Osteopenia in spine with low TBS (1.19). All else good

Have you had a FRAX score calculated? With your age, near-normal femoral neck T-score (and if no family or fracture history, no secondary causes), your FRAX is likely quite low even after adjusting for the TBS.

The medication that best targets low TBS is a PTH analog such as Forteo or Tymlos, but in reality, insurance approval might be a challenge given your T-score and no prior fracture. It might be worthwhile to see if approval is possible.

If I were in your shoes, I’d also consider HRT after completing the proper risk assessments to help prevent further bone loss. I’d do a bone turnover markers lab for a baseline. Rechecking your DXA and TBS in a year is a good idea. Please stay mindful with any exercises involving spinal flexion or twisting.

@mayblin Thank you for the reply. I'm going to see my gynecologist in January to discuss HRT. I still suffer with hot flashes, night sweats, anxiety, thinning hair and now this....I didn't want HRT in the past because the risks didn't outweigh the benefits for me, but now I'm thinking the risks are worth taking. I'll see what my doc says. My FRAX is quite low because it doesn't take into account my rather poor TBS scores. I have no family history of osteoporosis and I have never broken a bone (at least not that I'm aware of). I am thin and always have been. When I was running marathons I was even thinner! I'm very active and was shocked by my DEXA since I spent the summer building a stone wall and sawing up fallen trees. I've fallen and twisted my back in all sorts of awkward positions from skiing-could I have fractured my vertebrae without even feeling it? I agree that a PTH analog would probably be the best place to start if the HRT doesn't help. I really want to avoid any antireabsorbative medication at all costs. MONJ scares the daylights out of me! I'm told it's rare-maybe for those with great teeth-but I'm not one of those people!

soggybones, it is the loss of height that concerns me. Is it possible that there is a mismeasurement? You could have a initiated a fracture with your lifting, twisting and falling. Sometimes a small fracture will heal, sometimes it will continue to compress. I would be asking for a MRI especially of the thoracic.
Mayblin is much more reasonable. HRT is good in so many ways.
I'd want Forteo, and like you would want to avoid bisphosphonates. Forteo is much more advantageous to the trabecular bone and is protective against MRONJ. See if your doctor will agree, given your TBS. Combining Forteo with HRT can increase BMD better than either alone.

@gently Thank you for the response! I'm also concerned about the height loss. I had it measured twice to be sure it was real. I always thought compression fractures were very painful...I had minor back pain after lifting all those heavy rocks this summer, but it was so minor I didn't even entertain the thought of any kind of pain meds. Anyway, I think getting an MRI would be a good idea. I suppose that if I can prove I fractured my spine it would make it easier for me to get approval for Forteo or Tymlos....The only issue is that I believe both need to be followed up with an antireabsorbative and I was trying to avoid those because of my teeth. I suppose I may have no choice. I'm hoping I can stay on HRT indefinitely and perhaps that can help me maintain any gains.

soggybones,
you may not have a fracture. We sometimes lose height because of "normal" desiccation in the discs.
Compression fractures in trabecular bone happen gradually. The center of the bone is made up of a lacework of tiny bones. You can lose connection in a lot of those slender shafts before the vertebra loses shape. If you lose enough of those bones the vertebra can compress even without stress. Gradual compressions may not be painful hence the "silent disease."
Your doctor might be receptive to Forteo because he understands the importance of the microarchitecture of the trabecular bone. And because of the advantage of Forteo with any risk of ONJ.

@soggybones
Thanks for sharing your story. I completely understand why the DXA results surprised you. Unfortunately, the loss of estrogen after menopause can lead to noticeable changes in bone health despite good activity levels in many women. Your bone loss itself isn't severe, but the disproportionately low TBS is an outlier worth keeping an eye on.

Like you, i wanted to avoid bisphosphonates at my age (early 60s). My obgyn prescribed HRT without hesitation, though she did request a cardiology clearance. I imagine your doctor(s) will also review both cardiac and breast cancer risk as part of evaluation. Wishing you all the best as you go through that process.

@gently
"Combining Forteo with HRT can increase BMD better than either alone": I've had a hard time finding any studies showing that teriparatide + HRT is superior to teriparatide alone in improving BMD. I'll be facing this question myself in the future - curious if you have any reference to share?

mablin, this article is probably from before you were born. And maybe has been disproven. But doesn't it make sense.
https://academic.oup.com/jbmr/article-abstract/21/2/283/7593434

@mayblin Thank you! The risks I have for breast cancer are enough to require me to get both mamograms and mri's every year. My mother had breast cancer and I have dense breast tissue. It's my understanding that HRT will make my breast tissue even more dense-thus even more difficult to detect breast cancer. For this reason I have toughed it out with the menopause symptoms and avoided HRT because the risks didn't outweigh the benefits. Now I'm thinking the benefits may actually outweigh the risks. My menopause symptoms are horrible and now I'm dealing with osteoporosis. I'll ask my doctor for guidance. Best of luck to you as well!

@gently This is an interesting article. I noticed that they used a double dose of Teriparatide, 40mcg. They probably used the old HRT too, Premarin and Provera. Thanks for posting this.