HRT Safety

@mayblin I was initially prescribed 25 mcg/24 hour patch (Estradot), transdermal patch 2x/week with progesterone, micronized 100 mg capsule, 1 capsule QHS -- copied from ND's printout. I have a follow-up appointment next month to see how I'm tolerating this low dose. I recently had 24 hr calcium urine, parathyroid, A1c, cbc and metabolic blood work and CTX from other M.D. and ND I provided results from to women's health practitioner. The P1NP isn't available in this part of Canada, but I plan to get it across the border in Washington State. The menopause ND referred me for a type of coronary scan I haven't had yet and can't recall the name of. I will ask for another CTX in 6 months at my follow-up appointment. I have been on a minimal low dose statin for years I recently cut in half after starting Berberine supplement. The Berberine further reduced my LDL, triglycerides and A1c with reduced dose of Crestor statin, so I'm continuing Berberine combination!

Thanks for recommending "Great Bones", Yes I have read the entire 700 page book which was worth every page! That book has a vast amount of vitally important information I couldn't navigate this situation without. I know Keith McCormick doesn't promote HRT for women my age, with such low score and recommends it for prevention rather than regaining. There seems to be new information lately about the benefits and safety of HRT even for women long past menopause. I recently watched an interview with McCormick in which he states he has changed his position somewhat on HRT. I'm not hopeful the HRT can reverse my loss but hope it may stop the progression. My REMS Echolight fragility score showed incredibly that my bone quality was still on the border of green zone low fracture risk which may explain the mystery of why I haven't fractured yet with spine at -3.5! The REMS results were similar to DXA at -3 spine and -2.6 total hip compared to DXA at -3.5 spine and -2.5 total hip. I'm hoping with some quality of bone remaining and avoiding a fall I may be able to cope. I hope to start HRT in the near future with naturopath who specializes in it and menopause, but haven't consulted with her yet so not sure what she will recommend. I will have another DXA in 6 months, a year from my last. The internal medicine doctor from the Osteoporosis Clinic in Vancouver recommended Evenity which is at least an anabolic I would want. I would have wanted Tymlos if I chose a medication, but it appears Tymlos isn't available in Canada. I have read many of your posts on Tymlos which have been so informative and helpful for me. Thank you so much for sharing all your experience. The doctor said Forteo is available for a mere $12,000.00 a year! Evenity costs $8000.00. But even the cost is not my first reason for wanting to try all my options first. I may eventually book a video appointment with Keith McCormick if he still offers this. (Far less expensive than the medication costs!) Thank you again for responding.

@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.

@debbie1956, They record and repost soon within a week of their presentations so you will definitely be able to watch it after the fact! 🙂

Hi Debbie1956. I’m from Canada too. We have a new bio-similar, ONERO, available in Canada that is half the price of Forteo. I started it 3 months ago. At first I had some serious side effects (extreme fatigue, heart palpitations) but I stuck with it and the side effects disappeared after a month thankfully.

I’m 65 years old with T-scores similar to yours. DEXA shows -3.3 in spine and -2.8 in hips. My REMS scan showed slightly better results and my bone quality was still in the green (bordering orange). I haven’t fractured yet. I downhill ski fairly aggressively, backcountry ski, and cross country ski in the BC during the winter months, so I felt I had to build bone to continue doing these sports. I was reticent to try Evenity as it is relatively new compared to the use of teraparatide, plus I have a family history of cardiovascular problems, so until speculations of it causing heart issues are proven wrong, I’m sticking with ONERO for two years, likely followed by an oral bisphosphomate or maybe Reclast (although that makes me a little nervous). I’d love to try HRT, but cardiologist says since there are other options to mitigate bone loss open to me right now, it’s probably better to use those (I’m 17 years post menopause). I hope after 3 years of drug therapy (2 yrs ONERO, 1 yr Actonel), I can take a drug holiday for at least 3-5 years. Then I might try Evenity? Or another round of teraparatide?

Good luck with your journey and I’m sure I’ll be reading your input to this site again. We have some wonderful contributors.

Hi Debbie1956. I had a couple of phone consultations with Dr. McCormick. At the time (1 year ago) I had just learned that my spine was -3.1. He said I was on the cusp of needing a medication and recommended an oral bisphosphomate, until he found out I didn’t plan on giving up skiing. Then he recommended Forteo. A very well respected Canadian endocrinologist agreed with him, and prescribed ONERO, a bio-similar recently introduced by a Quebec pharmaceutical company. I’ve been on it for 3 months. It took me 9 months to do my homework, settle with a decision that was right for me, and find a practicing endocrinologist close by that would prescribe what I wanted to do.

I got a new baseline DEXA at a different hospital as they plan on getting TBS software. My T-score with that machine was -3.3 for my spine. I’m not sure if I’m lost some density in the 9 months that I was trying to decide on a course of action, or if the new number is simply because I changed machines. I was very careful with my diet and nutrition intake in those 9 months, and did strength training regularly as well. Perhaps not as much I wanted for 3 of those 9 months due to a knee injury backcountry skiing.

My cardiologist is an advocate of HRT if menopausal symptoms are intolerable, but he did say it does increase the risk of breast and cervical cancer, and can cause clots in the lungs/legs, so in his opinion those risks aren’t worth the benefit of taking it just to maintain or improve bones now that we have more pharmaceuticals for bone on the market.