Looking ahead after Tymlos: Reclast, Evenity or HRT?

Brand new to this forum - I did a lot of research when I was diagnosed (in April it will be 2 years ago), but never found this - wish I had! I was diagnosed almost 2 years ago. After a few months on Fosamax (couldn't tolerate due to reflux & I didn't like the possible jaw side effects - I'd just had a dental implant) I've been on Tymlos for almost 18 months. I had a DEXA at the 6 month mark & it had helped my spine a good bit (-3.2 to -2.8) although hips hadn't changed. My doctor had told me I could take it 18 months, but now I'm seeing 2 years, so maybe can push back the what to do next (which is how I found this forum!) for a little while longer. I'm 60, in good shape and eat healthy generally. I do pilates once/week and strength training 2x/week. I need to walk more, but have knee issues.

Going to my gyn next week and plan to ask her about HRT. I fall into the age group of never took it because it was "bad" for you & now studies have been updated and it is good to take. Also had ablation surgery at 42 and never had another period, and minimal menopause symptoms, so never had issues I needed to treat. I will be 61 this year and not sure what to do after the Tymlos. I hate taking medications, but know that I will have to continue if I want to maintain my active lifestyle.

Anyone else 60-ish and post Tymlos? What are you taking? Seeing my rheumatologist at the end of April and will need to make a decision. She discussed lots of options at my last appointment, but now I'm close to having to make the call on what to take. Thanks!

Hi All!
So much to read and digest since I first posted this thread. Thank you to everyone for experiences, advice and knowledge as I am still learning new things every day.

I finally saw my new endo and had a dexa to see what Tymlos was doing. Results are good.
Jan 2023 dexa -3.6
Feb 2025 dexa -3.1
Hip score was the same
I have asked about bone markers, albeit it was after I began treatment because I never heard of them until reading them here, asked about REM echolight, trabecular bone score, no dice. None of the drs I've seen use them, the tech never heard of echolight, etc. I don't live in a large metro area so my options are limited.

I didn't start Tymlos right away after my diagnosis, but started in Jan of 2024. I did not take it in Feb of 2024 pending finding out if it was ok to continue based on some heart racing side effects. I am still having that for around 30-45 mins after injection, but have continued to muscle through with some modifications to my morning routine. I am on month 13 of 24 now and will continue until the 2 yr mark. Fingers crossed the improvement continues and doesn't wane in the next year. I have read and learned from this site and others that the gains are not always as much in year 2.

So after year 2, the dilemma remains. What to do next. My new endo is supposed to be the osteoporosis guru at the teaching university near me. I was lucky to get an appointment with her.....however.....she has done extensive research and her published papers are mostly on Prolia. She is leaning to having me start that, which is a monoclonal antibody or a bisphosphonate after Tymlos to "seal in" my gains. She likes to keep Evenity (romosozumab) "in her back pocket" because you can only take it for a year, so save it for after the bisphosphonates or Prolia. Problems I see are if you seal up your gains by using Prolia or a bisphosphonate first, for however long, Evenity or an anabolic will not work as well because they can't penetrate the bone. I'm not wanting to seal anything up as long as there's a continuing chance to keep building more bone. I could go to Forteo, but she didn't seem to want to discuss all the options to in-depth until next year. I want to build bone that is strong for as long as possible.

I broached the subject of HRT with her and she was as absolutely against it as my rheumatologist is. It was a hard NO. All for the reasons of being past the 10 year mark from menopause, cancer risks, cardiovascular risks, yada yada. I asked if bioidentical HRT which is not processed through your liver and causes all the problem were ok. Again she said no because "estrogen is estrogen and it is all processed by your body the same". There are a lot of HRT studies and research that say the exact opposite, that bioidentical HRT actually protects against all of the things that the WHI report claimed in the early 2000s..... Because it is NOT processed through your liver which is what causes a lot of the problems.

I'm considering trying to find someone who can do the proper hormone testing and monitoring, which is imperative to get the dosage correct, starting the therapy and then next year see what happens. I wonder if it's better to act and ask forgiveness at my next visit in Feb 2026, than to not act at all.

In the meantime, I continue to do my workouts. I lift, do yoga, pilates, HIIT and other cardio. Am finally getting back into walking after a pesky knee injury that stopped me literally in my tracks. Goal is to get back to doing 5k runs this summer. Fingers crossed.
Cheers to all and Thank you all again!!

@psmnonna I'm curious if you had reached a conclusion regarding a follow-up med. I found the practice for op treatment varies greatly among practitioners. For example, my endo was not against HRT, however, she sent me for a second opinion (another obgyn) since I was more than 10 years past menopause. So far, it's working fine as an antiresorptive for me.

Hope you have your options sorted out soon and have an easy transition.

@mayblin Thanks so much for reaching out! My original post was last May 2024. I'm now about to start month 15 of Tymlos. I have seen 2 more endos since last May. In Sep the endo I saw just encouraged me to stay the course and was proposing bisphosphonates after I'm done with Tymlos. Hard no to HRT because of all the negative side effects associated with them....despite those being repeatedly refuted by current research. Plus I'm well more than 10 years past menopause. More like 20. No dexa at that visit, but my blood calcium levels were 11.1 and cholesterol had also risen again. Both of those levels were never out of whack until Tymlos.

In Jan 2025 I saw another endo at a the University of Iowa, about an hour from home, who only sees osteoporosis patients. She is supposed to be the "guru" of all things osteo. Same story with her. Stay the course and recommended Prolia after year 2 of Tymlos. I did have a dexa scan this visit and my Lumbar score improved from -3.6 to -3.2 from my first dexa in 2023. No hip score or cervical score because she "doesn't do those as they really don't matter." Also the calcium score was down some to a 10.6. Cholesterol was at a mind blowing 280. Another hard no to HRT or even considering it, same reasoning. This time I pushed back a little and asked about bioidentical HRT and also asked about her thoughts on the current research discounting all the bad press around HRT from a faulty study. She said exactly this, "No, no. It makes no difference what or where the estrogen in the HRT is made. Everyone's body reacts to estrogen the same. It is all processed the same way."

I was crushed....and disappointed that the supposed guru was so very set in her thinking. I'm not going to take Prolia. That is my hard no to the next step after Tymlos. I'm now trying to find a cardiologist to check out why my cholesterol is so elevated, getting a screening for arteries to see if there really is any blockage. If there is any that may prevent anyone from prescribing HRT. Then trying to find a doc who will prescribe is nearly impossible here. I live in a rural area where health care from functional, integrative and naturopaths are hard to find. Also on the search again for yet another endo. I do have a rheumatologist who is a hard no on HRT because her mother took it and ended up with breast cancer. No reason to push her on the subject as she has personal reasons for opposing.

The quest continues. I still have a handful of months left and I may just give myself a drug holiday of my own if I keep running into "hard no" answers! Take care,
Nonna

I found that the approaches to HRT differ quite a bit between your endos and mine. Mine determined HRT is a viable tool in my op management however she left the risk assessments to other physicians (obgyns and cardiologists). Yours determined risks > benefits in your case (without consulting obgyn and cardiologists?). I wonder if their opinions were based on "time hypothesis", which favors starting HRT within 5-6 years after menopause, or at least within 10 yrs post menopause with consideration of cvd risks as a general practice.

Here are a few videos in which menopause specialists (obgyns) talked about when is too late to start HRT:

I'd imagine there is a sizable ob-gyn dept at University of Iowa hospital system, and there may be physicians who specialize in menopause/hormone replacement therapy if luck is on your side. You'd definitely want to hear what obgyn/cardiologist has to say about you risk(s) in using HRT and then circle back to endo(s) to discuss again with the risk assessments from other physicians.

Without an antiresorptive following Tymlos, most people will lose bmd gains gradually within 1-2 years. There was a clinical study done on Forteo cessation which showed most lost bmd gains after 2 years if not follwed up with an antiresorptive. Women lost at a faster rate than men did. If you feel strongly about HRT but don't have enough time to get risk assessments done, you could discuss with your endo the feasibility of taking a 'gentler' bisphosphonate such as risedronate (brand name: actonel or altevia, the latter is delayed release form) or even alendronate for a short period of time then transition to HRT afterwards. If HRT not feasible, then either alendronate or iv reclast is the most probable path. It is very interesting to follow tymlos with prolia. I wonder the rational behind this choice and if this endo had a limited treatment term in mind (to be followed by a bisphosphonate).

@mayblin
Great videos. Thank you! I went to Dr Hirsh's website and watched more videos and they are very informative. Of great interest to me now is her interview with the cardiologist because of my current cholesterol numbers. Great watch and has nearly convinced me to start a statin.

Yes. My endos I've seen have a very different take on HRT than yours do, for sure. I suppose my being 18 yrs post menopause and now high cholesterol that put my risk vs benefit out of their comfort zone. Again the endo I most recently saw insisted that estrogen in any form is processed the same way. Which totally contradicts what all the studies show between using conjugated estrogen or bioidentical estrogen. No other consults or tests were offered, so that's on me, which is ok for now. I'm still looking for someone I can see before my yearly endo visit next January. Wait lists are my current friend.

As for my most recent visit, that Dr has some published papers on Prolia and I think that is her favorite drug of choice as a med to seal in gains from the anabolics. She said she likes to keep Evenity "in her back pocket" as it can be only used once for 1 year so doesn't like to use it early on. I know I'll have to take something after Tymlos.....but the research continues!

Thank you again for the support!

@seh801 Welcome! I'm 69, and was diagnosed with osteoporosis in 2022. I had bone marrow edema and fractures in my foot, ankle, ribs and vertebrae. I was started on Fosamax and then went to a metabolic bone specialist who prescribed Evenity.
Since you've responded well to Tymlos, I agree with your thinking that continuing with that to complete two years is a good idea. You can continue to build bone and then lock in your gains. Hopefully your doctor is amenable to discussing that with you, and it's heartening to read that she discussed options with you!
My trajectory thus far has been Fosamax >Evenity>Tymlos. I responded well to Evenity and had good gains. I did one year of Tymlos which I finished March 2025 and only had improvement in my TBS. I was thinking I'd request another year, but I had some issues in the final months of being on it and wasn't sure if they were due to Tymlos or not. Since I stopped it, my severe joint pain and fatigue have resolved. My doctor wanted to start me on Prolia which I did not want, and thankfully she listened to me and understood and ultimately agreed with my reasoning. The plan now is to do Reclast in May. I'm not a candidate for HRT as I have ALH and LCIS.
Best wishes to you moving forward.

@psmnonna if you can’t find a local doc who is open-minded about HRT, one option is to try Midi. It’s a telehealth service focused on HRT and women’s health. They are covered by many insurance plans. https://www.joinmidi.com

I am 61, about 8 years past menopause and started HRT last year. My doc was willing to prescribe, so I didn’t use Midi. But a good friend whose doc refused to consider HRT just started with Midi and has had a good experience so far. She is 63, 13 years past menopause and just started with HRT.

My understanding is that the advisability of HRT is very individual. If you have higher risk factors for various things (heart issues, breast cancer, etc) it could be riskier. It is so important to find a doc who is open minded about HRT to go through the decision process with you.

By the way, I’m watching this thread with interest because my endo wants me on Tymlos. I have the first dose in my fridge, but got her to agree to let me put it on pause until I can see what my first year in HRT does for me.

Good luck! These are such hard decisions with such limited data.

@wondering1, great information for others!

In the future when you decide to initiate treatment with Tymlos, could you share if you will be using Tymlos alone, or Tymlos + HRT. Please also share the reason for your choice. Thank you.