HRT Safety

Hi @mayblin , Debbie. It has been many months since you posted and I am wondering what you decided with HRT. I read through that study and felt encouraged by the findings - thank you for posting it.

I am 55. I have Osteoporosis (as did my mother, aunt, sister, and maternal grandmother). I was treated with Reclast over the last 3 years with the outcome of no change in Dexa scores. My endocrinologist said she has nothing further for me but suggested I consider looking into HRT (she said she doesnt know much about it).

I am particularly hesitant because my mother was given HRT in the 1990s post-menopause for Osteoporosis, did very well on it, but then was diagnosed with Breast Cancer in 2018. I too experienced cancer - I had Hodgkins Lymphoma in 2001. Based on these last facts, and my being 5 years past menopause, a gyn I visited recently quickly dismissed my idea of considering HRT and would not even discuss it with me. She said simply, "it's too late. You would have needed to take HRT in the first five years after menopause for HRT to help, and anyway you have a family history of Breast Cancer so no reason to think on it further." I found that perspective to lacking in recognition of the latest studies on HRT, the nuances of which HRTs do what, and the dooming realities of Osteoporsis on quality of life and mortality rates.

I am seeking a doctor who can actually give me a nuanced analysis and help me decided if HRT is in fact a good and safe idea for me. I would welcome any feedback / insight from anyone here.

Thank you all in advance!
Alyssa

Hi @andreamayo
It has been many months since you posted and I am wondering how you are doing with HRT.

I am 55, have Osteoporosis, and was treated with Reclast over the last 3 years with the outcome of no change in bone density scores.

I am hesitant to try HRT because my mother had HRT in the 1990s post-menopause for Osteoporosis, did very well on it, but then was diagnosed with Breast Cancer in 2018 and died from metastatic Breast Cancer in 2023. I too experienced Cancer - I had Hodgkins Lymphoma in 2001.

Based on these cancers, and my being 5 years past menopause, a gyn I visited recently quickly dismissed my idea of considering HRT and would not discuss it further. I found her perspective to lack in recognition of the latest studies on HRT, the nuances of how the different types of HRTs affect different population segments, and the dooming realities of Osteoporsis on quality of life and mortality rates. I just don't know if ignoring all HRT is the best decision.

I live in NYC and am seeking a doctor who can actually give me a nuanced analysis and help me decide. I would welcome any feedback / insight from anyone here.

Thank you all in advance!
Alyssa

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!

Dear @debbie1956, @mayblin , and @newenglandtransplant. Thank you so very much for your kind, thorough, and thoughtful responses!

Debbie1956,
Great idea to consider working with a naturopath and especially certified by NA Menopause Society - I had not thought of that and will look into it.
Indeed, I have learned how BHRT transdermal and micronized progesterone can be safe tho have risk of blood clots.
Also helpful to be reminded to ensure I include a plan for the appropriate frequency and type of testing such as lipid panel, CTX - turnover/resorption, coronary artery, vitamin d, ++.
Sorry to hear you had a vasculitis autoimmune condition and needed Prednisone - can only imagine the side effects and impact on bone integrity.
I also have only been learning about the REMS Echolight test so need to ask about that.
So incredibly frustrating to think that you could have avoided so much trauma and the same for me if the WHI study had not mislead a whole generation.

***
Newenglandtransplant, just a quick note - my mom had invasive lobular breast cancer. I am very glad your regimen includes bi-annual MRI and Mammogram screenings. please consider adding, if you don't already, always telling the technicians about your LCIS. My mom's gyn detected the tumor during a routine annual breast exam. It turned out this had been evident on mammograms in at least one prior year, but had been overlooked. By then, the tumor was stage 4. I recently read an article reminding that technicians and radiologists have varying skill levels and and moments of attentiveness (like anyone) and supervising radiologists can sometimes sign off without checking the scans. I know this sounds paranoid, but we were told later that "lobular masses are difficult to see on scans." Maybe the doctors were just trying to protect the radiologist from litigation (which we did not pursue for many reasons). Just please be extra vigilant.

I am now seeking new providers, will look for a breast clinic, and will ask about anabolic/bone forming medications. My lowest dexa score is -3.3 so I don't see why my endocrinologist was so ready to just have me wait and see, only ensuring osteo-specific exercise and vitamins.

***

Mayblin, thank you for sharing the study - extremely helpful. Such a reassuring statement: "A thorough literature review affirms that, in postmenopausal women, estradiol (E2) effectively relieves vasomotor symptoms and symptoms associated with the genitourinary syndrome of menopause, that is, vulvovaginal atrophy symptoms, while maintaining bone mineral density. The evidence also supports that estrogen–E2 is associated with decreased breast cancer and cardiovascular mortality."

I will definitely look into and ask about Evista (raloxifene).

I keep seeing references to "prior history of cancer and/or breast cancer or family history of either" often negates candidacy for HRT, and I know there a studies showing increased likelihood of recurrence, but I have not yet come across a study showing use of the newer forms of HRT and increased incidence of breast cancer. It certainly makes sense to consider this, I just would like to see more data so will keep looking.

I do understand that my primary focus of treating Osteoporosis is not aligned with the current prescriptions of HRT. I just want to try to avoid missing out on something that could at least maintain my bone density/integrity while also boosting the many other organs and systems that so heavily relied on hormones pre-menopause.

Thank you again to all three of you and I will stay involved here to share updates and see if I can help support in any way.

All the best for now!

I see this is an old post, but wanted to tell you that when I get a stress test, it is the nuclear stress test -- no treadmill. I don't know whether it involves contrast, but you could check.

@mayblin that doesn't make sense to me. The part where you say:
"The cardiologist I consulted said if ldl-c can be controlled under 55, there will be little chance for more plaque to build up. Also, both cardiologists like statin therapy to be in place (to stabilize any existing plaques)." I might disagree. If one has CAD Coronary Artery Disease, that may not be true. I am now on LEVEQIO, which is a notch up, which did lower cholesterol and stopping plaque deposits. Plaque deposits with artery diseases are not entirely controllable, is my understanding without added measures. Keeping cholesterol in line is part of it. Statins are part (I can't take them), drugs like LEVEQIO, exercise and low fat diets.
Happy Valentine's Day! No fatty steaks for this girl! I love restarting the BHRT since last fall! I'm sure the hormones will help with the accelerated bone deterioration experienced after stopping the HRT, at 58, when the old info said we should after being on it for 8 - 10 years. Now we can restart at any age, too!

I have both breast and my mom died of ovarian cancer. I am on Bio Identical hormones. @alyssa5455. There are options for carefully doing this. The dosages and "bio" part and balancing - and testing periodically (CA125 blood lab, annual pelvic ultrasounds, and mammograms) are the way to manage. I was also genetically tested and use that info as well into incorporating a risk/balanced approach. Please read the research, make notes, and ask your doctors. Be sure they are current.

@loriesco thank you for sharing your experience. Your advice is very helpful and validating.