Looking ahead after Tymlos: Reclast, Evenity or HRT?

@drsuefowler, your comment about the impact of estrogen and progesterone on osteo oclasts and osteoblasts is interesting. I hadn't heard that progesterone increases osteoblasts and estrogen decreases osteoclasts but it makes sense. My naturopath physician certified by N.A. Menopause Society, said that the BHRT may give me a small amount of gain and if it did, I would need to remain on the BHRT to maintain any small gains. My REMS Echolight scan showed an increase from spine t-score -3 to -2.6 over a 10-month period. I had also been taking supplements recommended by Keith McCormick. My CTX bone turnover was reduced by 80% from 688 to 138 over an 8 month period. I began taking BHRT at 67 lin July 2024 and have so far not fractured nor taken any OP medication, I wish to avoid, though I would not refuse it if things took a severe turn for the worse. I will have another CTX next week.

@debbie1956 That's fantastic you had gains from HRT! No osteo meds, just supplements and HRT! I think a gain like that in just 10 months is wonderful! Just what I needed to hear after being on HRT for only a week now. So hopeful it will help increase any gains I get from Tymlos in the next few months. If it works out it would be nice to just continue HRT after Tymlos to see if it can maintain gains or continue to build. I'm not interested in bisphosphonates or Prolia as a follow up. Too many negatives, even though they may be rare, that outweighs the "locking in gains" part for me.

Thank you for your comment! Cheers!

@psmnonna, when I consulted the menopause certified naturopath about starting HRT at age 67, my greatest hopes were to stop the progression of my rapid bone loss. I thought this would be a big win. The naturopath stated with certainty that the BHRT would stop my bone loss progression and may or may not provide some small gains I would have to remain on the BHRT to maintain. It was an unexpected bonus that my Echolight score improved a little. I also experienced the bonus of longer uninterrupted sleep and mild feeling of calmness and clarity. This result along with my 80% reduction in bone turnover on my CTX made me feel confident I had stopped the bone loss progression. I am using a low dose estradiol patch .25 and micronized progesterone 100 mg. The naturopath suggested getting a coronary artery scan. My results showed zero plaque which the naturopath said would make my arteries more flexible and receptive to estrogen. As I have so far not fractured I am okay with where I am at now though would like to increase my bone density further. I still have to monitor my OP as the potential for further loss is always there so will continue to get REMS Echolights, occasional DEXAS, CTX bone markers and vitamin D tests, take supplements, eat well with high protein, daily walking etc. Thank you for sharing your experience as well. I wish you all the best in your journey and look forward to hearing about your future results on HRT.

@debbie1956 Thank you for your reply and experience with BHRT. We are on the same dosages for estrogen and progesterone. I'm very hopeful I have good results as far as preserving everything that I've gained and hoping to preserve as long as possible. I get my vit D checked with every blood test. I supplement with D3, K2, Magnesium and take a multivitamin and get my calcium from food. I don't supplement calcium. I had several tests for cardio health done over the summer and my coronary artery scan was a zero, so glad to learn that is favorable for estrogen reception! Thank you for sharing and continued luck on your journey as well!

Also thank you to everyone for sharing your experiences! We ALL are in this together....knowledge is power!❤️

@debbie1956, Those are great gains on BHRT! It would be interesting to find out what your P1NP level is. Maybe ask your naturopath to add it to your blood work? What were your REMS hip results? I had good results from Forteo and Tymlos on DEXA and TBS, but REMS showed no change.

I am seeing a functional physician while I am in Michigan, but I return to Florida next week. I have a list of N.A. Menopause Society doctors there and will check them out. It sounds like your naturopath knows what she's doing.

Thanks for posting. I am encouraged by your results.

@drsuefowler My REMS right femur hip T score result was -2.3 in February, 2025, up from -2.6 10 months previous. So .4 increase in spine and .3 increase in hip. I did ask the naturopath about a P1NP. She said we could if I wished, or consider this test if my next CTX numbers are up from 138. I said it makes sense to hold off. I live near the Washington State border and would have to drive to Bellingham an hour away and pay of course. It isn't offered where I live in Canada. It is interesting to compare notes with your DEXA, TBS and REMS results. Interesting that your DEXA showed improvement while the REMS showed none. What was your percentage of improvement on the DEXA? Many people report a better score with REMS. My REMS was done 6 months after my shocking spine DEXA T score of -3.5 in November of 2023. The REMS showed -3, in April of 2024, so not wildly different. I hadn't started BHRT before my first REMS but had been taking Keith McCormick's recommended supplements for 6 months. A word of caution about DEXAS you may be aware of is that the machine must be exactly the same. My DEXA spine t-score in 2019 was -2.8. One year later after heavy long-term doses of Prednisone for my autoimmune diagnosis, my DEXA spine t-score had improved to -2.4! I knew next to nothing about OP and DEXAs at the time and hadn't heard of Keith McCormick. Another Mayo connect member observed last year that the serial number was different on the two DEXA scans at the same hospital. My family doctor should have questioned this increase while on Prednisone but happily informed me my BMD had improved while the opposite what's happening! So it was especially shocking to receive my -3.5 result 3 years later. I am waiting to have a DEXA with a TBS at Vancouver hospital, anxious to see my trabecular bone quality score. That is great you have had gains on Tymlos and Forteo and that you will be seeing a N.A. Menopause Society physician. I am so glad I learned about this qualification. Thanks for sharing your experience and helpful information. All the best to you.

@drsuefowler Yes our situations are similar! It seems that once your are past the golden 10 year mark of menopause that scares most of the Drs into saying no to HRT. We both will have some explaining to do to the endos!! I'm 67 and 18 yrs post menopause. I have taken the full dose of Tymlos since starting, and still have the heart racing issue after injecting. Finally figured out to get up about an hour early, inject, then go back to sleep and that seems to work. When I wake up for the day I feel like normal instead of being sluggish for an hour to hour and a half after injecting. I sleep through that stuff.

So far no ill effects from either the bioidentical estrogen or progesterone. I have a patch for the estrogen, 0.05mg, and change it once a week. So far it's been 1 week! I still have a uterus, and still taking Tymlos for another 4ish months. If they do work together, then all the better! I had either heard on a podcast or read somewhere the same thing about effects of these hormones on the osteoclasts and osteoblasts. I kept that in the back of my mind when the gyn Dr said at this point the HRT wouldn't have any effect on my bones. I'm hoping there is a little boosting power given to Tymlos. Is your estrogen a tablet or pill? If so, maybe going to a patch would help with dizziness? Bypass the digestive system?

My progesterone is 100mg capsule. So far no effects from that either that I can tell anyway. Possibly sleeping a little sounder, but still waking a couple of times a night. Fewer night sweats, but still get them. And it only has been a week, so I'm calling it a win, kind of, so far. What is the progesterone cream you were prescribed? I'd rather have that, I think, than take the capsule. I'd prefer to avoid anything that is processed through the liver, but the cream wasn't offered, so I now have a 90 day supply of the capsule. Is it comparable to your 50mg progesterone dose, or stronger since it wasn't helping sleep?

Here's to us both getting good results and trying not to miff too many endos in the process!😂

@psmnonna, I wrote you yesterday, but somehow my whole note disappeared. I like your idea of taking Tymlos before getting up in the morning, then going back to sleep. Since I usually get up twice in the night to go to the bathroom, it would be easy to try. I have been taking it at bedtime, but I think that it may interact with progesterone. The night before last, I think I used too much progesterone cream. My blood pressure went down to 90/60 at bedtime. I decided not to take my Tymlos since it also lowers blood pressure. I slept really well that night for the first time in forever! I do want to continue taking my Tymlos, since I have a lot left and I want to build or maintain bone. Last night, I took the regular 50mg cream dose a couple hours before bed and Tymlos at bedtime. I only got 2 1/2 hours of sleep at the beginning of the night. I'll try to take my Tymlos when I wake up for the second time.

The problem with the progesterone cream is you are never sure if you got the right amount. Mine comes in a pump container. The night I took too much, for some reason not much came out when I pushed it, so I pushed it 3 times. I wasn't sure how much I got. It is compounded and a lot of physicians don't recommend that. It is not FDA approved. I also have a compounded 50mg capsule that I may try again. I think my physician wants me to increase to the 100mg like you are taking.

My estrogen patch is much weaker than yours, 0.014mg compared to .05mg. I like it and feel like it is the progesterone that is troublesome. I could be wrong. The estrogen has enlarged my breasts and they are sensitive. I also have leg pain, but that may well be from Tymlos. It's good to hear that you have some improvement with sleep and hot flashes and no negative side effects! Thanks for your response and please keep us informed on how you are doing.

@drsuefowler Oops!
I mistyped my estrogen dose. It's a .025mg patch, NOT .05mg. So far I have not had any breast tenderness.
I hope that taking Tymlos after your second waking works better for you. I usually try to take it between 5 and 6am at the latest. It has helped me build bone, but not great gains. I was -3.6 in Jan 2024 and -3.1 Jan 2025. I was hoping to be up in the -2s after a year, but didn't quite make it.

Psmnonna, My DEXA never was very bad, but I broke 5 bones and suffered a concussion within in 18 months. The last fracture was my foot just from going on a walk. I now haven't fractured in 19 months!

I'm at Quest this morning, waiting to give blood to see how the BHRT is doing. Wishing us both super good luck with our bones!