强健的骨骼，强健的身体，更强壮的下半场——与乔塞琳·维特斯坦博士谈第二部分

在《Unpaused》节目中表达的观点和意见仅属于嘉宾本人，仅供信息和娱乐目的。

The views and opinions expressed on unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only.

本播客或任何相关材料的任何部分均不旨在替代专业的医疗建议、诊断或治疗。

No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.

在上一期《Unpaused》中，我们与乔塞琳·惠特斯坦医生展开了一场对话。

In our last episode of Unpaused, we started a conversation with Doctor.

探讨了我们在中年阶段，关节、骨骼和肌肉究竟发生了怎样的变化。

Jocelyn Whitstine about what really happens to our joints, bones, and muscles as we move through midlife.

为什么骨关节炎对女性的影响更严重？

Why osteoarthritis hits women harder?

为什么冻结肩似乎特别青睐这个人生阶段，以及激素如何贯穿其中。

Why frozen shoulder seems to love this life stage, and how hormones weave through all of it.

那是一场让许多原本看不见的线索突然连成一片的对话，我们有太多内容要聊，一集根本讲不完。

It was one of those conversations that made a lot of invisible dots suddenly connect, and we had far too much to talk about for just one episode.

所以今天，我们带来第二部分。

So today we're back with part two.

医生。

Doctor.

维特斯坦是一位执业骨科外科医生、研究员，同时也是杜克大学骨科外科的副教授。

Wittstein is a practicing orthopedic surgeon, researcher, and associate professor of orthopedic surgery at Duke University.

她的研究聚焦于女性在不同生命阶段的运动表现、创伤后关节炎、冻结肩，以及她所称的更年期肌肉骨骼综合征。

Her work focuses on female athletes across the lifespan, post traumatic arthritis, frozen shoulder, and what she calls the musculoskeletal syndrome of menopause.

她是女性运动医学论坛的主席、杜克女性运动员计划的核心领导者，也是米尔肯研究所女性健康创新计划的成员，并合著了《完整的骨骼与关节健康计划》。

She's President of the Forum for Women in Sports Medicine, a core leader in the Duke Female Athlete Program, and a member of the Milken Institute Women's Health Innovation Initiative, and co author of the Complete Bone and Joint Health Plan.

她不仅治疗患者的骨折，更在追问：为什么女性的关节和骨骼会以这种方式运作，以及我们究竟可以做些什么。

She's not just treating fractures in patients, She's asking the bigger questions about why women's joints and bones behave the way that they do, and what we can actually do about it.

在本集中，我们将以大多数人从未听过的角度，深入探讨激素、疼痛与软骨的关系。

In this episode, we get into hormones, pain, and cartilage in a way that most of us have never heard before.

乔塞琳解释了雌激素和孕激素如何调节疼痛，为什么纤维肌痛和弥漫性关节疼痛在中年女性中如此常见，以及睾酮在女性关节炎风险中的作用。

Jocelyn explains how estrogen and progesterone modulate pain, why fibromyalgia and diffuse joint pain so often show up in midlife women, and the role testosterone plays in arthritis risk for women.

她带我们了解她当前的研究，探索衰老与性激素如何影响关节的韧性，以及激素替代疗法未来是否可能缩小女性与男性之间的关节炎差距。

She walks us through her current research to understand how aging and sex hormones change the resilience of our joints, and whether hormone therapy might one day help narrow the arthritis gap between women and men.

更重要的是，她提出了一套切实可行的预防方案，包括她自己如何保护骨骼和关节。

And perhaps most important, she outlines a real world prevention plan, including what she does to protect her own bones and joints.

这场对话内容详尽、充满希望，且极具可操作性。

This conversation is detailed, hopeful, and incredibly actionable.

如果你错过了第一部分，我希望你能回去听听。

If you missed part one, I hope you'll go back and listen.

如果你准备重新思考自己的运动方式，采取全方位的策略来保护骨骼和关节，那么你一定要听这场对话。

And if you're ready to rethink how you move and take a three sixty degree approach to protecting your bones and joints, then you need to listen to this conversation.

好了，我们来谈谈疼痛。

All right, let's move on to pain.

激素、疼痛与肌肉骨骼健康。

Hormones, pain, and musculoskeletal health.

你提到雌激素和孕激素是疼痛的调节因子。

So you've talked about estrogen and progesterone as pain modulators.

这是如何起作用的？

How does that work?

你认为这些激素是如何真正影响我们的疼痛的？

How do you think these hormones actually influence our pain?

这并不是我自己的研究，只是我读到的一些我觉得有道理的内容。

And this isn't my own research, just things that I, you know, read that make sense.

有一项研究来自……同样，很多这些发现都基于动物实验，而我们正是通过动物实验学到这么多知识，或许未来能将其应用到人类身上，从而获得更深入的理解。

There's a study out of And again, a lot of this relates to animal data, which is where we learn so many of these things and maybe hopefully eventually apply to humans and learn more.

加州大学旧金山分校进行了一项关于小鼠的研究，观察了位于脊髓中央区域的细胞，结果显示雌激素和孕激素能刺激这些细胞产生一种内源性镇痛物质。

There was a study done on UCSF on mice looking at basically cells located like centrally in the spinal cord and showing that estrogen and progesterone stimulate these cells to create like an endogenous analgesic, basically.

明白了。

Okay.

也就是止痛剂。

Which is pain reliever.

止痛剂。

Pain reliever.

这表明或许存在某种中枢性的疼痛调节机制。

You know, so suggesting that maybe there's like some central pain modulating effect.

有一些针对纤维肌痛患者的研究，显示了孕激素水平与疼痛之间的关系。

There are some studies on people with fibromyalgia showing relationships between progesterone levels and pain.

什么是纤维肌痛？

What is fibromyalgia?

这有点复杂，因为纤维肌痛的实际定义涉及肌肉筋膜组织上特定数量的压痛点。

That's a tough thing because the actual definition of fibromyalgia relates to these very specific number of painful points on, you know, myofascial tissue.

我认为随着时间推移，我们会对纤维肌痛有更多了解，因为我有点怀疑，很多更年期女性都被诊断出患有纤维肌痛。

I think we'll learn more about fibromyalgia over time because I half wonder, we see it a lot in, a lot of menopausal women get diagnosed with fibromyalgia.

所以有些人，沃达，曾告诉我，她怀疑纤维肌痛中有多少其实是肌肉骨骼综合征和更年期的表现。

So some people, Vonda, you know, has stated to me that she wonders how much of fibromyalgia is just musculoskeletal syndrome and menopause.

我的意思是，这是一种临床定义，基于你确实感到疼痛。

I mean, it's a clinical definition based on you're having pain

在特定部位，是的，就是在肌肉筋膜组织上。

in certain Yeah, and that in myofascial tissue.

她认为，与其说这是一种全新的疾病，不如说很多情况只是更年期的一种症状。

She thinks a lot of it, rather than just being this de novo condition, could just be a symptom of menopause.

是的，有可能。

Yeah, could be.

我确实看到更多患有纤维肌痛的女性，而不是男性，我都不知道男性也会得这个病。

I I do see many more women with fibromyalgia than men I didn't know any men had it.

是的，我不确定我是否认识任何男性患者，但这种病在女性中确实更常见，我认为随着时间推移，我们会更了解它。

Yeah, I don't know if I have any Yeah, it's definitely more common in women, and it may be something I think we understand more over time.

这些病症又被赋予了某种名称，但最终我们会不会后来才真正弄清楚它们的本质呢？

Again, these things get named something, and, you know, do we figure out what they are later?

我还有很多女性因为新出现的关节疼痛而被检查是否患有风湿性疾病，但X光片尚未显示异常，她们只是经历了明显的多关节痛。

I also have a lot of women who get worked up for rheumatologic conditions because they have this new onset joint pain many times, but x rays that don't look abnormal yet, and they're just having, you know, a lot of polyarthralgia.

我有时觉得这可能与全身性炎症有关。

And I sometimes think that is just related to systemic inflammation.

甚至一些早期的女性健康倡议研究也表明，包含雌二醇的激素治疗可以减少疼痛和疼痛关节的数量与严重程度，而停用后则会出现反弹或疼痛加重。

And even, you know, some of the earlier studies from the Women's Health Initiative did show reduction in number of and severity of pain and, you know, painful joints with hormone therapy that included estradiol and then even rebound or worsening of joint pain with withdrawal of that.

当她们停药时。

When they stopped it.

还有一些系统性综述和荟萃分析并未明确显示关节痛与绝经期激素治疗之间存在关联。

And there are some systematic reviews and meta analyses that don't clearly show a relationship of joint pain and use of menopausal hormone therapy.

我认为甚至更年期学会在其网站上也有类似声明，即我们在这方面的研究还需要更多进展。

And I think even the Menopause Society has a statement like that on their website you know, that we need more research in this area.

我现在正在研究这个问题。

And I'm studying that now.

但我确实认为我们需要更好地理解这一点。

But I do think we need to understand that better.

但如果女性在50岁左右出现如此显著的膝关节炎发病率差异，肯定是有原因的——

But there's gotta be something if women have this really disparate rate of, especially like knee arthritis at age 50, it's just, you know, there has to be-

好像是突然出现的。

Comes out of nowhere.

是的。

Yeah.

所以你感觉这是疼痛耐受性的一种综合表现。

So it's a combination you feel of the tolerance to pain.

你的意思是，我们由于雌激素撤退，镇痛效果减弱，同时炎症增加。

You're saying, you know, we have less of an analgesic effect combined with increasing inflammation from estrogen withdrawal.

睾酮在这里面有作用吗？

Does testosterone have a part anywhere in here?

因为我们不像男性那样大幅降低睾酮水平。

Because we don't tank our testosterone like men do.

就像雌激素和孕激素那样。

Like estrogen and progesterone do.

更渐进一些。

More gradual.

在年龄增长过程中更渐进。

It's more gradual with

年龄。

age.

是的。

Yeah.

有一些新数据表明，曾有一项大型研究长期追踪了女性和男性。

There's some data coming out that seems to relate There was a large study that looked at women and men over time.

我认为这项研究包含了大约9000名受试者，其中约5000名为女性，研究团队持续跟踪了他们的性激素水平与关节炎发病率。

I think it had like 9,000 subjects in it, about 5,000 women in it, and they followed them over time with sex hormone levels and rates of arthritis.

他们发现，女性随着时间推移，睾酮水平降低与膝关节和手部关节炎风险增加有关，但在男性中并未观察到这种关联。

And they did see a correlation with lower testosterone levels in women over time in terms of risk of knee and hand arthritis, but they did not see that correlation in men.

所以，是的，我们正看到越来越多的研究表明，女性晚年睾酮水平可能也与膝关节和手部关节炎相关，而这些部位恰恰是最常见的发病部位。

So, yeah, we're seeing some, I think, more research about testosterone in women later in life potentially being also related to knee and hand arthritis, which are, of course, very common sites.

是的。

Yeah.

对。

Yeah.

我正在试图找到这个问题的答案。

I'm trying to get at the answer to that.

我正在开展一项研究，或者正试图启动一项研究，我们已经完成了大部分前期工作，这项研究将重点关注50岁出头的男女在软骨早期阶段的变化，并结合睾酮、雌二醇和孕酮水平进行分析，实际上我们是利用了之前ACL研究中构建的那些模型，就是我们做的那些模型，嗯。

I'm doing a study or trying to launch a study that we've done a lot of the preliminary parts for that will really look at early changes in cartilage in women and men, you know, in the early fifties, as well as correlating with testosterone and estradiol and progesterone levels using some of those models we built from the ACL research, actually, on these models we make where we yeah.

如果有人在听这个，并且想当我的研究仙女教母，愿意给我300万美元来解决男性与女性关节炎的问题，我已经有这个研究方案了。

And if anyone is listening to this and wants to be my research fairy godmother and wants to give me $3,000,000 to solve this arthritis in men versus women, I have the study.

我们利用了之前在机器学习上所做的工作，构建了膝盖软骨的模型，其中我们已经对膝盖各个部位的软骨进行了完整追踪。

So we took all the work we did on the machine learning to build the models of the knees where we have all the cartilage traced all over the different parts of the knee.

我们使用了一种非常相似的模型，该模型原本用于研究前交叉韧带撕裂后创伤性关节炎，我们会让受试者前来，让他们休息三十分钟，使软骨完全放松。

And we use a very similar model that we use to study post traumatic arthritis in ACL torn knees, which is where we bring people in and we have them rest for thirty minutes so their cartilage is fully rested.

我们会对他们的膝盖进行静息状态下的核磁共振成像，从而测量软骨的厚度。

We do a resting MRI of their knee, and then that shows us the thickness of their cartilage over it.

然后让他们在跑步机上行走三十分钟，这会压缩软骨——而软骨正是膝盖的光滑滑动表面。

Then we have them walk for thirty minutes on the treadmill, which compresses your cartilage, and the cartilage is the smooth gliding surface of the knee, compresses it.

接着我们将他们重新送入核磁共振扫描仪，用特定序列每六分钟扫描一次，持续约三十分钟。

And then we put them back in the MRI scanner, and we kind of rescan them with this one sequence every six minutes for like thirty minutes.

在这三十分钟内，我们观察软骨恢复其正常厚度的程度。

And over the course of those thirty minutes, we see how much the cartilage rebounds its normal thickness.

然后我们生成一条曲线，显示软骨恢复到正常状态所需的时间。

And then we generate a curve, and it tells us how many minutes it would take for the cartilage to go back to normal.

所以在普通人身上，大约需要二十五分钟。

So like in a normal person, it'd be like twenty five minutes.

而在经历过ACL撕裂的人身上，即使在受伤一两年后，由于他们更容易因创伤而逐渐发展出关节炎，恢复时间会超过一个小时。

In people who've had ACL tears, even just like one or two years after their injury, because they're so prone to developing arthritis over time from the trauma, it takes, like, you know, more than an hour.

需要很长时间。

It takes a long time.

因此，我们正在将为ACL损伤后创伤性关节炎开发的这套工具应用到新的领域，只不过这里的损伤不再是ACL撕裂和创伤性关节炎。

So we're applying this same tool that we developed for post traumatic arthritis after ACL injury, except for the injury is not the ACL tear and PTOA or post traumatic arthritis.

而是衰老、性激素，以及是否接受激素治疗。

It's aging, sex hormones, plus or minus hormone therapy.

我们会检测他们的睾酮、雌激素和孕激素水平，并观察在男性和女性中，有无激素治疗的情况下，关节炎的早期迹象是如何出现的，同时了解他们的激素水平。

And so then we'll have their testosterone, their estrogen, their progesterone levels, and we will see how the early signs of arthritis are appearing in men versus women with and without hormone therapy with tests, you know, knowing their levels.

简单来说，我的假设是，我认为维持或补充雌激素水平确实有助于保持软骨的弹性。

Basically, you know, my hypothesis is that I do think that, you know, maintaining or supplementing, you know, the estrogen levels will preserve that resiliency of the cartilage.

这就是我的假设。

That's my hypothesis.

我可能是错的。

I could be wrong.

所以这可能具有预防作用。

So that it could be preventative, potentially.

如果我们能这样做，这正是我们正在研究的。

And if we can that's what we're studying.

我们想知道，因为这个问题还没有明确的答案。

We want to know because this isn't clearly answered.

我们想知道，包含雌二醇、睾酮和孕酮的激素疗法是否对软骨有保护作用，尤其是在女性中，从而缩小膝关节关节炎35%的性别差异？

We want to know, is hormone therapy that may include estradiol, testosterone, progesterone, are these things protective of the cartilage, especially in women, so that we can narrow that gap, that thirty five percent difference in knee arthritis?

如果我们最终证明软骨的恢复能力或弹性与雌二醇和孕酮水平有关，这可能为激素疗法的用途提供另一个依据，或者拓展我们对激素疗法作用的理解。

If we do end up showing that the resiliency or that ability of the cartilage to rebound is restored or maintained or related to the estradiol and progesterone levels, that may be another indication or it may expand our thoughts about like, what is hormone therapy for?

但我们尚未明确证实，而且许多早期研究使用的又是不同形式的激素疗法。

But we haven't clearly shown, and a lot of the old research, again, is on like different forms of hormone therapy.

对。

Right.

而且仅针对潮热的有无。

And only for the presence or absence of hot flashes.

是的。

Yeah.

但与关节炎相关时，它并不一定是在直接观察软骨的实际健康状况。

Or related to arthritis, though, it's kind of it's not necessarily looking at the actual health of the cartilage.

所以我们正在。

And so we're Yeah.

因此，我们已经向国立卫生研究院提交了另一份资助申请。

So that we've submitted another grant to the NIH.

我刚刚向另一家私人基金会提交了申请。

I just applied to another private foundation.

如果有人想帮助我解决女性的关节炎问题，就联系我吧。

And, so if anyone wants to help me solve arthritis in women, call me.

你可以来我们的实验室。

You can come to our lab.

我可以向你展示我们是如何完成所有工作的。

I can show you how we do everything.

我真的非常希望我们能获得这笔资金，因为这是我很期待的一项研究。

And I really, really hope we get money for this because that is one of the studies I'm extremely excited about.

你提到在你以前的论文中说过，帮我复述一下，EPOT，EPOPS试验，

You mentioned that in your previous writings that and help me say it, EPOT, EPOPS trial,

M S

M S

E F O P S，这项研究探讨了长期运动对骨量减少女性骨密度和骨折风险的影响，与LIFMORE试验不同。

E F O P S, which studied the effect of long term exercise on bone density, fracture risk in osteopenic women different than the LIFMORE trial.

它是否证明了能预防骨折？

Did it show fracture prevention?

是的。

Yes.

我喜欢EPOPS试验的原因之一是，我们知道有很多研究都表明，跳跃有助于提高髋部骨密度。

One of the reasons why I like the EFOPS trial is, you know, we have all these studies that show, okay, jumping helps with hip bone density.

力量训练有助于改善，特别是腰椎的骨密度。

Strength training helps, you know, improve especially lumbar spine bone density.

那么，我们真正想预防的是什么？

Again, what do we really want to prevent?

是的，保持骨密度很好，也很不错，我们通常认为，就像许多药物所显示的那样，提高骨密度可以降低骨折风险。

Yes, maintaining bone density is great and nice, and we presume in most cases, like we know from many medications, you know, that improving bone density reduces fracture risk.

但这项研究真正做的是追踪了这些女性。

But what that trial did was they followed women.

我认为她们在入组时平均年龄约为55岁，然后追踪了她们16年，也就是现在到了70岁左右。

I think most of them were on average when they enrolled them like 55, and then they followed them for sixteen years, so now after like age 70.

这真的很有意思。

This is really interesting.

我的意思是，她们有监督的训练课程，然后是独立训练，并且持续了这么长时间。

I mean, they had these supervised sessions, then independent sessions, and they carried this out like all this time.

他们不仅追踪了她们的骨密度变化，还追踪了骨折风险。

And then they their bone density over time, but they also followed obviously their fracture risk.

因此，很少有试验能真正展示运动计划对长期骨折风险的影响。

And so there aren't a lot of trials that really show you the impact of an exercise program on long term fracture risk.

因为测量需要很长时间。

Because it takes a long time to measure.

是的。

Yes.

再说一次，我总觉得有时候会想，为什么美国没有开展这样高质量的试验？有些试验根本没做到这种水平。

Again, I just feel like sometimes I feel like, why don't we have these trials in The United States that are this some of them are just not this good.

无论如何，他们发现，随着时间推移，参与运动组的女性相比对照组，骨折风险降低了大约百分之五十。

In any case, what they found was over time that the women who participated in the exercise group as compared to the control group had approximately fifty percent reduction in fracture risk.

对。

Yeah.

但有趣的是，在试验接近尾声时，你知道，一开始女性们进行的力量训练包含了力量训练和冲击性运动，并且采用了周期化安排。

But interestingly, near the end of the trial, you know, at first, the women who were doing the strength training it included strength training and impact, and they kind of used periodizations.

并不是一直都很剧烈。

It wasn't always intense.

有时强度较低，但他们确实有高强度的阶段。

Sometimes it was less intense, but they did have periods of higher intensity.

他们发现，骨折风险明显降低。

And what they found was obviously a major reduction in fracture risk.

早期，骨密度的差异更大。

And earlier on, there were larger differences in bone density.

锻炼组的骨密度在增加，而另一组则在减少，正如

The exercise group was gaining, whereas the other group was losing, as

我们所知。

we know.

随着时间推移，这些收益逐渐减缓。

Over time, those gains trailed off.

在研究后期，锻炼组的骨密度仍在下降，但速度较慢。

And near the end of the study, the exercise group was losing bone density but at a slower rate.

好的。

Okay.

但我的观点是，我之所以特别喜欢这项研究，是因为它表明，即使骨密度在以较慢的速度下降，运动对于预防骨折仍然有效。

But my point is, and why I like that study so much, is it shows the effectiveness of exercise for fracture prevention even as bone density is declining maybe at a slower rate.

但运动的意义远不止于骨密度。

But there's more to exercise than just the bone density.

它还涉及你的协调性和平衡能力。

It's like your coordination and your balance.

骨折预防不仅仅关乎骨密度。

Fracture than just your bone density.

是的。

Yes.

对。

Yeah.

所以如果你不容易摔倒，身体不那么僵硬，如果你……

So if you don't fall, if you're more if you're less stiff, if you are

你的活动能力更强，平衡更好，摔倒的可能性也更低。

You have better mobility, better balance, like, less likelihood of falling out.

所以我喜欢这项研究，因为我认为他们在降低骨折风险方面做得非常好。

So so I I like that trial because I think they did such a good job of falling through with the the the fracture risk.

好的。

All right.

我们再回到骨折的话题。

So back to fractures.

我经常被问到这个问题，我们诊所也深入研究了现有的研究，我想听听你的看法。

I get this question all the time, and our clinic has dug into what research is available, and I'd like to hear it from you.

具体来说，需要多少雌激素、雌二醇水平才能起到保护骨骼的作用？

How much estrogen, estradiol levels specifically, is needed for bone protection?

是的。

Yeah.

这是一个非常有趣的问题。

So this is a very interesting question.

我读过很多关于这方面的内容。

I read about this a lot.

我认为关于这个问题的困惑源于一项研究，该研究考察了骨转换标志物与雌激素水平之间的关系。

And I think the confusion around this question comes from, there was a study that looked at markers of bone turnover and associated levels of estrogen.

他们发现，当雌二醇水平达到每毫升60皮克或更高时，骨转换标志物的降低最为显著，也就是说，骨分解减少了？

And they found that if the estradiol level was 60 picograms per ml or higher, basically, there was the greatest reduction in markers of bone turnover, so basically breaking down bone?

所以对于我们的听众来说，你知道，骨骼并不是静止不变的。

So for our listeners, you know, bone is not static.

它一直在不断更新。

It is constantly turning over.

在30岁左右之前，也许在

And until 30ish, maybe in

我们20多岁后期，我们生成的骨量多于被吸收的骨量。

our late 20s, we're building more bone than we're chewing up.

但我们的骨骼每十年就会完全更新一次。

But we're constantly, like your bones turn over every ten years.

我们一直在进行骨重塑。

We're remodeling.

我们在不断重塑。

We remodel.

是的，我们在不断重塑。

Yeah, we're remodeling.

我们的肌肉也会发生类似的变化。

Our muscles do something similar too.

所以当我们进入更年期并随着年龄增长时，我们分解骨质的速度超过了新骨生成的速度。

So when we go through menopause, and with aging, we accelerate how much we chew versus what we lay down.

在更年期，这种失衡会加剧，我们分解的骨质远多于生成的骨质，从而导致骨量流失，进而引发骨质疏松。

And in menopause, it goes crazy where we chew up way more bone than we lay down, and that leads to bone loss and then osteoporosis.

甚至在围绝经期就已经开始了。

And even maybe in perimenopause.

哦，

Oh,

对。

yeah.

加速幅度巨大，而且

Massive acceleration of And

我最近读到一项研究，显示在围绝经期，有些人骨质流失更快，有些人则较慢。

I read a study recently that showed that there are faster and slower bone losers in perimenopause.

而那些在围绝经期骨质流失最严重或流失速度最快的人，往往是那些月经频率最低的女性。

And just looking at basically the people who had the greatest bone loss or acceleration of bone loss in perimenopause were the women who had the lowest frequency of population.

也就是说，当我们逐渐接近绝经期时，

Like, they're you know, had a obviously, as we get towards menopause

雌二醇水平更低。

lower estradiol levels.

是的。

Yeah.

对。

Yeah.

她们的周期更少，但那些周期间隔更长、更分散的女性，在围绝经期反而流失更多骨质。

They have, like, you know, less you have less cycles, but people have, like, this longer period of more spread out cycles were the people who lose more bone and perimenopause.

所以，这种周期频率长期降低的现象，可以作为绝经前期骨质流失速度快的一个标志。

So it's like, you know, that prolonged decreased frequency of cycles is kind of a marker for being a fast bone loser perimenopause.

所以是骨转换标志物。

So the bone turnover marker.

哦，转换标志物。

Oh, turnover marker.

是的。

Yes.

我们的身体在不断分解和重建骨骼，会有一些化学物质被排泄到血液中。

We're chewing up bone and laying down bone, there's little chemicals that get excreted into the blood.

因此我们可以说，她正在经历大量的骨转换。

So we can say, Oh, she's going through a lot of bone turnover.

骨骼和骨质流失，没错。

Bone and bone loss, yep.

所以这是一种衡量这些药物效果的方法，而无需等待两年才看骨密度变化

So that's a way to kind of measure how these medications are working without having to wait two years for a bone

骨密度，所以这项研究表明，如果你的水平至少达到每毫升60皮克，这些标志物的下降幅度最大，表明你的骨流失最少。

density So this study showed that if you were at least at 60 picograms per ml, you had the greatest reduction in those markers, so suggesting you're having the least bone loss.

而一旦达到90或更高，就不再有差异了，这很合理，因为80是许多月经周期女性黄体期的正常水平。

And then once you got to 90 or higher, there was no difference, which makes sense because 80 is the level and luteal phase of many women who are menstruating.

那么，你为什么需要高于这个水平呢？

So why would you need to be higher than that?

大概不需要。

Probably not.

因此，这促使人们认为，我们至少需要达到60的水平。

So that sort of led to, I think, made people think, Oh, we need to be at least 60.

但另一方面，来自所有Menostar研究的数据也显示，这种超低剂量的经皮雌激素（14微克剂量）即使使用者的雌激素水平未超过每毫升20皮克，也能保护骨骼、减少骨流失，甚至使腰椎骨密度提高约2.5%。

But on the other hand, there is also data that comes from all of the studies of Menostar, which is the ultra low dose transdermal estrogen, the fourteen microgram dose, showing that using that and even people not even exceeding a level of twenty picograms per milliliter protects bone and reduces bone loss and even increases density in the lumbar spine by like 2.5%.

因此，我认为这导致了人们对究竟应该维持在什么水平的困惑——是不是越高越好？

And so I think that kind of leads to this confusion of where do we need to be, is more better.

而在我的领域，更年期学会和妇产科文献中，大家对此都非常谨慎。

And there's, in my world, in the menopause society and the OB literature, they're very hesitant.

他们不想测量雌二醇水平。

They do not want to measure estradiol levels.

他们说：不，我们只治疗潮热。

They're like, No, we treat hot flashes.

你给她足够的雌激素来缓解潮热。

You give her enough estrogen to treat a hot flash.

但我的骨科同行们认为，仅仅缓解潮热并不意味着她的骨骼

But my bone people are like, just because you're protecting her from hot flashes does not mean her bones

也一定得到保护。

are necessarily protected.

我认为可能

I think maybe

他们非常关注剂量。

They're very keen on dose.

是的。

Yeah.

我不希望越界，超出我的专业范围。

And I don't wanna, like, overstep my boundaries or my sphere of practice.

你认为为什么会有这种犹豫呢？

Why do you think the hesitation?

有一项名为Ultra试验的研究，再次考察了Menostar的14微克剂量，当你查看女性体内的雌激素水平时，发现所有这些女性的水平都低于20，而这本应是绝经期女性的典型水平。

There was trial called the Ultra Trial where, again, looking at Menostar, the fourteen microgram dose, where if you looked at what level of estrogen women were at, they were all like, all these women under 20, which should be typical of menopausal women.

你的意思是

People who You mean

雌二醇水平为20吗？

an estradiol level of 20?

是的。

Yes.

雌二醇水平。

Estradiol level.

对。

Yeah.

都在那个范围内，所以这就是为什么

Were within that So that's how

我们向听众定义绝经为雌二醇水平低于20，基本上属于绝经后状态。

we define menopause to our listeners as an estradiol level less than 20, pretty much postmenopausal.

但这些绝经后女性，即使在低于20的范围内也存在差异。

But these postmenopausal women, there's even variation within that number under 20.

有些人雌二醇水平甚至低于5。

So some people live like under five.

有些人则在15左右，你知道的，所以你可以把这些分成四分位数。

Some people are at 15, you know, so you could have these quartiles, let's say.

在关于Menostar剂量的研究中，有一项研究发现，处于最低四分位数的人对Menostar的反应最明显，他们的骨转换标志物显著降低。

And in the study of the Menastar dosing, one study found that the people who were in the lowest quartile had the greatest response to the Menastar, so they had reduction in their turnover markers.

所以我认为，有人对检测激素水平感到担忧，可能是因为不同人对激素的反应不同。

So I think maybe some of the concern about looking at levels is that people respond differently.

有些人天生就处于不同的水平，因此重要的是相对变化。

Like, some people just live at different levels, and then it's a relative change.

那么，如果你在检测一个水平值，这个数值对这个人和对那个人意味着什么？

So then if you're checking a level, what does the level mean for this person versus that person?

所以我觉得这项研究让我想到，也许这就是人们犹豫的原因。

And so I think that study actually made me think, well, maybe that's why people are hesitant.

这其中有一些细微差别。

There's some nuance.

是的。

Yeah.

但另一方面，如果你看剂量，比如你看看FemRing，这是一种全身性雌二醇，可以保护骨密度，你是在使用经皮雌激素。

But on the other hand, if you look at dosing, I mean, for If you look at FemRing, which is systemic estradiol, which can be protective of bone density, you're looking at transdermal estrogen.

如果比较50微克剂量和100微克剂量，两者在骨密度增加方面并没有显著差异。

If you compare the fifty microgram doses to one hundred microgram doses, there really isn't a significant difference in the increases in bone density.

它们非常相似，但100微克剂量的提升略高一些。

They're very similar, but they're a little higher with the one hundred mg doses.

所以，如果某人出现了副作用或症状，比如乳房胀痛之类的，在50微克时没有，但在100微克时出现了，那么让他们使用50微克剂量并不会对他们造成不利影响。

So if someone is having side effects or symptoms like breast tenderness or whatever, and they don't have it at fifty micrograms, but they do it one hundred, you're probably not doing them a disservice to have them at the Right.

五十微克是因为，如果你看看各种研究中14微克、25微克、50微克和100微克的对比，比如14微克持续两年可使腰椎骨密度增加约2.5%，这与雷洛昔芬的效果相当，增加幅度相似。

Fifty because So if you look at the fourteen micrograms versus 25 versus 50 versus 100 in various studies, like the 14 over two years increased lumbar spine bone density like two and a half percent, which is on par with Evista, you know, similar amount of increase.

如果你看25微克的剂量，效果会稍好一些。

If you look at the twenty five microgram dose, it does a little more.

如果你看50微克和100微克的剂量，你会发现骨密度增加了大约5%，而Menostar只有2.5%。

If you look at the fifty and one hundred microgram doses, you're seeing, you know, a five ish percent increase as compared to two and a half percent with the Menostar.

所以显然，剂量很重要。

So obviously, dose matters.

但当你用到50或100微克时，并不是说

But when you get to the fifty or one hundred, not that

没什么不同。

Not different.

差别不大。

Not much of a difference.

作为一名骨科医生，这就是我的理解。

As an orthopedic surgeon, that's my understanding.

这其中是有细微差别的。

There's nuance.

在我们的Nuance诊所也是如此。

And in our Nuance.

在我们的Nuance诊所，是的。

Clinic Yeah.

而且，对于我接触的大多数更年期患者，我们不会只是给他们贴上一片雌激素贴片，然后说‘去吧，好好生活’。

And most of my, you know, the menopause kind of people, we don't sit here and slap an estrogen patch on someone and be like, go and live.

你知道的。

You know?

如果你想保护骨骼，就必须做所有该做的事，包括生活方式的调整。

It's like, if you wanna protect your bones, you have to do all the things, which includes the lifestyle.

是的。

Yes.

如果你不改变生活方式，包括饮食、营养、降低炎症等各方面，那么这种治疗很可能不会产生最佳效果。

You are not doing the lifestyle changes, including diet, including, including, you you know, know, nutrition and lowering inflammation and all the things, you are not This is probably not likely going to have, you know, not the greatest effect.

减少炎症的饮食有助于降低骨折风险，你需要摄入足够的钙、镁和维生素D，所有这些都很重要。

Diets with less inflammation, reduced risk of fracture, You you need adequate calcium, magnesium, vitamin D, all those things.

我曾经以为化妆就是要多一些。

I used to think makeup meant more.

更多的步骤，更多的流程，花更多的时间。

More layers, more steps, more time.

厚重、粉感重，但怎么都不像我。

Heavy, cakey, and somehow it still never looked like me.

关键是，尤其是随着我们的皮肤随年龄变化，我不想遮盖我的脸。

And here's the thing, especially as our skin changes with age, I don't want to cover my face.

我想呵护它。

I want to support it.

我希望我的皮肤看起来健康、水润，真正属于我自己的样子。

I want my skin to look healthy, hydrated, and like it actually belongs to me.

这正是我喜欢琼斯路美妆的原因。

And that's exactly why I love Jones Road Beauty.

他们的奇迹润唇膏是一款让人一用就懂的产品。

Their Miracle Balm is one of those products that just makes sense.

它能提升你的肌肤状态，而不是掩盖它。

It enhances your skin instead of masking it.

你无需叠加任何产品，就能获得清新、健康、比原本更好的光泽感。

You get that fresh, healthy, your skin but better glow without piling anything on.

我用它当腮红，多涂一点在脸颊上，有时甚至用在嘴唇上。

I use it as blush, a little more than my cheeks, and sometimes even on my lips.

一款产品，多种用途，搞定。

One product, multiple uses done.

我真正欣赏的是，Jones Road 专注于使用对皮肤友好的成分，打造纯净且高效的产品配方。

What I really appreciate is that Jones Road focuses on clean, high performing formulas made with skin loving ingredients.

没有厚重感，没有堵塞感，只有真正适合你肌肤的彩妆。

Nothing heavy, nothing cloggy, just makeup that works for your skin.

他们还有像‘Just Enough’调色保湿霜这样的经典产品，提供轻盈均匀的遮盖力，同时让真实的肌肤自然透出。

They also have staples like their Just Enough tinted moisturizer, which gives a lightweight, even coverage and lets your real skin show through.

这种妆容是与你的皮肤协同工作，而不是与之对抗。

This is makeup that works with your skin, not against it.

现代妆容，纯净、精准且多功能，让日常护理轻松无负担。

Modern day makeup that's clean, strategic and multifunctional for effortless routines.

限时优惠，我们的听众在结账时使用代码 UNPAUSED，首次购买即可免费获得一款时尚润唇膏。

For a limited time, our listeners are getting a free cool gloss on their first purchase when they use the code unpaused at checkout.

只需前往 jonesroadbeauty.com，并在结账时使用代码 UNPAUSED。

Just head to jonesroadbeauty.com and use the code UNPAUSED at checkout.

购买后，他们会询问你是从哪里了解到他们的。

After your purchase, they'll ask you where you heard about them.

请支持我们的节目，并告诉他们你是从我们的节目得知的。

Please support our show and tell them our show sent you.

在我们的诊所，我们会讨论生活方式、激素替代疗法，当然还有其他药物，比如双膦酸盐，特别是对于已经确诊的患者。

In our clinic, we talk about lifestyle as well as HRT and of course some of the other drugs, bisphosphonates, know, if they're already diagnosed.

但你跟我聊聊运动和药物之间的区别，以及各自的疗效如何。

But, you know, talk to me about the difference between exercise versus medications and what are the outcomes.

是的

Yeah.

所以，我当然不是想暗示你永远不需要药物。

So certainly, I don't want to imply that you're never going to need a medication.

比如，如果你患有骨质疏松症，并且你的FRAX评分显示未来十年内髋部骨折的风险超过百分之三，那你很可能需要服用某种骨质疏松药物。

Like if you have osteoporosis and, you know, your FRACS score says you have a more than three percent chance of having a hip fracture in the next ten years, like you should probably be on some osteoporosis medication.

这些措施对你有什么作用呢？

What do all these things do for you?

生活方式、药物还是激素疗法？

Lifestyle versus medication or hormone therapy?

我喜欢稍微理清一下思路，想想你的投入回报比。

I do like to kind of just level things a little bit and think about, you know, what are your returns on investment?

如果我们看一下你付出努力的时间线以及可能获得的回报，比如你开始进行一些负重运动，在六个月的时间里，你的髋部骨密度可能提高1%。

So if we look at, you know, the timeline for your effort and what you might get out of it, if you're doing Like, let's say you initiate some impact exercise and, you know, over a six month period, you might increase your hip bone density by 1%.

这是一笔六个月的投资。

That's a six month investment.

我的意思是，我认为你应该继续，但想象一下，6%和1%。

I mean, I think you should continue it, but you've got So imagine that, 6%, 1%.

比如，如果你在进行‘Lift More’方案，八个月内我们预计你的腰椎骨密度会增加3%。

If you were doing the Lift More Protocol, for instance, and over an eight month period, we would expect you to see a 3% increase in your lumbar spine.

所以好好想想这一点。

So think about that.

八个月，增加3%。

That's eight months, 3%.

如果我们考虑雌二醇治疗，两到三年内可以使你的髋部骨密度增加3%，腰椎区域增加5%，大致如此。

If we think about estradiol therapy over two or three years, giving you a 3% increase in your hip, five percent in your lumbar spine region, generally something like that.

也就是说，使用药物三年，让你的腰椎骨密度增加约5%。

So that's three years of using a medication to get 5% increase ish in your lumbar spine.

想想运动带来的影响。

You know, think about the impact of exercise.

如果你进行八个月的训练就能获得3%的提升，这真的很有成效。

If you're doing an eight month program and you're getting a 3% increase, that's really impactful.

所以我只是想强调一下

So I just wanna emphasize the

还有

And

时间周期

the timeline

运动。

the exercise.

是的。

Yes.

你还会

You're also

获得这么多其他好处。

getting so many other benefits.

这么多其他好处。

So many other benefits.

你的胰岛素抵抗。

Your insulin resistance.

是的。

Yeah.

对于你的肌肉质量。

For your muscle mass.

对。

Yes.

然后像唑来膦酸（Zoledernate）或利塞膦酸钠（Reclast）这类药物，你知道，每年一次的双膦酸盐输注，例如，可以使你的髋部骨密度提高约5%，脊柱骨密度提高约7%。

And then medications like zalendernate, like the or Reclast, if you know the brand that, you know, once per year infusions of bisphosphonate, for example, those are going to increase your hip bone density about 5%, your spine bone density about 7%.

你的脊柱骨折风险将降低70%，髋部骨折风险降低40%。

You're You're going to get a seventy percent reduction in fracture risk, say, of the spine, forty percent of the hip.

就像我说的，我们没有像运动那样确切的数字。

Know, we don't have, like I said, with exercise, we don't have all those numbers.

所以，这相当于每年接受一次输注，持续三年。

So that would be like three years of getting a once a year infusion.

所以这些数字更大。

So those numbers are larger.

但同样，如果你只是看这些数字的规模，生活方式干预的效果确实也很显著，但从规模上来说，很难说清楚：比如激素治疗，如果看荟萃分析，我们知道骨密度的这种提升能将髋部骨折风险降低约30%，椎体骨折风险降低约40%。

But again, like if you just look at the scale of them, like the lifestyle things do And quite a again, scale wise, it's hard to say, okay, for hormone therapy, if you look at a meta analysis, we know that this corresponding increase in bone density reduces our hip fracture risk by about thirty percent or vertebral body fracture risk by about forty percent.

我们没有运动干预的精确数据，也不能直接把药物的数据套用过来，说这个百分比就等于多少骨折风险的降低。

We don't have those exact numbers for exercise, and you can't really take the numbers from medication and be like, this percentage equals this much fracture reduction.

事情并不是这样精确对应的。

It doesn't work exactly like that.

但我的观点是，如果你只是看这些数字的规模，1%的提升已经是非常重要的了。

But my point is if you just look at the scale of these things, 1% gain is a really big deal.

3%的提升更是意义重大。

3% gain is a really big deal.

如果我们能这样思考，我认为这能帮助人们更重视这些运动干预措施。

And if we think about that, I think it just helps people value these exercise interventions more.

好的。

Okay.

这说得通。

That makes sense.

所以我祖母有多处骨折，不是髋部，而是前臂、肋骨，多次跌倒，

So my grandmother had multiple fractures, not hip, but she had forearm, had ribs, multiple falls,

你知道，最后三到五年她患有痴呆症，最后几年完全卧床不起。

you know, spent the last three to five years with dementia, and then the last couple of years completely bed bound.

而且，我母亲88岁，患有阿尔茨海默病，所以我肯定她母亲也有。

And, you know, my mother is 88 and has Alzheimer's, so I'm sure her mother had it too.

是的。

Yeah.

新年那天，她得了尿路感染，出现幻觉，以为听到我爸爸在叫她。

And on New Year's Day, had a UTI, hallucinated, thought she heard my dad calling her.

她下床时摔倒，髋部骨折。

Got out of bed, fell, broke her hip.

谵妄。

Delirium.

她完全没有心血管问题，完全能挺过手术。

Has no cardiovascular issues whatsoever, it was perfectly fine to survive the surgery.

她的髋部，你知道的，已经腐烂了，他们对她做了各种处理。

And had her hip, you know, rotted and whatever the hell they did to it.

但她现在仍然能完全靠轮椅移动，这真是太糟糕了。

And it still just scoots around in a wheelchair completely, you know, with That's terrible.

所以跟我谈谈，我该如何避免这样的命运？你有什么建议吗？

Her So talk to me about how I can what would you recommend for me for avoiding this fate?

我可以接受痴呆，但跟我谈谈我的情况吧。

And I can handle the dementia, but talk to me about my Yeah.

是的，痴呆当然，运动的好处是巨大的。

Yeah, the dementia, of course, you know the benefits of exercise, which are huge.

对于女性来说，锻炼是预防痴呆最有效的保护措施。

That is the most protective thing women can do to prevent dementia is exercise for our brains.

给我制定一个方案。

Build me a protocol.