The nature of healthy bones
Stress, ovulation, and your bones — are you feeling at home in your body? An interview
with Jerilynn C. Prior, MD
by Dr. Susan E. Brown, PhD
I’ve often wondered about the connection between emotional wellness and the
health of our bones. On my blog and in my articles I talk a lot about how to eat,
exercise, and use supplements to support bone health, but it’s time to talk
about a difficult subject, one we all tend to avoid: stress and our emotions. It
seems many women who come to see me have some component of worry connected to their
bone story. After seeing this connection over the years, I thought we should consult
someone who has extensively researched the effects of stress on bone health.
I met Dr. Jerilynn Prior, M.D. when I was giving a lecture in Vancouver years ago.
I was struck immediately by her warmth and her knowledge of both science and human
nature. After eating lunch together that day, we became friends and colleagues.
Dr. Prior is a professor of Endocrinology and Metabolism at the University of British
Columbia (UBC) in Vancouver. She directs the BC Centre of the Canadian Multicentre
Osteoporosis Study (CaMOS), and is the founder and Scientific Director of the Centre
for Menstrual Cycle and Ovulation Research (CeMCOR). She’s authored three
books, including her most recent, Estrogen Errors — Why Progesterone is Better
for Women’s Health.
Our conversation covers some of the many pathways to stress, how it can disrupt
our health and bones, and what lies at the root of it. No matter how old or young
you are, I encourage you to read this interview and to share the empowering news
with your sisters, daughters, mothers, and friends. As you’ll see, simply
feeling good can support healthy bones — and much more.
Stress, ovulation, and bones
How many of us have experienced a late or missed period when life seems particularly
overwhelming? We know that our cycles are certainly influenced by our emotional
state, but many women don’t know that their cycles are also tightly linked
to bone health. This pathway, starting with emotional stress and leading to missed
periods, can end with weaker bones and premature fractures. Here’s what Dr.
Prior told us:
JCP: Many of the negative effects of stress on bone are acting
by disturbing normal ovulation. One of the main reasons why women do not consistently
and normally ovulate relates to a combination of environmental, nutritional, or
emotional stresses. And I think that, of all of the various kinds of stress women
encounter in today’s world, emotional stress is the big driver.
When it comes to bone, there’s a teeter-totter of two processes that are closely
linked. First of all, in any one section of bone, there has to be the taking away
of older bone that’s not strong anymore and replacing it with new bone that’s
stronger. The hormone estrogen works through many ways of affecting osteoclasts
(bone breakdown cells) to slow bone loss, while the hormone progesterone works on
the osteoblasts (bone-building cells) to increase bone formation.
“Many of the negative effects of stress on bone are acting by disturbing normal
ovulation.”
—Jerilynn Prior, MD
SB: To give people some background, in the normal menstrual cycle,
estrogen gradually increases from a low as you progress toward ovulation. Then estrogen
decreases to a lower plateau after ovulation as progesterone rapidly increases,
to a very high level. Both estrogen and progesterone then drop off just before menses.
So this balance is important for the way bone is maintained.
JCP: Right. But the stress hormone, cortisol, can disrupt this
balance. It can both increase bone breakdown and prevent bone formation. Progesterone
and cortisol are similar and often compete — for example, cortisol can sit
on osteoblast receptors and prevent the bone formation effect of progesterone. Progesterone
levels need to be high to counteract that effect, and they are highest during the
days following ovulation and before menses, known as the luteal phase.
There are also hints that the sympathetic system stress hormones, adrenaline (epinephrine)
and noradrenaline (norepinephrine), are also negative for bones, but we have less
understanding about how they may work. We know, for example, that the rate of bone
resorption (breakdown) appears to be increased in those who have high levels of
adrenaline.
SB: At any stage in a woman’s life, she could be internalizing
various forms of stress and having abnormal ovulation or missing periods altogether.
Does this mean a particularly stressed young woman is bound to have weak bones?
JCP: Not necessarily. Let me give you a personal example: I was
a terribly stressed young woman. I had to adapt to dramatic changes when I moved
to urban USA from a village in Alaska. I was struggling to pay my bills. I had to
work double time while I was going to school — and I’m sure I didn’t
ovulate normally until I was in my mid-20’s. Yet I have perfectly normal bone
density now, and I’ve never fractured. So that speaks to the body’s
great potential to recover.
Self image and bone health
Listen to Dr. Brown and
Dr. Prior discuss self-image and bone health:
As women, we are inundated with messages about how we look and what we eat. When
I asked Dr. Prior to talk about eating patterns and how they can impact bone, she
explained that even worrying about what to eat can increase stress hormones and
disrupt the balance of bone breakdown and formation. It turns out that the body
is much more influenced by our emotional fabric that we might think.
JCP: Whenever we’re not eating enough calories to cover our
body’s needs, we make too much cortisol. As we just discussed, cortisol increases
bone resorption and decreases bone formation. For many years I’ve been collaborating
with Dr. Susan Barr, a professor of nutrition here at UBC and also an expert in
sports and bone, on what’s called cognitive dietary restraint. In other words,
it’s the attitude that constantly worries: If I eat this food it’s going
to make me gain weight! So it’s carefully weighing everything that you think
about eating for whether it might be bad for you or make you gain weight.
…Many of us are discontented — discontented with our relationships, discontented
with our jobs, discontented with how our body looks, just in a state of unease,
or dis-ease — which in the long run is bad for bones.
—Jerilynn Prior, MD
It isn’t necessarily that you eat differently or that you eat less. In fact,
those who have cognitive dietary restraint tend to weigh a little bit more than
many who pay no attention at all and eat what they want when they want it. So it’s
a form of very subtle stress.
SB: And what is the relationship between worrying about what we
eat and bone density?
JCP: Well, in repeated cross-sectional studies and even a recent
prospective study, eating restraint has been associated with increased bone loss.
And the mechanism for this is through a shortened luteal phase of the menstrual
cycle, or through anovulation (not making an egg). In either short luteal phase
or anovulatory cycles, our bodies don’t make enough progesterone.
SB: What can women do to avoid this kind of stress and worrying?
JCP: I like to simplify this in a sort of folksy sort of way by
saying: You need to feel at home with yourself — in other words, at home in
your own physical body, in a supportive emotional environment in which you are challenging
yourself, reaching achievements, and at home with the vision of what you see ahead
for yourself, whatever that vision might be. And that may sound very simplistic,
but many of us are discontented — discontented with our relationships, discontented
with our jobs, discontented with how our body looks, just in a state of unease,
or dis-ease — which in the long run is bad for bones.
So that kind of emotional, social, and environmental security is crucial, and once
you have that, it’s a matter of fine-tuning: to make sure that you eat whole
grains, fruits and vegetables, and a variety of foods; that you have sufficient
protein; that you get enough vitamin D and calcium; and that you get adequate exercise.
A 38-year-old woman fractures…
Listen to Dr. Brown and
Dr. Prior discuss fractures in young women:
Dr. Prior has an interest in younger women’s bones. She told me that she’s
seen six different women with hip fractures who weren’t yet perimenopausal.
I asked her what course of action she’d take when a 38-year-old woman walks
into her office with an unexpected fragility fracture (without a major trauma like
a car crash).
JCP: The first thing to do when somebody’s worried about
their bones is to engage them in being part of the solution, making sure they understand
that there is a solution, and that they are in charge.
Then we try to figure out how she got here, and so I would need to find out about
her health, what her health was like when she was a child, what her family history
of fracture is. I’d want to know about her first period, and how regular her
periods are. I would also ask her if she can tell, by the way she feels, that her
period is coming. If she can’t, she is likely not ovulating normally.
I’d also want to understand what her life is like, what work she does, who’s
at home with her, how she gets her relaxation and recreation, how she feels about
her body. In other words, I would try to understand how she feels about food and
whether she may have eating restraint. Oftentimes you’ll find a woman like
this is going to school and working, but who never feels like she’s done enough.
She’s always striving to do something better because she doesn’t feel
good about herself. And quite commonly she won’t be sleeping well. So she’s
high on adrenaline and cortisol all of the time, and that’s a recipe for poor
health in general, but especially for poor bone health.
SB: And so your suggestions to this woman would be…
JCP: Okay. The first thing is, you have to earn her trust. And
that means that you have to spend enough time with her to help her see that she’s
driven, that she’s not living her life. She’s striving for some future
day when things will be super, some idealized version of “perfect.”
And this takes skilled counselors. It takes help from family members. It takes help
from friends. Because once this pattern has set in, it’s hard to change. But
it is possible to change. Mind-body therapy has been used and shown to induce ovulatory
cycles in women who didn’t ovulate before.
Once she realizes that this is a partnership, then I would ask her to start keeping
track of her menstrual cycle (using our Menstrual Cycle Diary©). If she’s
been on the Pill, I’d ask her to use something else (like a diaphragm or cap,
plus spermicidal jelly) for contraception. And, I would ask questions about and
then make suggestions related to improving equality in her relationships.
Once she starts tracking her menstrual cycle, she starts to gain a sense of her
own self-worth — she now knows more about herself than the doctor knows. Then
I’d teach her to take her first-morning temperature, and learn how to do quantitative
basal temperature analysis (http://www.cemcor.ubc.ca/files/uploads/QBT_instructions.pdf).
Using this technique she can tell: This is the day that my temperature shifts; therefore,
this is the start of the luteal phase, and progesterone’s has increased. This
will enable her to see how long her luteal phase is and that she is ovulating.
There’s also a whole bunch of other lifestyle things that help, too: I’d
get her walking if she’s not doing any exercise. If she’s physically
active, I’d try to get her to do things with other people, and team-type things,
rather than lonely long-distance running, for example. I’d increase her calcium
intake primarily from food (with a bedtime calcium supplement). And vitamin D would
be the other key nutrient that I would want to make sure she’s getting enough
of. I would go through her diet and find out what she’s eating, how she’s
eating it, when she’s eating it, if she’s eating on the run and picking
up junk food. We have an article called the ABCs of Osteoporosis Prevention (for
Premenopausal Women) on the CeMCOR website that readers can refer to for more information
on these lifestyle change ideas.
If a woman has been tracking her menstrual cycles and ovulation, following the ABCs
of Premenopausal Osteoporosis Prevention, and has begun to deal with the stressors
that created the ovulatory disturbances in the first place, but still not ovulating,
or if the luteal phase is not 10 days or longer by quantitative basal temperature
analysis (the quantitative is important because the old-fashioned BBT is not accurate),
I would prescribe for her cyclic progesterone.
The ideal cyclic progesterone therapy is oral micronized progesterone (OMP) 300
mg at bedtime (it could be Prometrium or compounded oral micronized progesterone
in oil) during cycle days 14-27. Or, if a woman's periods are irregular, then I
would suggest 14 days of taking it and 14 days without taking it. However, if a
woman can't afford OMP, then Medroxyprogesterone 10 mg/day in the same cyclic fashion
will also help her bones.
SB: Getting back to something you said earlier, what is your reasoning
behind getting this woman involved in team sports?
JCP: Any social support is good! She needs the give-and-take of
other people. She needs to touch and hug and learn to trust others. There are a
lot of young women who are so emotionally cut off from other people and from their
bodies that human touch is healing.
What the research shows
Listen to Dr. Brown and
Dr. Prior discuss research connecting emotional support with bone health:
Though it may seem like Dr. Prior’s approach to the young woman we discussed
above is simply her warm nature as a physician, it is in fact backed in years of
research. Her studies have shown that giving women emotional support and empowering
them to better understand their cycles can make real changes in the body. She talked
specifically about two of her trials and what was surprising about them.
JCP: We did a study some years ago where we gave women who had
abnormal cycles or abnormal ovulation 10 days of a synthetic form of progesterone,
or additional calcium, or both.
First of all, every woman in that study — and 61 women finished it —
had no cycles, abnormal cycles, or abnormal ovulation when they enrolled. After
a year, when they were off of all study medicines for a complete cycle, 29 out of
those 61 women now had perfectly normal ovulatory cycles. And it wasn’t the
progestin. It wasn’t the calcium. Rather, it was getting to know their own
cycles, and having somebody (such as a research assistant) to talk to about what
was going on in their lives. The research assistants knew the names of their dogs
and their kids, so they got social support by being part of the study, and just
those simple things were enough to be associated with recovery of the cycle.
So it was participation in the trial, keeping records, talking with research assistants,
knowing that somebody cared about how they were doing — that kind of contact
was enough to make their cycles normal.
SB: Twenty-nine women! Almost half of the group spontaneously returned
to normal ovulation.
JCP: Let me give you another example. We enrolled women who were
not on the Pill, who agreed to do one cycle of diary keeping and to collect about
eight first-morning urine samples across one cycle, and in that study, about a third
of the women had previously had difficulty with infertility. Well, our biggest reason
for dropouts was that they became pregnant! In the very cycle after we taught them
how to keep the diary and gave them their supplies, they had to drop out because
before their next period came they were pregnant! There were some women who’d
been through three years of infertility treatments including in vitro fertilization
therapy, who then got pregnant.
SB: That’s very interesting. It reminds me of the old Korean/Taiwanese
adage: The way to have a child is to adopt a child. It’s powerful, the idea
that our thoughts, tensions, and beliefs have so much more influence than we might
expect.
Getting older: debunking the myth that it’s all downhill from here
In terms of menopause and aging in general, I’ve always believed that it’s
best to maintain physical strength for as long as possible. Dr. Prior enhances this
idea by empowering women to gain some emotional strength. Our culture tells us that
we are becoming decrepit and useless as we age, but some metaphysical understanding
that life is a good place to be can indeed improve your health and your bones. Here’s
Dr. Prior’s perspective:
JCP: Even though perhaps your roles in business or industry or
education or whatever are decreasing, there are still so many ways in which healthy
elders can contribute to society. Take “the grandma hypothesis,” for
example. My granddaughter really benefited from having “Granny J” to
be with recently when her mom and dad were in the hospital with the new baby.
SB: Yes, there are emotional challenges with menopause because
it’s burdened with the concept that, it’s all downhill from here, but
we can feel good about whatever life stage we’re in.
JCP: Absolutely. We have a community center in my neighborhood,
and you find people of all ages and places in life, from toddlers in a daycare program,
to the very elders, to teenagers in wheelchairs playing a pick-up basketball game.
There’s always a place where you can contribute, as a volunteer or as a participant.
We build community by investing in each other and in our local environment. Not
just by way of universal healthcare like we have in Canada, but other things like
community centers and recreational programs and music programs and the like. Venues
and forums that are accessible to people of all ages and abilities.
…There’s always a place where you can contribute, as a volunteer or as a participant.
—Jerilynn Prior, MD
SB: Mattering is really important, and it is something that people
struggle with, especially when they become infirm and feel like they can’t
participate. It starts a decline that’s hard to climb out of.
JCP: Yes, social isolation is not good for emotional or physical
health. I mean, if your eyes are still good, you can read to somebody who’s
blind. It’s ideal to focus on setting up the potential for each person to
both give and receive.
SB: I thank you so much for your time and for sharing your perspective,
Dr. Prior. I hope this conversation has inspired our readers to think about how
they might reweave the emotional fabric of their lives, to create a feeling of safety
and peace around their choices. Ultimately these emotional shifts will help lead
to healthier bones and healthier bodies.
The Personal Program for Better Bones: the approach I recommend for naturally strong bones.
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Original Publication Date: 09/14/2010
Last Modified:
07/10/2012
Principal Author: Dr. Susan E. Brown, PhD