You asked a question about whether there should be concern about your low CTX scores. The only responses to your initial query that I saw were: 1) low CTX is good and 2) others posting CTX results similar to yours.

I am going to play devil's advocate here. It seems to me that it is possible that CTX can be too low. First, I note several posts indicating that dental work is not recommended with CTX lower than 150. Second, I considered the established reference range of about 171-970...seems to me there ought to be a reason why the reference range low is about 170. Perhaps, we are just perplexed about what that reason might be (in addition to the dental issue.)

Third, I reviewed relevant sections of McCormick's Great Bones....and that produced a bonanza of info. McCormick prefers a different CTX relevant range for post-menopausal women (his suggested range is 100-375). He does not want to see anything below 100 because....

"....bone needs to have osteoclastic bone resorption. If resorption activity gets too low, it can lead to adynamic, or low-turnover, fragile bone, which will increase fracture risk and predisposed a patient to osteonecrosis of the jaw and atypical femur fractures." (P. 148.)

McCormick's take on a too low CTX score comports with my new conceptual understanding of the dynamics of bone remodeling (see below.)

He further strongly urges a testing protocol for CTX of having blood drawn a) as early in the day as possible;b) after a night of strict fasting (he says CTX can go down 20% without fasting) and c) to stop taking any biotin and collagen supps for 48 hours.

I assume you followed this protocol?

I have admittedly had trouble conceptually with what is often described as a 'dynamic process' of bone breakdown and bone creation. This process is often referenced as 'bone remodeling.' But I still search for better info about what the balance or the relationship between these 2 processes might be.

I recently viewed a video posted in one of the Connect threads. https://youtu.be/Cd0YT-OV97c?si=FHXCpupgt1A5AaQP. It really helped me understand some things.

As a result, I now see bone remodeling as similar to painting. (Chuckling is allowed.)

Everyone knows that when something needs to be painted, you just do not slap a coat of paint on top of the old paint and call it a day. Rather, you want to prepare the surface for a new coat of paint. For example, removing peeling paint and certainly doing some sanding. Proper prep work makes the difference for the application of a new coat of paint that will last.

Likewise bone formation needs proper prep of the existing bone via the resorption activity of osteoclastic cells.

Now that you are finished chuckling about my painting analogy, would appreciate any thoughts about anyone seeing flaws in my new and improved understanding of bone remodeling.

So the bottom line? If you are confident about your CTX results, it appears your bones are likely not being properly prepared for the osteoblastic production of new bone.

If it was me, I would be looking for a medical consult about what can be done to increase the CTX score. I would be reluctant to play doctor on myself even though it might be tempting to simply stop taking/reducing the post-Prolia alendronate. Perhaps some other medical condition is depressing the CTX score?