Forteo (teriparatide) followed by HRT: My Experience

@mayblin Congrats on your improvements and being so informed to choose the right path for you. As much as I am intrigued by HRT for follow up, I am also hesitant because prior to my quick decline in bone density, I had been taking estradiol for several years I stopped after menopause and that's when I started fractures . I had been unable to tolerate bisophamates and because of that, I think Forteo worked well for me. One shot of Prolia after two years of Forteo was a disaster on my dental health, so I switched to Raloxifene , which held my gains for 8 more years. Raloxifene is easily available and covered by my insurance. Pretty much zero side effects. It says it acts as a hormone and protects agains some breast cancers. Feels like a safer option to use this again, and back up plan would be to go back on Forteo if I needed another boost in 5 years time. Reclast sounds too risky and Evenity is made by Prolia, so I do not trust it either. Tricky though, because it seems if you don't follow advice of your endocrinologist they will just refer you off to someone else and I believe we need a Endocrinologist special authority request to get Forteo, especially a repeat course of it. Scary journey. I am a poor case study because since my 13 compression fractures, they can no longer read my spine for bone density, which is where Forteo mainly does the most work.

@broken13
Try REMS bone scan; it should work for you.
"Radiofrequency Echographic Multi-Spectrometry (REMS) technology is designed to work in cases of multiple spinal fractures, making it a suitable diagnostic tool where conventional DXA scans might fail."
REMS provider search: https://www.echolightmedical.com/en/find-your-rems-center-in-usa/

@psmnonna thanks so much for the valuable information. You are in the same age range and years of being postmenopausal. I do have some calcification in my arteries though. When I did go to see a hormone doctor, she said there is a risk in the first year of using a low dose estradiol patch (along with progesterone) of some plague dislodging and causing a stroke. That scared the daylights out of me, so I didn’t move forward. She was unable to give me a percent risk!

@lynn59
That's quite understandable! It is so hard to weigh risk vs benefit and try to make the safest choice. Especially with osteo meds and their possible side effects.

Have you looked into vitamin K2 as @kathleen1314 suggested? I use D3 and K2. Also magnesium. Surprisingly my cholesterol total dropped in this last year and maybe the K2 helped?
I wasn't aware of a connection there as I was using it to help direct calcium to the bones. We learn more everyday, don't we?

@kathleen1314 Thank you, but that link does not seem to open for me. Is that (REMS) available in Canada?

@broken13
ok, for usa let's try this:
https://us.echolightmedical.com/find-a-provider/
and for Canada, does this work?:
Canada Locations
UC Baby 3D Ultrasound locations (specifically New Westminster, BC, and other locations listed via bonescan.ca)
SonoHealth CA

Thank you for the alert that the link was not working, 🙂

@mayblin thanks as always for response. I have talked to my cardiologist about it and he felt I should stick with the osteoporosis medications, as he said there are decent choices out there now. He wasn’t completely against BHRT, but he felt the risks may not outweigh the benefits. He said pulmonary embolisms are likely my biggest risk with estrogen. I’m 18 years post menopausal and 67 years of age. You were right on the cusp of the medical arbitrary cut-off of 10 years post-menopausal and 60 years. of age. I do really want to go on it, but I am afraid. Strokes and embolisms are killers, not just side effects. And that’s what scares me, yet I’m still strongly pulled to it as it just feels more right than Reclast.

@lynn59
You’ve really nailed the key difference here: I’m at the proximity to that 10-year postmenopausal line and you are a bit further past it - as the window of opportunity shifts, the risk profile naturally shifts too. Even if all our other baseline factors were the same, that gap puts you on slightly shakier ground regarding cardiovascular risk.

Your cardiologist’s concern about Pulmonary Embolism (PE) is likely based on the WHI study, which is the biggest randomized clinical trial (RCT) we have. However, that study used oral CEE (Conjugated Equine Estrogen or Premarin), which we know spikes clotting factors in the liver. While some observational studies show that transdermal estradiol (the patch many physicians prefer nowadays) doesn't seem to increase clot risk in the general population, it’s not 100% conclusive. The Cleveland Clinic website notes that the data quality being "average".

As for the "plaque destabilization" your hormone doctor mentioned, that also stems from the oral estrogen data in the WHI where CEE was used. For the patch specifically, the ELITE trial is the most relevant study. Essentially, for women in our cohort (more than 10 years out), it showed no heart benefit and even a potential hint of harm, though again, it wasn't definitive.

One thing to keep in mind, the dose (Premarin 0.625mg oral) used in the WHI that showed a real bone protective effect was roughly equivalent to a 0.05mg/day estradiol patch. The Menostar (brand name, transdermal patch also) you mentioned is an "ultra-low' dose at 0.014mg/day.

In case you decide to seek a second opinion for a more detailed cardiovascular risk assessment, there are a few labs and tests you might want to request. Having these data can make your decision easier: ApoB and Lp(a); carotid ultrasound (could include abdominal aorta and lower extremity as well); genetic clotting panel. Bone turnover marker CTX in case you need to figure out estradiol patch dosing.

Hope this info helps somewhat. I’m still learning and keeping up with the latest data myself, but I thought these details might help you weigh the possibilities.

@mayblin Congrats on your improvements and being so informed to choose the right path for you. As much as I am intrigued by HRT for follow up, I am also hesitant because prior to my quick decline in bone density, I had been taking estradiol for several years I stopped after menopause and that's when I started fractures . I had been unable to tolerate bisophamates and because of that, I think Forteo worked well for me. One shot of Prolia after two years of Forteo was a disaster on my dental health, so I switched to Raloxifene , which held my gains for 8 more years. Raloxifene is easily available and covered by my insurance. Pretty much zero side effects. It says it acts as a hormone and protects agains some breast cancers. Feels like a safer option to use this again, and back up plan would be to go back on Forteo if I needed another boost in 5 years time. Reclast sounds too risky and Evenity is made by Prolia, so I do not trust it either. Tricky though, because it seems if you don't follow advice of your endocrinologist they will just refer you off to someone else and I believe we need a Endocrinologist special authority request to get Forteo, especially a repeat course of it. Scary journey. I am a poor case study because since my 13 compression fractures, they can no longer read my spine for bone density, which is where Forteo mainly does the most work.

@mayblin you are clearly educated in the medical field and communicate your knowledge very well. Thank you very much. Risk/benefit. It’s a tough decision, as I hate to create a new problem if I’m not gaining something that is hard to gain by other means. I’m not sure if heavy weight training and adequate calcium/vitamin D is enough to maintain my gains over the next ten years (after teraparatide and Reclast). I don’t think I’m brave enough to skip the Reclast and go straight to BHRT:). I want to make sure I keep those hard earned gains!