1. < Osteoporosis & Bone Health

Effects of HRT: Alone, in Combination or Sequencing

Posted by mayblin @mayblin, Jan 17 9:22am

Have you used HRT as the sole modality for osteopenia or osteoporosis? How about using it in a therapy sequence or in combination with another osteodrug, either an anabolic or an antiresorptive? What is the outcome of such choice(s)?

After a diagnosis of osteoporosis nearly 3 years ago, I elected Forteo as my first drug therapy then transitioned to HRT afterwards. Forteo gave me a jump start on building bones: lumbar bmd +8.6%, hips r/l +4.8/2.2%, femur necks r/l +8.9/3.4%. Bmd improvements are as follows after 22mo Forteo followed by 6mo HRT (scans were done with same machine and by same tech):

Lumbar spine bmd +18%, T score from -3.4 to -2.3;
Right hip bmd +9%, T score from -2.3 to -1.8;
Left hip bmd +4.1%, T score from -2.1 to -1.8;
Right femur neck bmd +16%, T score from -2.4 to -1.6;
Left femur neck bmd +9.8%, T score from -2.5 to -2.0;
TBS from 1.264 to 1.322

So far so good but I know this is just the start of a long road ahead.

I’m very grateful for the existence of Mayo Clinic Connect. Without this forum I’d never thought HRT would be in the cards as I’m more than 10 years past menopause. Many thanks to @vkmov for initiating the thread “Transdermal HRT”, @teb for her generous sharing of personal experiences, and countless members for their in depth discussions and suggestions.

The inclusion of HRT in the management of osteoporosis isn’t mainstream, in fact it is not approved for the treatment of osteoporosis so data and evidence are lacking. It will be helpful if we could share the outcomes of HRT among those of us who have chosen to use HRT under the care of our team of physicians. Dexa results possibly with bone turnover markers and/or TBS info if available will be nice. By the way, my CTX trended down to 163 after 6mo HRT from a high of 793 at end of Forteo treatment, a change I didn’t anticipate at all.

Any comments or analysis are welcome; and best luck to us all no matter what therapy path(s) we choose!

Interested in more discussions like this? Go to the Osteoporosis & Bone Health Support Group.

dooshie | @dooshie | Feb 16 12:18pm
In reply to @mayblin "Hi @dooshie thank you for sharing your experiences and your inquiry. Yes, I went from Forteo..." + (show)
@mayblin

Hi @dooshie thank you for sharing your experiences and your inquiry. Yes, I went from Forteo directly to HRT (without testosterone). Coincidentally like you, I started HRT last July. Looks like it has held my bmd so far (per Jan 2025 DXA scan) and helped gaining more.

Looking forward to hearing your dexa results. It will be nice to get bone marker labs done to see if they correspond to dexa results.

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@mayblin…my rheumatologist is not happy with me and insists I need Evenity, and I may at some point, but my integrative gynecologist feels differently and said I could try hormones for at least 6 months in hopes that my bones remain where they were when I completed that protocol. My numbers were very severe (-4.7 spine, -3.8 hips) so pretty severe, but Tymlos for 2 years gave me a 15% improvement in my spine and 5% in my hips, so I’m praying not being on a bone building med after Tymlos doesn’t take me back to those horrible numbers. Time will tell.
I’m really active (pickleball, hiking, weights, bone loading) so one slip up could be a problem. So far, I’ve been good.
Keep me posted on ur progress and once I revisit my doc and have my next DEXA, I’ll report back.
Have a great Sunday! Rose 🌹

REPLY
bayhorse | @bayhorse | Feb 16 12:22pm
In reply to @dooshie "@bayhorse hello, my cardiologist was not against me taking Evenity, he was not familiar with OP..." + (show)
@dooshie

@bayhorse hello, my cardiologist was not against me taking Evenity, he was not familiar with OP meds, but he was very educated on HRT. He had done extensive cardiac testing on me when I first started seeing him to get a baseline of any cardiac risks I had. I had had an ablation done in my 30’s for SVT but other than that, I have no heart issues. So, not taking Evenity, as of today is my choice. To be honest, I was on Tymlos for 2 years with good results and very mild side effects, but with Evenity, I have to go into my rheumatologist’s office once a month for an injection and with our travel schedule, that would be difficult. If I could have remained on Tymlos passed the 2-year limit, I would have. I may be making a mistake not taking an OP med, I’m very active and know I may be risking a fracture. My new integrative gynecologist is much in favor of me taking hormones. She also is very educated and progressive. I will be visiting her soon and hope that my bone density is remaining stable. If not, I have a decision to make. Rose 🌹

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I so wish I could find an integrative doc who is very knowledgeable about HRT in women who have heart risks. I'm in Austin, Tx. If anyone can recommend a physician here, please do!

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bayhorse | @bayhorse | Feb 16 12:27pm

I have been warned off HRT -- I am 73, slightly more than 10 years past menopause onset, and I have cardiomyopathy. But I started wondering whether vaginal estrogen could help even in a tiny way to preserve bone density. I have been on Tymlos for 2 years, have to transition onto another osteoporosis drug, and the more I research, the longer it's taking me to decide which drug. I found a 2007 study that did find vaginal estrogen helped ever so slightly with the bones. Has anyone out there ever been prescribed it -- certainly NOT as a first-line OP treatment, but just as a little boost? I have severe osteoporosis and need all the help I can get.

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1 reply
samclembeau | @samclembeau | Feb 22 2:30pm
In reply to @goseve "Hi Gravity3. I am a 66 yr old woman with severe osteoporosis. My T-score of my..." + (show)
@goseve

Hi Gravity3. I am a 66 yr old woman with severe osteoporosis. My T-score of my hip was -3.2. I am very concerned about taking Fosamax due to thr risk of ONJ and losing teeth. I am interested in Transdermal HRT but my PCP is against it. I read that you met a functional medicine provider. I don't know of any here in McKinney, TX. Do you know if a y other Dr that would consider HRT? I've met with 2 endocrinologist and they also were against it. Thanks for any help or suggestions.

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You may want to go to a gym for HRT. They may be more up on that more recent studies than your PCP. At least that was my experience

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wondering1 | @wondering1 | Feb 23 6:29am
In reply to @bayhorse "I have been warned off HRT -- I am 73, slightly more than 10 years past..." + (show)
@bayhorse

I have been warned off HRT -- I am 73, slightly more than 10 years past menopause onset, and I have cardiomyopathy. But I started wondering whether vaginal estrogen could help even in a tiny way to preserve bone density. I have been on Tymlos for 2 years, have to transition onto another osteoporosis drug, and the more I research, the longer it's taking me to decide which drug. I found a 2007 study that did find vaginal estrogen helped ever so slightly with the bones. Has anyone out there ever been prescribed it -- certainly NOT as a first-line OP treatment, but just as a little boost? I have severe osteoporosis and need all the help I can get.

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As I understand it, there is a very low dose transdermal Estradiol patch (0.014 mg/day ) that is intended only for bone protectiveness. Something to look into, if you haven’t already.

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bayhorse | @bayhorse | Feb 23 12:21pm

Hi, @wondering1 My doctors are reluctant (or refuse) to order the patch, but perhaps they are thinking of one that is a higher dose. I was asking about the vaginal estrogen because it's supposed to pose absolutely no risk at all, so I thought I could get someone to prescribe. But I didn't know there was an estradiol patch as low as .014mg. Thanks for telling me! I will ask about it as well.

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1 reply
wondering1 | @wondering1 | Feb 23 1:20pm
In reply to @bayhorse "Hi, @wondering1 My doctors are reluctant (or refuse) to order the patch, but perhaps they are..." + (show)
@bayhorse

Hi, @wondering1 My doctors are reluctant (or refuse) to order the patch, but perhaps they are thinking of one that is a higher dose. I was asking about the vaginal estrogen because it's supposed to pose absolutely no risk at all, so I thought I could get someone to prescribe. But I didn't know there was an estradiol patch as low as .014mg. Thanks for telling me! I will ask about it as well.

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Good luck @bayhorse! My primary didn’t seem aware of the ultra low dose either before I mentioned it. I believe the brand name is Menostar.

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1 reply
samclembeau | @samclembeau | Feb 23 3:13pm
In reply to @wondering1 "Good luck @bayhorse! My primary didn’t seem aware of the ultra low dose either before I..." + (show)
@wondering1

Good luck @bayhorse! My primary didn’t seem aware of the ultra low dose either before I mentioned it. I believe the brand name is Menostar.

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My gyn said you can cut the patch to lower the dose.

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1 reply
mayblin | @mayblin | Feb 24 9:44pm
In reply to @samclembeau "My gyn said you can cut the patch to lower the dose." + (show)
@samclembeau

My gyn said you can cut the patch to lower the dose.

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Thank you @samclembeau for pointing this out! I've heard this method from a gyn also that the patches could be cut to adjust the dose especially when withdrawing from estrogen. This helps the gradual dosage adjustment downwards without the need for extra prescriptions.

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1 reply
sonodeka | @sonodeka | Feb 25 7:52am
In reply to @mayblin "Thank you @samclembeau for pointing this out! I've heard this method from a gyn also that..." + (show)
@mayblin

Thank you @samclembeau for pointing this out! I've heard this method from a gyn also that the patches could be cut to adjust the dose especially when withdrawing from estrogen. This helps the gradual dosage adjustment downwards without the need for extra prescriptions.

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I'd hoped to cut my patch, at one point, but read that there are different types. Matrix type patches can be cut without disrupting the even release of estrogen, while others, reservoir types, when cut might have a sudden release. It might be smart to check the brand you're using before cutting. I hope this information is accurate. I didn't end up cutting, got a lower dose prescribed.

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