HRT Safety

I found this interview on bioidentical hormone safety with Margie Bissinger, P.T. and Dr. Felice Gersh, M.D. integrative health gynocologist, informative and reassuring if you haven't seen it:
https://www.google.com/search?q=Margie+Bissinger+Felice+Gersh&sca_esv=64160ab7fa5a873f&sca_upv=1&ei=FrZmZqSJJc-_0PEPte_C2QE&ved=0ahUKEwik7Mn_y9CGAxXPHzQI

@debbie1956 I wish there was more definitive research on HRT and breast cancer. I am still confused and taking the precautionary approach. I wish I could use HRT for my general health and even for bone maintenance- after medications- but my history of cancer, for me, makes HRT a big no and I worry that this matter has not been adequately settled as yet for others.

Dr. Gersh's video is great but she does not seem to understand the risk of recurrence for hormonal breast cancer continues to go up even after 5 years. In fact risk rises forever for hormonal cancers, She implied that HRT would not be approved for more recent breast cancer but might be appropriate after 5 years and that is just wrong, based on risk increase over that time.

Apparently the idea in her video and the study posted above is that estrogen (estradiol) does not cause hormonal cancer but can make existing cancers grow (or recur, spread). But there are still problems.....

Dr. Gersh also does not seem to understand that clear margins and lymph nodes does not mean that no cancer cells are circulating in the body. I read once that doctors should never say "we got it all." That is just not how it works.

I also wonder about women (and men) who have breast cancer that has started but is not yet detectable. What will hormones do in that case? The statistic of one in 8 women getting breast cancer is real and the majority are over 60.

In the study posted by @gently, the statistics for risk reduction for breast cancer with HRT- (except for combos with progestin/progesterone or progestin alone, which raise risk) were really reassuring to read. Much more convincing than Dr. Gersh. However I did note that HRT was mostly prescribed to women without an "intact uterus." What does that mean for the study? It is unclear. Here is the conclusion:

"Our study suggests the possibility of important health benefits with use of menopausal HT beyond age 65 years. The use of ET, mostly prescribed to women without intact uterus, can protect against risks of all-cause mortality, developing cancers (breast, lung, and colorectal), CHF, VTE, AF, AMI, and dementia. The implications of EPT for women who still have their uterus are less clear. The use of EPT does not increase risks for almost all conditions but does increase the risk of breast cancer. However, low dose of transdermal and vaginal EPT (especially E+ progestin) can mitigate the risk of breast cancer. In general, risk reductions appear to be greater with low rather than medium or high doses, vaginal or transdermal rather than oral preparations, and with E2 rather than CEE as emphasized by others.35

Our follow-up began when women entered Medicare at about age 65 years, but it is likely that many of them started taking HT closer to the time of their menopausal symptoms and continued it into their Medicare years. If so, our positive results align with the timing hypotheses36 that asserts that HT use early in menopauses is better than later, but extend it by reporting positive effects with usage continued into Medicare years. Our findings offer important insights into the variations among different menopausal hormone therapies, which could assist in tailoring postmenopausal HT on an individual basis."

My intention is definitely not to promote HRT over OP medications. I have no investment in promoting HRT. I thought the study you quoted from my Medscape post up top I opened the discussion with, which Gently kindly posted the direct link to study from, might be of interest to those on HRT or considering it. You are extremely well informed about the risks of HRT with your history of breast cancer . With your history I would also be extra cautious, vigilant and scrutinizing of any study or "expert" opinions as you should be. We all need to be extremely cautious and informed about our health conditions and any treatments we consider. I have regrettably been terrified of HRT since menopause due to the WHI study and with no history of breast cancer wish so much now I had looked into it sooner.

With your knowledge and health history, you look at HRT studies and presentations with a more informed and critical eye which benefits us all. I thought Dr. Gersh presented some valid and helpful information but did also wonder about breast cancers not yet detected "hijacking the estrogen" as she explained. Dr. Gersh also doesn't go into specific treatment methods and doses, as the Menopause study does, such as transdermal vs oral and so on.

I received my advanced OP diagnosis 6 months ago. At this time I am still in the decision making process and investigating all my options. At age 67, I am looking at a long term lifetime plan I can live with weighing the benefits and risks, side effects and quality of life. I have a history of severe medication side effects prescribed for other diagnoses with some causing permanent damage. OP drugs can also pose serious health risks such as heart issues, stroke, future fracture... so I am willing to look at HRT to possibly stop progression, though well aware it will not build bone. I am not under any illusion I will never fracture because I haven't yet and still feel fine as this disease is a silent killer. Reading about fracture experiences from people like you is invaluable information and so appreciated.

As Keith McCormick says, the BMD score is only part of the picture. Bone quality is equally important. He says bone quality can improve a lot before BMD scores improve. My fragility bone quality score on the REMS Echolight gives me some comfort as it puts me still close to good quality zone amazingly with my REMS spine T score at -3. The combination of my REMS bone quality score and REMS T score reduces my fracture risk considerably compared to my FRAX score based only on the DXA . The DXA scored me at -3.5 but DXA alone doesn't measure bone quality. Dr. Kim Zambito, Orthopedic surgeon, explains the REMS report much better than I can: https://www.youtube.com/watch?v=v0tclg8LYAo

Bone quality measurement can go the other way as well. Someone with a fairly good BMD T score can have poor bone quality putting them at high risk for a fracture they are unaware of with misleading BMD scores. A TBS is another method for measuring bone quality which I hope to obtain. My hope is that if I can maintain my present bone quality and halt the progression of bone loss on my next DXA in November, I may be able to avoid OP medication. However, I am a realist and will consider future medication if I continue to lose BMD.

@windyshores I meant to ask you what side effects you experienced with Evenity? This is the medication that was recommended for me. I would want an anabolic but this would not be my choice. I am wondering why it requires a follow up antiresorptive when it is a combined anabolic and antiresorptive medication. If anyone else knows the answer, please let me know.

@debbie1956 that is a very insightful comment. The reality is that Evenity is so new that studies are still going on. I have read there is a study with a bunch of combinations (I won't remember them all): 6 months Evenity and 18 months Reclast, or 12 months Evenity and 12 months Reclast for instance. In that study the point is, can Reclast be substituted for the antiresorptive part of Evenity?

My doctor said they actually don't know everything about how Evenity works. It is actually not a strong anti-resorptive but is very potent because of its inhibition of sclerostin. We need more research and it will take time!

I don't like to say too much about my side effects because most people do so well with so few side effects on Evenity. I have lupus and neuropathy and some other things and have a history of weird sensations. Evenity gave me burning, tingling sensations that were beyond what I could tolerate and I tolerate a lot for my bones! A few others have had this but it is very rare. It is listed in side effects on the Evenity site as "tingling" and I have seen "paresthesias" listed as well.

Evenity "turbocharges" bone density/growth (I read that term!). I had some concerns about the function of sclerostin throughout the body but Evenity was only two years out when I decided on Tymlos. I am sensitive to meds and Tymlos felt safe with its adjustable dose. As you may know, I could not handle the full dose and went down to 1/4 dose and ramped up. I had excellent gains on Tymlos.

My doctors have not followed Tymlos with Evenity for any other patient but I convinced him. I did 4 months, two of them 1/2 dose. This week I am doing a 20% dose of Reclast (due to kidney disease and afib). We have to make these meds work for us!

@debbie1956 I just noticed this:

" I have a history of severe medication side effects prescribed for other diagnoses with some causing permanent damage. OP drugs can also pose serious health risks such as heart issues, stroke, future fracture..."

If you read the actual study on Evenity, there was no difference in cardiovascular risk between Evenity and placebo. There was a small but statistically significant difference with alendronate (Fosamax). I have read two analyses: one says this might be because alendronate is slightly protective, and one said this result was from chance, and tried to prove that.

The occurrence of jaw necrosis and atypical fracture applies to anti-resorptives like bisphosphonates and Prolia, and to a lesser degree the second half of Evenity. These are pretty rare and happen more to cancer patients on high doses. I have been told that bisphosphonates are relatively safe in this regard for 3-5 years and Prolia can be taken longer (but McCormick suggests not doing more than a year and a half due to rebound).

I felt really safe taking Tymlos because the dose is adjustable. When the full and half dose both were tough, I started again at 1/4 dose and moved up slowly, and eventually had amazing gains. I am sensitive to so many meds, foods, scents etc. etc. so I was so grateful to be able to take it.

@windyshores thanks for all the info. I have an autoimmune blood vessel disease and find the warnings on the Evenity website concerning. Like you I am very sensitive to medication and can get side effects not even listed. Too bad Tymlos is not an option for me here. Thanks again for all your information, resources and shared experience.

@debbie1956 can you do Forteo?

@windyshores it sounded like I could choose Forteo when I asked. Doctor thought Evenity would work best, but as mentioned, I'm hoping I might halt progression with other interventions before next scan when I'll make decisions. The cost in Canada is staggering without government coverage unless one has already fractured! But like I said that's not my top reason for medication concerns.

I just started HRT at age 56 for bone health. 6 weeks in and I feel fabulous.
I'm in Canada and as I understand it my Naturopath could prescribe it but my MD was only able if I cited hot flashes or other uncomfortable menopause symptoms.