There’s a lot here to unpack. Apo-E (Apolipoprotein E) is involved in the metabolism of fats. Every human inherits one copy of the gene. There are three variants of the ApoE protein: e2, e3, and e4. The combination of these variants determines your ApoE genotype. For example, you could have a 2/2, 2/3, 3/3, or 3/4 genotype, among others. Some combinations can be protective, neutral, or harmful. I have the ApoE 3/4 genotype, which is associated with an increased risk of both Alzheimer's disease AND cardiovascular diseases. The most feared one is 4/4 genotype.

Apo-E binds to lipids to form lipoproteins. To simplify things, because of my APOE 3/4 allele, my body struggles to clear LDL efficiently. This causes LDL to linger longer, leading to oxidation and increased inflammation.

My understanding of Lp(a) and APOB is the same as yours except
Lp(a) is treatable with three medications available today. However, these medications cannot fully address Lp(a) in a way that is highly effective for those with high levels of it. They are approved for lowering LDL and not specifically for Lp(a). Despite this, I believe they should still be used. Statins, for example, can increase Lp(a) by 8-24%.

Repatha can reduce Lp(a) by an average of 27%, Praluent can reduce it by about 25%, and Leqvio can also lower it by around 25%. Both oral and transdermal estradiol can reduce Lp(a) by up to 22% in postmenopausal women, but as we know, both estradiol and Lp(a) can also contribute to plaque instability in postmenopausal women who have heart disease.

Most doctors want to increase statin dosages to lower LDL to very low levels with people that have heart disease and not address Lp(a). But why not use one of these three medications to treat both high LDL and Lp(a) until newer Lp(a) drugs are released? The main obstacle is the complex approval process and insurance challenges. Repatha and Praluent are covered under Medicare Part D, while Leqvio is covered under Medicare Part B and is generally easier to get approved. I have been approved for Leqvio but still waiting to start it.

I’m not sure if calculators are always helpful. You can have a CAC score of 0 and still experience a heart attack. My MESA score with CAC is 4.5%.

I had a hysterectomy (uterus and cervix removed) when I was 44, 1994. Afterward, a coworker gave me a book about bioidentical hormones, and I became aware of the potential for bone loss, even with intact ovaries. Around 1995, there was some news about testosterone helping women with bone health and libido.

I used the compounded bioidentical hormone doctor my coworker recommended for estradiol for about a year and also a had a Dexa scan for a baseline. Then I added testosterone cream a year later after hearing about it in the news. After a year of testosterone I had another Dexa scan (I was paranoid about osteoporosis). The results showed improvement with the testosterone. Two years later, the doctor moved to a different state, and when I tried to find another doctor to prescribe testosterone, many of them were horrified and I couldn't find anyone who would prescribe it.

I became overconfident and went for about 12 years without a DEXA scan. In 2022, I had one and found out I have osteopenia. I had another scan June 2024, and the results showed minimal change. The last June scan, I had only been on the Estradiol 0.025 patch for about 2-3 months, so I don’t think it had any effect on my DEXA results. I do believe that adding testosterone and increasing my estradiol patch to 0.05 will make a difference, but I won’t know for sure until June 2026.

I’ve seen two endocrinologists that don't believe in bone markers. I would like to have them done, but I’d have to find a doctor who would actually perform them. There isn't any facility here doing TBA scoring for cortical bone. Both doctors said they wish there were but it was about $.

When I found out about my osteopenia, I was very focused on preventing osteoporosis. I joined Mayo osteoporosis forum to learn more. After reading people’s experiences with osteoporosis and medications, I became scared. That fear kicked off my journey with hrt, which ultimately led me to discover I have cardiovascular disease. It’s been quite a journey.