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Low Bone Turnover
Hello. I have had osteoporosis since I was 35, I am now 56. I have taken a variety of medicines but have done well until 2 years ago. I have had 2 metatarsal stress fractures that took months to heal. Recently, I got a third. It is not from any kind of running, hiking or walking a great distance. I have curtailed my activity. I have been on HRT since 50 taking a high dose of estrogen (.1mg patch) along with progesterone. I never had bone turnover markers done until summer of 2023. After 5 months of Evenity, my P1NP was 26 and CTX was 86. These are low especially since I had 5 months of Evenity. I had them repeated in March of 2024. P1NP was 13 and CTX was 90. I do these fasting and early in the morning. I believe this low bone turnover is contributing to my inability to heal my bones and to the recurrent fractures. I have lowered my estrogen to .05mg and progesterone to 100 mg mid April. Does anyone have experience with the impact of differing doses of HRT on bone turnover or any other thoughts as to why this number is so low. I did take Fosamax from August 2021 to July 2022. Thank you.
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Hi @lisanne may I ask a few questions regarding the time line of your treatment? When is the start and finish of your evenity therapy? When was your second bone turnover markers done in reference to evenity therapy?
Did you have good bmd improvement with evenity?
I am sorry to hear your metatarsal stress fractures. Did the second one occur during or after evenity? Also it seemed like you continued your HRT throughout evenity therapy, but recently reduced your estradiol dosage from 0.1mg to 0.05mg patches, right?
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1 ReactionThe evenity started February 2023 and I stopped June 2023. The second set was 9 months after stopping. You are correct with the HRT. Spine improved 6.1% and hip improved 4.5%.
Thank you.
@lisanne, the bone markers changes during evenity is dynamic. The peak increase of P1NP is at 2 weeks after initial dose according to clinical trial data, with an average increase of 145%. After that it trends down. Your btm lab was at 5 month of evenity, most likely the increase of P1NP was missed due to timing of lab.
Your CTX results is a bit more challenging to read, since you had evenity + HRT simultaneously. As you know, a typical transdermal dosing of 0.05mg estradiol could be used as an antiresorptive, although estrogen has many other roles in benefiting bone health. Evenity in itself is a dual agent serving as an anabolic as well as an antiresorptive. It’s maximal effect on CTX also started at 2 weeks after initial dose, although first few months of evenity therapy is anabolic. So your CTX at 5mo evenity would be under influence of both evenity and HRT. When CTX is reduced, P1NP usually follows due to coupling effect, therefore you see both markers suppressed.
Good studies on HRT’s effects on CTX and P1NP are hard to find. Id expect there is a dose-effect response relationship, especially at lower doses. Antiresorptive effect may reach a plateau at higher dose of estrogen. Did you discuss reducing HRT from 0.1 to 0.05mg with your physicians? After evenity treatment, the main goal is to maintain what’s gained, so I’d think adequate antiresorptive dosing is important.
I’m sorry to hear that you had reoccurrence of foot fracture as they tend to take time to heal. During healing, supportive footwear might be very important.
Btw, you had nice gain on evenity, noting not everyone will have bmd gains as advertised. You only took fosamax for about a year. It may not affect evenity that much, although it’s hard to say for sure.
Thank you for taking the time to comment on my situation. I understand your interpretation of BTM. It just seems that the overall values are very low. I unfortunately do not have a baseline to compare. I did talk to my gynecologist about reducing estrogen to .05mg. She agreed it might help to raise the CTX and then the P1NP because of the coupling effect. I did re initiate Evenity May 11, 2024 to try to finish 7 additional injections. So now I can not get a real read of the value of CTX/P1NP change due to reduced estrogen. I guess I keep looking for any additional reasons I am fracturing my metatarsals (only right foot) and what to do to improve my situation.
Thank you again for your insight.
may I ask was there a reason that you did a 5 month course of evenity last time?
My read of your overall btms is that 0.1mg HRT might already give you a reduced CTX to start with. Then evenity further reduced it and take P1NP along with it. The window of P1NP increase was simply missed because of timing.
Foot bone fracture seems occur to some ppl for whatever reason. I was surprised to know radiologist could easily see my feet bone loss just by looking at X-rays (I had my feet examined by a podiatrist for feet problems other than fractures). The podiatrist recommended wearing shoes with good sole support.
It’s great that you are starting evenity again. If monitoring btms are in the cards, it will be nice to do the lab between 2 weeks -2 months to ‘catch’ and observe the increase of P1NP. 3 month might not be too late either. Since you are restarting evenity, reducing transdermal HRT dose could be a wise move. Wish a great success for your second part of evenity!
I stopped after 5 months because of neck pain and hip pain. I agree that the higher HRT might be pulling the CTX down. I would like to have repeat labs but I doubt I can get them ordered. I think they are useful. I certainly will try.
I do wear supportive shoes and even had a custom orthotic. The custom orthotic takes up a lot of space in the shoe so it is not the best.
Hopefully round 2 will go smoothly.
I thank you again for your suggestions.
Hope your feet are doing better!