the market in the 90s, and we were prescribing them very widely and keeping women on them for decades, which we've learned that's not the right way to do it.

Gina: So we don't treat you indefinitely anymore. If you take it for too long. There are some rare side effects, like this type of stress fracture of the thigh bone. But when we use it very infrequently or for short periods, we really are not seeing that anymore. I think it has an excellent safety profile and it should be utilized more.

Gina: And of course, we're seeing an upswing in menopause hormone therapy. So that in and of itself should help to, you know, prevent a lot of osteoporosis. I think the fact that we haven't been prescribing hormones for the last 20 years has resulted in my clinics overflowing with women with terrible osteoporosis.

Brent: And what does two doses mean? It's a so I it's a flu like symptoms. Okay, that's not fun. But it seems like that's a good ROI compared to what I'm getting. In terms of the study that you were referencing, so are the two. Am I swallowing a pill? I'm somebody sticking a needle in me.

Gina: It's an IV infusion. It takes about 30 minutes.

Brent: IV infusion. So I'm laying down and I'm getting a needle in the arm, and, it takes 30 minutes. And. Is that a comfortable 30 minutes?

Gina: Yeah. I mean, patients get it in an infusion center. So, you know, they'll get an IV. The medicine is infused with some saline, but for 30 minutes, you just sit there in a nice, comfy chair. They take the IV out and you go home. No big deal.

Brent: And I do that twice over. What time period?

Gina: A decade.

Brent: So I do that once, and then I do it a second time ten years later.

Gina: Five years later, five.

Brent: Years later. Okay. And then is and then is that, is that typically covered by insurance? Is it only for women? Is it for women and for men?

Gina: I haven't seen studies in men that would be interesting to see, but because men don't experience menopause, which is the time where we have this rapid bone loss, you know, I don't think people are looking at that as closely, but this drug is approved for prevention by the FDA. It is not commonly used. So it may take a little work to get it approved by insurance.

Gina: You know, you might get questioned if you send a patient who has normal bone density for an IV infusion. You might get, you know, in denial. But, you know, I think that you could fight it and say, this is approved for prevention. This is what we're doing. It's a generic drug. The drug cost $120. There's no reason why we shouldn't do this.

Gina: Do you.

Brent: Use it preventatively.

Gina: When I can? But honestly, to get into my clinic, you can't have normal bone density because I've got an eight month waiting list for people who've got severe.

Brent: But I mean, you personally, will you use it?

Gina: Have I personally taken it.

Brent: Or will you.

Gina: Will I? Yeah, well, that's a good question. I am choosing option one of those three that I gave you which is menopause hormone therapy. So I'm on hormone therapy. But if and when I stop the hormone therapy, I will definitely take a dose of this medication.

Brent: And are they mutually exclusive?

Gina: They're not, but they haven't been studied in combination. And I'm not sure how much added benefit there is. I have thought about should I take a dose of it in addition to the hormone therapy? But so far my bone density, I check it annually and, I'm in the normal range and I'm not seeing any declines, so I haven't pulled the trigger yet.

Brent: And what would you tell your I mean, I don't know anything about you personally, but your husband or your brother or, you know, somebody really close to you who's male about recast and whether or not they should consider it.

Gina: What I, my, my husband has osteopenia. I mean, I should tell him to take it.

Brent: Well, why haven't you? I mean, I think that's interesting, right? Because it seems to be a little bit of a breakthrough that it's under utilized and doesn't have a lot of attention. And so.

Gina: So I've gotten him doing strength training. So I've got that an impact exercises. So I got him on that once we got his Dexa done. There's not a reason not to do it. It would not hurt to do it I think for, for a man, it would be a harder, harder to get approved.

Brent: But but are you saying it's not expensive like in your husband's case? Let's just say I'm assuming you. I think you had mentioned $150 and. Okay, you've got a great job. And so I'm assuming it's, you know, 150 bucks for his bone health is is doable.

Gina: Well worth it. So, that's the cost of the drug. It's 120 for the drug, but you also have to pay for the infusion center administration.

Brent: It's so limited on attention that even, you know, you're you're deep in the space and you're, you're a proponent of it, that it's like, oh, I haven't even really fully considered it for my own husband. And that's I'm not saying that critically. I'm saying it's it's kind of an interesting note on where it is against maybe where it should be.

Gina: Yeah. I think, you know, it depends on how proactive you want to be in your health. And, if you're someone who wants to be do everything and more then, yeah, go for it. I do think you're going to have to advocate because it's not in the routine workflow in US health care at the moment.

Brent: It's such a secret within the medical community. If I went to my concierge doc or my endocrinologist or my primary care physician and say, hey, I want two doses of class over the next five years for preventative, you know, bone health. They would say, what are you talking about?

Gina: Yeah. Tell them. January 2025, New England Journal of Medicine, Ian Reid and colleagues.

Brent: And then what is the difference between menopause hormone therapy and just your traditional HRT that, that, women would use semantics.

Gina: The preferred term is menopause hormone therapy, not hormone replacement therapy. It's not a full replacement dosing necessarily, but.

Brent: It's the same thing. If somebody's thinking about HRT you're doing effectively HRT, but you don't what you're you're in the business. And so you say, yeah, that's just the wrong term. I don't like that term. It's an imprecise term. Menopause hormone therapy is just a better term. So that's the one you use.

Gina: Yeah, exactly. I mean I don't I don't have any problem with HRT. I know what you're talking about. I happen to use it. It's just semantics. Tomato, tomato.

Brent: Yeah. I don't know words matter though. Yeah. I mean, you're, you know, you're you're you're quietly objecting with your choice of, of term, which is great.

Gina: I think it relates to the dosing.

Brent: So there actually is a difference. I thought it was just a that's the same thing. But it's a bad hormone replacement therapy. So it's not like the term.

Gina: Term replacement implies that you're taking the estrogen levels to the same point that they are in a premenopausal woman. And at the doses we're using it's lower.

Brent: Okay. So what you're saying is, hey, the the estrogen levels are they're just going to come down over time. And in menopause, hormone therapy, we just want to make sure we're on the right trajectory even if it's lower than pre menopause. Whereas in hormone replacement therapy we might actually be trying to take your estrogen levels to a place that would be very unnatural for a postmenopausal woman.

Gina: Yeah. Sort of. So yeah. Like a say a premenopausal woman's estrogen levels run between 100 and 200 picograms per mil at the doses that we're giving for men. And then in menopause, it's like undetectable low, less than 20 picograms per mil post menopause. So we're replacing to maybe I mean, there's not a specific target necessarily, but say roughly, you know, 50 or 60 picograms per mil.

Gina: So we're we're giving enough to prevent the bone loss and the symptoms. But we're not fully replacing it. So the dose, for example, a woman who has early menopause, say at below the age of 40, if I'm prescribing hormone therapy for her, I would get if I was giving her a patch, I'd give her 0.1mg, which is the highest dose, because for her age that's appropriate.

Gina: But if I'm giving someone post-menopausal hormone therapy, I would probably start at 0.05. So half the dose.

Brent: And then this does seem like it's one of those places. I mean, bone health and this Dexa can't scan topics specifically. I don't know enough about this to say that that it's true, but it seems that we have an issue with, particularly with women, where we tend to do a lot of studies on men, and we've neglected women, and we're starting to correct that.

Brent: But in this case, it seems the opposite, where we've got all these great studies on women and we know a lot about women, and we're neglecting the men, and we all have bones. Yeah. And it's. Yes. Okay. You know, men don't have menopause, but like that men have the study of how these things impact men has has been neglected.

Gina: It has been neglected. I mean, there was one large study called Mr. Oz that was a study of osteoporosis in men. So we're lucky to have that data. But, you know, it's frustrating that the, U.S. Preventive Services Task Force reviewed their recommendations on osteoporosis screening. And again this year, they continue to give screening men an eye for insufficient evidence.

Gina: So they say that they're not saying you shouldn't screen men. They're just saying the evidence is insufficient. But the bottom line is until they endorse it, insurance is not going to cover it. And so what the level of evidence they require to endorse it is going to require huge, long, expensive studies. When we know that bone density predicts fractures in men just as well as in women, the drugs work just as well as in men, and women and men fare more poorly after a fracture.

Gina: Compared to women. They have higher post fracture mortality rates. So I don't know why we have to spend the money to do these large studies to endorse this very simple, inexpensive screening test in men.

Brent: That's unfortunate. We get it wrong, although it feels like they get it wrong, least of all of these bodies. Right. They they're the gold standard for a reason. So they tend to do well. They're just missing it here.

Gina: If money and time were not an issue. Sure. Let's get the gold standard data in men, but it's going to take a lot of money and a long time to get that data.

Brent: Okay, so the last question I have for you is how is AI changing your job? Is it at all? Is it making it harder or easier? Neutral.

Gina: It's making it easier. In terms of our clinical I use it for, you know, non patient care related things all the time. And it's made it it's been a game changer for me. But in terms of patient care not so much yet. The only things we are using it for our clinic has. If you add everyone's effort together, say it has about ten full time endocrinologists here we get about 17,000 mychart messages from our patients per month as a group, and only 7% of those messages can be answered with one touch.

Gina: So it's a tremendous amount of messages because, I mean, it's great to have access to your doctor, but, you know, every time a question pops into your head and you shoot off an email to your doctor, that's another message in the queue for all of us to have to screen and respond to. So AI is generating replies it doesn't automatically send.

Gina: We still need to review. And I have never just simply sent send like I always edit something, but that's one way it's helping.

Brent: I assume from a privacy perspective you're not allowed to do that. So let's assume you were allowed to do it. Then the question is, would you want to be like, oh, I really think this I'm going to make something up. It's going to sound stupid to you, but this might be, osteopenia type B, but I'm not quite sure.

Brent: I'm just going to throw the image and the reading into ChatGPT and see what it thinks. Would you do that if you could, from a privacy perspective, like, do you think it would be a helpful thought partner or. No, it's really far from that.

Gina: ChatGPT no, I would not for that type of thing. Maybe open evidence. I use that, a lot for just general queries. I haven't used it for, you know, diagnosing a specific patient's condition or image. But, I mean, I think it's a great tool.

Brent: Awesome. All right, doctor Gina Woods, thank you so much for the time and for helping us understand, Dexa scans and bone health.

Gina: Yeah. My pleasure. Thanks for having me.

Brent: Death clock is recorded in Boulder, Colorado, sometime San Francisco, California. Produced by Patrick Gudino, music by Patrick Lee, and hosted by yours Truly Brent Franson.

Brent: Founder and CEO.