@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.