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Forteo (teriparatide) followed by HRT: My Experience
I wanted to start a thread sharing my experience with Forteo → HRT, since this treatment sequence is less discussed but may be very helpful for other women navigating osteoporosis.
I was diagnosed with osteoporosis at age 59. My lowest T-score was –3.4 at the lumbar spine, with hip and femoral neck in the osteopenia/borderline osteoporosis range. My endocrinologist ruled out secondary causes. Without a family history, postmenopausal estrogen deficiency seemed the most likely contributor, though low BMI, protein intake, and activity level/type may have played a role.
Shortly after diagnosis, I improved my diet and added weight-bearing exercise. I started Forteo (teriparatide) within a few months and continued for 22 months. P1NP was 137 µg/L at the end of Forteo.
At age 61 (11 years postmenopausal), I transitioned to HRT: transdermal estradiol 0.025 mg/day patches plus oral micronized progesterone 100 mg/day. It’s now been 15 months on HRT. CTX stayed 110–130 pg/mL after 6mo starting HRT.
Since the start of Forteo to 15 months on HRT, my results have improved as follows:
• Lumbar spine T-score: –3.4 to –1.9
• Total hip T-score: –2.2 to –1.7
• Femoral neck T-score: –2.5 to –1.8
• TBS: 1.264 to 1.34
All DXA scans were performed on the same machine by the same technician. Detailed DXA results, including percent changes from previous scans and baseline, T-scores, and TBS values, are presented in the attached spreadsheet if anyone is interested.
Between my last two DXA scans, I also used three leftover Forteo pens with off-label dosing.
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Note: I use the term “HRT” because it’s widely recognized. In medical literature, “MHT” (menopausal hormone therapy) is the standard term. In my case, I used regulated, body-identical estradiol and micronized progesterone, sometimes referred to as bHRT.
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Thanks for reading! I would love to hear your thoughts, experiences, and insights. Also please feel free to ask any questions.
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@mayblin
Thank you. This is timely for me. I had Evenity for a year with great results. I have had two prolia shots and now wondering if I could return to evenity i stead of having a lighter dose of reclast followed by evenity again. I
also began bhrt one year ago and hope that this will help support a transition from prolia.
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1 Reaction@tillymack are you considering transitioning from reclast to HRT?
@gravity3
From my own experience, CTX levels reached their maximum suppression about 6–9 months after starting estrogen, similar to what’s reported, so you’ve almost certainly achieved that effect by now.
If you continue HRT, estrogen should, in theory, provide some protection against Prolia rebound. The challenge is that the degree of protection is not studied yet so you don’t know how much to rely on it.
Reclast option: a lower dose of Reclast hasn’t been studied for Prolia discontinuation, so that brings uncertainty also. When you add the “unknown” of estrogen’s contribution, it’s hard to say what reduced dose (if any) would be safe - and it depends on what your endo is comfortable with. Good that you only had 2 doses of prolia. Oral Fosamax could be another option if you could tolerate it, since it gives more flexibility in dosing and monitoring. Either way, monitoring CTX levels could be important.
Evenity option: the paper by Kendler looked at sequences involving Evenity (2yr) -> Prolia (1yr) -> Evenity (1yr), though not specifically for rebound prevention. For the year of Evenity after prolia, lumbar spine BMD increased 2.3% while hip and other sites were maintained. Again, with HRT in the mix, the effect could differ.
Each strategy could potentially work, though there is some uncertainty with each. I’m very interested in hearing your final choice and how it turns out. Thank you for exploring untested waters.
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3 Reactions@mayblin I would be interested but my usual doctors will not prescribe either due to my age or lack of experience.
@mayblin
Thanks. This is very helpful. I am very interested in hearing what my endocrinologist has to say about this idea. Uncharted waters. He has not been open to ctx monitoring in the past but in his favor is his willingness to consult with other endocrinologists. I will report back after my appointment in November. Thanks again.
@tillymack To clarify, I should add that lack of experience refers to lack of experience on the part of the endocrinologist in managing HRT issues.
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1 Reaction@mayblin
I've already taken 5 years of fosomax. Dare I take it again in this situation?
How did you determine dosage of HRT? I've been on bio-identical HRT for many yrs, but never with bone health in mind...except for now. It causes me think that my dosage may need to be increased with a diagnosis of OP.
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1 Reaction@gravity3 You’re right to wonder about using Fosamax again after 5 years of prior exposure. In my view, Reclast is essentially equivalent to additional years on Fosamax in terms of bisphosphonate exposure at this point, but it’s always best to confirm with your endocrinologist.
In your case, your prior Fosamax use and ongoing HRT both could help lower rebound risk after stopping Prolia. The decision really comes down to balancing total bisphosphonate exposure, residual effect, HRT coverage, dosing flexibility, and practical factors - Reclast works quickly and reliably with a single infusion, while Fosamax takes longer to reach full effect and depends on how well it’s absorbed.
It’s worth bringing up the idea of monitoring CTX, since it can help confirm that the transition is going smoothly. And in case Fosamax alone isn’t enough, Reclast can always be used as a backup.
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1 Reaction@tillymack
Estrogen isn’t approved for osteoporosis treatment, so an endocrinologist should decide whether HRT is appropriate based on your bone status and overall health. You can always get a second opinion if unsure.
Risk assessment is best handled by specialists like cardiologists or OBGYNs. In the end, it’s a shared decision between you and your care team, balancing bone protection, overall health, and personal preferences.