Why Are Women More Prone to Osteoporosis? With Dr. Nicholas Soong (UCSI Hospital)

Introduction

Host: Welcome back to Medifly. Today we have Dr. Nicholas from UCSI Hospital, about an hour from the Kuala Lumpur city centre. Welcome to the podcast.

Dr. Nicholas: Thank you for inviting me. I'm Dr. Nicholas, consultant orthopaedic surgeon at UCSI Hospital.

Who Does Dr. Nicholas Treat?

Host: What age range do you focus on, and what do you treat?

Dr. Nicholas: There is actually no specific age group I focus on in particular. I treat from the young all the way to the aging.

For children, the majority suffer from traumatic injuries. If they break their elbow, I apply a cast. If the fracture requires more than a cast, I perform pin fixations. For teenagers and young patients who need surgery, I do that as well.

As we look at an older demographic, we see sportspeople, who typically suffer from sports injuries such as shoulder rotator cuff injuries, knee joint injuries, and ankle sprains that may require surgery.

For office workers, the concern is occupational hazards. Working too long with a mouse, for example, can lead to carpal tunnel syndrome. I treat nerve conditions, and also tendon injuries such as tennis elbow and golfer's elbow caused by repetitive, sustained positions.

And then, of course, with the global rise in aging populations, we see joint degeneration, the wear and tear on joints, and osteoporosis, which involves loss of bone mass and muscle mass. For joint degeneration I perform knee replacement surgeries. For patients with osteoporosis, we use bone mineral density (BMD) scanning, work to prevent falls and fractures, and where fractures have already occurred, we fix them and aim to restore as much functional capability as possible.

The Five Most Common Conditions

Host: Orthopaedics is a very broad subject. What are the top five conditions you focus on?

Dr. Nicholas: The top five would be:

1. Back pain
2. Joint arthritis
3. Nerve entrapments
4. Lumps and bumps, for example lipomas and sebaceous cysts
5. Trauma: fractured bones that need fixing

What Brings Indonesian Patients to UCSI?

Host: What is the most common reason Indonesian patients visit you?

Dr. Nicholas: At this point I would say it is mainly elective cases. Emergency trauma cases would be too urgent and life-threatening for patients to undertake such a journey. So, I am mainly seeing elective patients, primarily from the aging population presenting with arthritis, and also patients coming for regular bone density scans to ensure they do not have osteoporosis.

Understanding Osteoporosis

Host: What is osteoporosis?

Dr. Nicholas: Osteoporosis is a condition where bone density is reduced. This is largely due to aging, especially in the female population, who lose the protective effect of their hormones after menopause. With this loss of bone density, the risk of sustaining a fracture from a trivial fall is much higher.

"For this group of patients who have osteoporosis, their bones are no longer as strong as we normally think. They would easily sustain a fracture from a slip and fall in the toilet."

Osteoporosis, Falls, and Fractures

Host: Falls are one of the top causes of death. How does osteoporosis relate to that?

Dr. Nicholas: If you had an accidental slip and fall in the toilet, or on a slippery road, you would not normally expect to fracture a bone, because healthy bone is built to be strong and to withstand such traumas. You might expect a fracture from high-level sports or a car accident, but not from an everyday slip.

For patients with osteoporosis, however, that is no longer the case. Their bones can no longer withstand even minor stress.

"Sometimes we have cases where a patient sustained a spine fracture just from sitting in a car that passed over a road bump."

Preventing Osteoporosis

Host: Is there anything a patient can do as they age to prevent osteoporosis?

Dr. Nicholas: We plan for patients to have yearly or biannual bone mineral density tests to confirm they remain within a healthy range.

For prevention, we advise weight and resistance exercises to strengthen both muscle and bone, because bone strengthens itself when it meets resistance.

If a patient is already at a critical stage of bone density loss, we would start them on medication to strengthen their bones. Well-known examples are Fosamax, denosumab (such as Prolia) and Forteo. These strengthen the bone and prevent further loss of bone density.

When to Start Screening, and Peak Bone Density

Host: At what age does osteoporosis worsen most, and when should someone start screening?

Dr. Nicholas: The poster patient for osteoporosis is the aging woman. The highest concentration of osteoporosis patients falls roughly 10 to 20 years after menopause, so around 60 to 70 years old, when bone is at its weakest.

An important point to understand is that the peak bone density in women is reached at 30 years old. After 30, bone density begins to decline, even before menopause arrives. When menopause sets in and hormones drop, bone mass falls more sharply.

"The peak bone density of a lady is actually at 30 years old. After 30 years old, it begins its decline, even before menopause."

For prevention, we advise starting calcium supplementation before menopause begins. For screening, we typically recommend it around 10 years after menopause, at approximately age 60, to confirm bone density is at a healthy level. For those who are very health-conscious or physically active, we may recommend screening even earlier, because building bone back up is far more difficult than preventing its loss in the first place.

Osteoporosis in Men

Host: What about osteoporosis in men?

Dr. Nicholas: Men are fortunate in that we are protected by testosterone, which is produced throughout life. Male-related osteoporosis is therefore rare.

However, for men who notice loss of muscle, increasing generalised weakness, or aching throughout the body, we would advise them to come in for a bone density scan to ensure osteoporosis is not a contributing cause.

The Bone Mineral Density Screening Journey at UCSI

Host: For a typical female patient who went through menopause around 10 years ago, can you describe what the BMD screening journey looks like at UCSI?

Dr. Nicholas: The patient simply comes in and requests a bone mineral density test. They undergo a dual-energy X-ray absorptiometry (DEXA) scan, where we pass X-rays through the bone to measure how dense it actually is. A report is generated showing exactly whether the patient is at:

• A normal level,
• An osteopenic (at-risk) level, or
• A confirmed osteoporosis level of low bone mineral density.

Once we have the result, we provide the patient with a suitable treatment plan. Managing bone mineral density encompasses quite a lot: not just calcium supplements and medication to prevent further bone loss, but also steps to prevent complications such as falls and fractures.

This is where physiotherapy becomes very important. Physiotherapy helps strengthen muscles, increase bone mass and, at the same time, improve proprioception, balance, and gait. Our rehabilitation team also teaches patients practical tips to prevent falls: keeping the toilet dry and non-slippery, ensuring well-lit spaces, wearing appropriate footwear, and for patients with poor coordination, using walking sticks.

"We do not just want to treat the osteoporosis, we want to prevent further complications from happening as well."

Holistic Care at UCSI

Host: What is the advantage of coming to UCSI for screening?

Dr. Nicholas: UCSI has a large panel of doctors, which makes cross-referral straightforward. The moment a patient comes in with a problem, we can refer to colleagues and have multiple concerns addressed at the same time.

When aging patients come in, say for knee pain, they often have other hidden conditions they are unaware of, such as hypertension or diabetes. Our approach is to screen for these as well and provide a more holistic standard of care, ensuring a greater overall sense of well-being rather than simply treating one condition in isolation.

On the question of whether BMD screening is included in a standard health screening package: it is a separate, tailored test, because not every patient requires it. It is reserved for patients who genuinely need it. Patients can request it through our screening doctors, or come directly to me and we can tailor the appropriate tests to their situation.

Closing Remarks

Host: Thank you very much, Dr. Nicholas. This has been very informative, particularly for patients who don't always know which health screening is right for their age and circumstances. UCSI Hospital is just about an hour from the Kuala Lumpur city centre.

Dr. Nicholas: Thank you very much.