Hi @alyssa5455,
Nice to hear from you. Thank you for sharing your medical journey. Hearing
about others' experiences always broadens my perspective. It is interesting
that your gyn suggested the possibility of HRT. I read several studies,
listened to podcasts and heard from other women my age (67) or older on
osteoporosis Facebook taking HRT before making my decision to try HRT. I
read convincing studies, listened to interviews and podcasts explaining
that the estrogen patch is safer than the oral estrogen as it bypasses the
liver and minimizes risk of blood clots. My understanding of BHRT estrogen
is that it will not independently create cancer but could increase it if
you develop it while on it and would then need to come off the BHRT.

I found a well qualified naturopath certified by the North American
menopause society who agreed to prescribe the BHRT estradiot patch and
micronized progesterone. She initially cautioned there could be a small
increased risk of blood clots due to my age and that the BHRT may be less
effective with my stiffer arteries at age 67. She checked my cholesterol
levels, breast cancer history (none so far) mammogram, A1C and weighed me.
She also suggested a coronary artery scan to check for plaque in my artery.
My plaque scan was perfect with score of zero and my other tests were good.
She recently suggested a lipoproteinA blood test, ordered another CTX to
recheck bone turnover resorption rate and vitamin d levels. Based on
coronary artery scan results, she said she has no additional concerns about
my safety than for a younger woman and that my arteries would be as
receptive to estrogen as a younger woman's. I have been taking BHRT since
August of 2024 with no side effects except I feel calmer and sleep better.
This feels like the best option for me at this time as I wish to avoid
medication, having taken Prednisone for my vasculitis autoimmune condition
with horrible side effects including osteoporosis increase. My dexa t score
was -3.5 in November 2023. My REMS Echolight score was -3 in April of 2024.
I am booked for another Echolite this month and will request another DEXA,
hoping to have a TBS this time. I have so far not fractured. The Echolight
showed my fracture risk was still borderline low. The naturopath says the
BHRT will stop further osteoporosis progression and possibly restore a
small amount of bone density annually. She is anxious to see results of the
DEXA and Echolite to be sure there has been no further loss. I am hoping
that I am still at a low risk of fracture with no further loss so that I
can remain on this maintenance plan. If my numbers have dropped a lot more.
I will have to consider other options. I will let you know of my bone scan
results.

It is unfortunate so many doctors still refer to the flawed WHI study and
will not consider HRT. It is especially surprising you met this response at
your younger age. I think it's quite possible I would have avoided
osteoporosis had I been on HRT 15 years ago and also would have avoided the
horrible symptoms of menopause for 10 years.

Let me know how things go for you and what you decide.

Hi, @alyssa5455 When I was 47, I was diagnosed with lobular carcinoma in situ. Despite its scary name, it isn’t considered invasive breast cancer but is a strong risk marker for a future diagnosis. At that time, I took tamoxifen to reduce the risk. Also at 47, I went through menopause. And I went from being a great sleeper to having extreme insomnia. At 49, I stopped the tamoxifen, but the insomnia persisted. I accepted it as a menopause symptom that I had to just tough out as my increased risk of breast cancer ruled out HRT.

And last year, at 52, I was diagnosed with osteoporosis. As I considered different treatment options, I dug deep into HRT and breast cancer, reading every study I could find. And finally I scheduled an appointment with my oncologist for a HRT risk / benefit conversation, during which I focused on my insomnia rather than osteoporosis. We had a conversation weighing quality of life against risk, and I decided to move forward with HRT with her agreement. (I should note that I am screened twice a year, alternating MRI with mammogram. This factored into our risk assessment.) My gynecologist, herself a menopausal woman, ordered it for me. Each of them, by the way, was unwilling to consider HRT for osteoporosis as “there are treatments for that”.

I started HRT the same day I had my first evenity injection. My course of evenity will be completed in August followed by a dexa scan. Will the HRT have a synergistic effect? Maybe, but I’ll never really know since I started them together. I do know that I’m sleeping better and my quality of life is so, so much better for it.

As you are looking for a doctor to help you make an informed decision, you might look to see if there is a breast clinic near you. My oncologist is with a breast clinic in an academic medical center. And definitely a new gyn.

Also, I’m curious that your endocrinologist told you there is nothing more she can do - has she already talked to you about Evenity, Tymlos, and Forteo? If not, it would be well worth getting a second opinion.

Best of luck to you as you navigate these questions.

Hi @alyssa5455 I'm sorry to hear the challenges in your drug selection going forward based on past medical history and/or family history.

The breast cancer risk associated with estrogen use does exist especially with longer term use, although the data from WHI (conjugated equine estrogen CEE and medroxyprogesterone acetate MPA were used) can not be extrapolated or applied to topical estradiol and micronized progesterone which are commonly used currently. Here is a great read:
https://journals.lww.com/greenjournal/fulltext/2024/07000/a_contemporary_view_of_menopausal_hormone_therapy.3.aspx
It reviewed breast cancer risks for estradiol and/or micronized progesterone.

According to this paper below
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.061559
Figure 3: HRT use is stratified into 3 risk groups. The high risk group is advised to avoid HRT. There are different online tools/models to calculate breast cancer risks. In case you know your mom's breast cancer type (very sorry for your loss!), you could be a candidate for gene test such as BRCA.

All these info could aid you when you meet the right obgyn to further discuss your risks.

Since you had reclast treatment for 3 years, would it be possible to ask your endo to monitor CTX (bone resorption marker) to see how suppressed your bone turnover is? If very low, it could buy you some time to seek second opinions and take time to choose carefully the next suitable treatment.

One thought, has your endo ever brought up Evista (raloxifene) - a SERM, Selective Estrogen Receptor Modulator, in case HRT is not suitable for you? Like estrogen, it's a mild to moderate antiresorptive which could be used for prevention and treatment of osteoporosis in postmenopausal women. Evista affects same receptors that estrogen does, but not at all sites throughout the body. One benefit is that it has the potential to block some estrogen effects such as those that leads to breast cancer. The main concern of using evista is the association with increased risk of clotting ~2%. Some people who are on it omit a few doses when they have to be sendentory, for example during a long flight, to reduce the chance of possible thrombosis.

Did your endo rule out any osteoanabolic as next step?

My exploring of HRT use was focused on cvd risks as I already have a mild cad (coronary arteries disease). Through the process I did notice my endo leaves the risk assessments to other physicians, she determines whether or not HRT is the appropriate agent for my osteoporosis management path. I started HRT after I completed Forteo, 11 years post menopausal.

Wish you the best in your bone journey!