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Anyone use HRT as their immediate follow-up to Tymlos or Forteo?
I'm 63 and will finish 24 months on Tymlos six months from now. At that time, I'll have 6 final months on my commercial insurance before starting Medicare.
I'm one who is probably above-average motivated to delay using a bisphosphonate to "lock in gains" for as long as possible. I don't want to do it anytime soon because I feel like a lot of changes are afoot in this field and best practices are evolving to where more and more people are going to be "allowed" to stay on anabolics past 24 months. That excites me and I don't want to do a bisphosphonate and then dampen the future efficacy of any anabolics I might be offered.
Anyway, I've been researching new-fangled approaches to drug selection and sequencing for my impending "24-months-on-Tymlos-is-now-complete" phase. Working hard and smart on a Prior Authorization for Evenity after Tymlos intrigues me as one possibility as does the use of late-start (11 years after menopause) HRT alone for my next phase.
When we touched on possibilities for this next phase (as we often do in my appointments) my endo caught me off guard because we had just gone over extra lipid testing I had done (APOB and LIPO(a) ) and when I asked him how he was "feeling" about the eventual possibility of using over-60, late-start HRT for locking in gains he said "I have no problem with HRT for you-- your LIPO(a) is near 0 and your other numbers look good. Why do you want to wait till you're done with Tymlos? Why don't you start now and get the benefits of HRT now?"
This was a 20 minute appointment and time was up and the nurse came in and I got whisked away to get my A1C checked or some such thing. I told him I had a lot more questions and would make a longer appointment very soon--he said great/good idea, that he always forgets I'm one of his only patients who does her own research and has her own ideas (?!) and he welcomed the discussion. He said he was calling in .025 patches and 100mg micronized progesterone that day, anyway, so that I'd have them available if I decided I want to get started now.
TLDR: I believe there a couple of you on here who are using HRT as your Tymlos or Forteo or teriparatide follow-up regime... (?). If so, did any of you get started on the HRT while on the home stretch of your anabolic? Or did you wait till your course of Tymlos, Forteo, etc., was complete?
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@cliffdweller
Also check out Dr. Lauren Stricher and Dr. Risa Kagan: Your Bone on and off Estrogen;
https://substack.com/@drstreicher/note/p-162890954
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2 Reactions@kfhoz
Another perspective on estradiol levels and Dr. Louise Newsome:
https://open.substack.com/pub/vajenda/p/a-master-class-in-hormone-levels
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2 ReactionsHi @cliffdweller, have you noticed any correlations between your blood estradiol (E2) levels and the timing of the blood draw in relation to a patch change? I've read that maintaining a consistent blood draw timing relative to patch change is ideal, specifically, drawing right before a patch change to capture the trough level.
Do you monitor your bone turnover markers such as CTX and/or P1NP?
A blood level of E2 reflects the degree of absorption - it can vary significantly from person to person. Even at same E2 levels, different individual can have varied degree of biological responses. Because of this, i think it makes sense to track the impact of HRT on bone health with 3 distinct tiers: 1) serum E2 level - measures delivery and individual absorption; 2) bone turnover markers (BTMs), serve as a proxy for the biological response at one point of time; 3) DXA scan for ultimate confirmation.
For example, I use a 0.025mg/day patch, a low dose, and my trough E2 level was 42pg/ml, indicating decent absorption. I've only had my level checked once as my docs are not keen on monitoring hormone levels (i will push for another lab just for my own curiosity). However, my periodic CTX results have been consistently staying below 120pg/ml, showing a strong biological response. My 1st year with HRT (post-Forteo) DXA remained stable with a 5% BMD increase in L-spine, and my DXA after 2nd year HRT is pending.
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2 Reactions@cliffdweller Thank you for this information/links. I hope that in the next 2 months, my gynecologist or my PCP will move me up to .05 patch. I'm doing alright with the tiny amount I'm currently.
@mayblin - I've read of optimal levels of E2 being 60mg/ml or even higher to make an impact on bone health. But your BTM are telling the story that we want to hear even w/lower levels of estradiol!
What T-score did you achieve with Forteo and was there an overlap with HRT for you? If you started HRT after you finished with Forteo, then the increase in the spine and stabilization of the other BMD areas is even more encouraging. I look forward to reading about your results after a 2nd yr of HRT.
My ortho dr is not a fan of chasing BTM and I haven't asked my new gyn if she will test/monitor hormone levels. I do have baseline levels on all those labs, so worse case scenario I will use a self-pay lab to track my progress now that I've finished the Evenity course.
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1 Reaction@singingbones
First, my apologies for my hurried and imprecise description in my earlier post "My 1st year with HRT (post-Forteo) DXA remained stable with a 5% BMD increase in L-spine"
Actually, my BMD gains during my first 15mo on HRT were significantly higher! See the attached image and follow the green-highlighted T-score progression at each skeletal site
I had only a one-week overlap between Forteo and HRT, which I consider negligible in terms of BMD impact. Because of the high-turnover state elicited by Forteo that lasted to the end of treatment, subsequent HRT acted as an essential antiresorptive "helper" to consolidate those gains rather than the primary driver of BMD gains. A bone specialist helped me understand the complex underlying mechanism.
Fundamentally, estrogen in mature adult bone acts as an antiresorptive - slowing down osteoclast activity to preserve existing bone, unlike during childhood and adolescence when higher levels actively support bone acquisition. This is why my primary objective with HRT is its antiresorptive effect, and the reason for monitoring BTMs ahead of DXA scans. While my trough serum E2 is 42pg/mL on a low-dose 25mcg patch, the consistent suppression of my CTX (most recent reading is 87!) is clear. This highlights that the relationship between dose, serum blood level, and actual tissue-level biological response isn't always linear or predictable based on arbitrary serum targets. For my skeleton, this low dose is functionally adequate to achieve meaningful turnover suppression.
Since my 2nd year on HRT is free from the confounding tailwind of Forteo treatment, it will be very interesting to see the upcoming DXA results. Theoretically, given such profound turnover suppression and no known secondary causes, BMD should remain stable 🤞
Please share your progress with us too!
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2 Reactions@mayblin Incredible results!
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1 Reaction@kfhoz There is an estradiol daily gel that is not really messy. It’s an alternative.
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2 Reactions@annie208 you dont need to wait. Your doc is smart. I started right away with BHRT. I took it 20 years ago for 10 years. Then took a 10 year break and then started along with the bone meds. It made perfect sense. Menopause does a destructive number on your bones because you no longer have hormones. So it was a simple "do" for me to get back on them after I read the research and I could! So here I am having -- I think (next month I do DEXA again) I think it is not hurting but increasing my chances of optimizing my bone quality. I do a mix of gel or patch. Does not matter to me.
I had a spine xray done yesterday and the difference in density was AMAZING. I am hoping it wasn't a technical difference of the xray but a real indication my bones ARE getting better. The first year result on Tymlos was disappointing, but I was not injecting in the tummy. the second year, which is forecast to be less rewarding might actually be better for me. Fingers crossed! I'll have results in late August!
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2 Reactions@mayblin
I have wanted to get CTX and P1NP, but haven’t yet. Former primary care didn’t know what they were, crossed her arms and referred me to an endocrinologist who blew me off when I mentioned bone turnover markers. My new primary care, just out of residency, didn’t know what they were, but listened, and says he is willing to revisit this. He’s reluctant to do so now because after recent hip replacement surgery (and anemia after), my labs are all over the place. He did point out that my Alkaline phosphatase (ALP) was not high, which is another marker of bone health. I had just run across that info. so I feel hopeful that he is considering bone health.; hopeful that he will work with me and perhaps step out of the recommended guidelines for testing BTM’s. My most recent DEXA 2 years ago showed osteopenia of the spine (-1.8) for the first time. I have a DEXA with TBS scheduled in the next month or so.
I haven’t noticed any significant correlations with estradiol levels in the timing, because I really wasn’t paying attention to patch changes and timing of the test. I did get a baseline before I was on hormone therapy and it was very low. I believe it was like a 6. I wasn’t even sure what the number meant when I got the test on my own, but i thought it may be useful as I learned more. I had two DEXAs before this, so I know that menopause/lack of estrogen had a huge effect on my bones, and I believe I am in the category of what they call “fast losers” where, without estrogen, I lost bone very quickly.
Besides reading NIH research, I do subscribe to the Substack of menopause experts Dr. Jen Gunther, Dr. Lauren Stricher, and Dr. Mary Claire Haver. I find Gunther to be conservative in her approach. She’s very research based which is good, but doesn’t waver if we don’t have the research to support something. which I think that can miss a lot. Dr. Haver is very knowledgeable, but sometimes leans too far out of the research. And for me, Dr. Stricher is my happy medium and my go to. Very science based and reputable, but willing to consider what we don’t absolutely know because of lack of studies. She does a monthly Ask Me Anything podcast for subscribers that I find very helpful.
That said, I probably won’t continue to chase the perfect estradiol numbers. I won’t say that I will never test again because information changes. But I’ve been getting more information on how so many things effect estradiol numbers and the FDA approved doses in research studies demonstrated that they worked. I did notice that Dr. Stricher had a Substack on estradiol absorption, referencing the study by Louise Newsome; but later changed her view of that and she does not recommend testing estradiol levels, neither does Gunther. Although Gunther’s posts tend to be oppositional in general. Consider checking these out:
https://substack.com/@vajenda/note/c-267173842
https://substack.com/@vajenda/note/p-165788009
https://substack.com/@vajenda/note/p-203003919
https://substack.com/@vajenda/note/p-149954989
https://substack.com/@drstreicher/note/p-207085614
https://substack.com/@drstreicher/note/p-162890954
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