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Femoral neck -2.8: Would you start treatment now?
From Osteopenia to Osteoporosis in Five Years - what would you do?
Hi everyone, I'm 57 and was recently diagnosed with osteoporosis after progressing from osteopenia over the last five years.
My 2026 DXA results are:
Left femoral neck: T-score -2.8 (osteoporosis)
Right femoral neck: T-score -2.3
Total hips: -1.7 and -1.9
Lumbar spine average: -1.2 (although I'm investigating whether this may be masking more significant bone loss, as L4 alone is -2.2)
My previous scan in 2021 showed a lowest T-score of approximately -1.3, so the drop to -2.8 has been a shock. I went through menopause without HRT, had a demanding job, did very little exercise, and paid little attention to bone health. Although my doctor knew I was menopausal and had osteopenia, I wasn't aware how much bone loss could occur during this period. I have seen my doctor and am being referred to a specialist. MHT/HRT and osteoporosis medications have both been suggested. I am now about five years post-menopause. I don't have menopausal symptoms such as hot flushes, and my main concern is bone health.
My dilemma is deciding whether to:
Start MHT/HRT now and see whether it helps protect bone.
Go directly to osteoporosis medication.
Spend 12 months focusing on exercise, nutrition, calcium, vitamin D, and strength training, then repeat the DXA before making a treatment decision.
I am also concerned about the long-term commitment involved. MHT may be reasonable for five years, but I'm uncertain about the balance of benefits and risks beyond that, and I've read about the potential for bone loss after stopping treatment.
My questions are:
Has anyone started MHT/HRT around five years after menopause primarily for osteoporosis?
Was it worthwhile for your bone density?
Did anyone choose to monitor and focus on lifestyle changes for a year before starting medication?
If you had a T-score similar to mine (-2.8 at the femoral neck), what treatment path did you choose and why?
Looking back, would you make the same decision again?
Thank you. I'm still coming to terms with the diagnosis and would really appreciate hearing about other people's experiences.
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@agag Was the prior DEXA done incorrectly? Going from -2.8 to -1.4 sounds like the technician screwed it up.
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2 Reactions@dduh
I started bhrt at 77 and use a functional medicine provider.
If you are interested there are a number of physicians who are addressing that old thinking. Of course we are all individual with our own medical histories. Here is one
Dr Susan Hardwick-Smith on YouTube
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1 Reaction,
@njx58 they sure did, but it was a wake up call.
@dduh Because my first DEXA showed a much larger drop over five years (from -1.3 to -2.8) than expected, I wanted to rule out secondary causes of osteoporosis (as suggested by members in this group), including excessive calcium loss in the urine. Fortunately, the 24-hour urine calcium test and my parathyroid hormone (PTH) levels were both normal, which was very reassuring. My rheumatologist looked at the whole picture rather than just the T-score. My FRAX score is still low, I've never had a fragility fracture, and I'm relatively young (57). She felt it was reasonable to focus on lifestyle measures first—progressive resistance and impact exercise, adequate calcium and vitamin D, and discussing HRT and repeat the DEXA before committing to lifelong osteoporosis medication.
HRT is something I've thought about carefully. While I'm still within the recommended window to start it, I'm already six years post-menopause. My understanding is that, to maintain the bone benefits, I would likely need to remain on HRT for many years, possibly into my late 70s, and that the degree of bone protection depends on the type and dose of HRT prescribed. As I understand it, the breast cancer risk associated with combined HRT increases with longer-term use, particularly beyond about five years. If I decided to stop HRT after five years, I would most likely need to transition to osteoporosis medication anyway to help prevent the rapid bone loss that can occur after stopping. Personally, I'd prefer to avoid being on medication for the next 20–30 years if possible, so for now I'm focusing on exercise, nutrition, and monitoring, while keeping an open mind if my situation changes.
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1 Reaction@agag There's a huge difference between -2.8 and -1.4 ! No way I'd use medication for -1.4. That's mild osteopenia. If you were at -1.0, that's considered normal.
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2 Reactions@agag Thank you for that thorough explanation. Very helpful to understand the rationale. The more knowledge the better for all of us. It certainly isn't an easy decision whether it's about HRT or osteo medications. I hope you find the best strategy to work for you. My best wishes for that. I recently found out I have idopathic hypercalciuria causing me to lose calcium in my urine. I only found out because I pushed for a 24 hr urine test after emergency surgery for a first kidney stone. Ive had osteo treatment for about a decade. Never was I tested for hypercalciuria as part of my osteoporosis. Instead I ended up with kidney stones, a co-morbity. Now I feel a 24 hr urine test should be done when diagnosed with osteo. Now I am waiting for treatment and finding a doc who will treat me and getting through a lengthy waiting period. The urologist who did the surgery says he doesn't treat. At my insistence, I was referred to a nephrologist and a long waiting list. The endocrinologist I saw for osteo won't see me for almost 2 years as she put me on a bisphosphonate drug holiday before Evenity. She said, the nephrologist can deal with the hypercalciuria (despite a long waiting list). It's disheartening.
@meri8181 Recent studies have shown that REM is not an accurate scan. You need a DEXA scan. Best wishes.
From Gemini:
Recent critical evaluations published in peer-reviewed literature have raised important questions regarding how REMS (Radiofrequency Echographic Multi-Spectrometry) calculates bone mineral density and whether it functions as a direct measurement or relies heavily on algorithm estimates.
Key papers examining the methodology and output variance of REMS include:
1. Chan et al., Osteoporosis International (2026): This study investigated the underlying mechanics of REMS-generated outputs and found that a vast majority of the variance in REMS-reported BMD and Fragility Scores could be explained directly by patient age and weight input variables alone. The authors highlighted potential limitations regarding whether the ultrasound technology is directly measuring microarchitectural density changes or if demographic modeling plays an overly dominant role in the final score.
2. Zambito et al., Bone & Joint Open (2025): This analysis looked at comparative tracking limitations and noted discrepancies when evaluating specific bone density trends via ultrasound-based spectrometry versus standard attenuation benchmarks.
Why DXA Remains the Clinical Standard
While proponents point to Echolight's multi-center validation studies showing high correlation coefficients with DXA, mainstream endocrinology and metabolic bone specialists still view DXA (Dual-Energy X-ray Absorptiometry) as the gold standard for several key reasons:
Treatment Guidelines: Major regulatory bodies, pharmaceutical clinical trials, and insurance protocols universally rely on DXA T-scores to diagnose osteoporosis and qualify patients for medications like Tymlos, bisphosphonates, and other bone-building therapies.
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4 Reactions@agag
Good info and current thinking on bhrt/hrt
Dr. Susan Hardwick-Smith on YouTube
Dr. Mary Claire Havers book The Pause Life
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1 Reaction@gravity3 y
Whether I go on anabolic may be dependent on how much my dexa shows a loss. I was on hrt for years after a foot fracture in my 50's & bone density kept going down til taking fosamax.