Need advice for wife

njx, Forteo would be a better choice for your wife than Tymlos, because it works best in the spine, not because she is female. It is clearest to understand the loss of bone in women by understanding the loss of estrogen's effect on bone. It isn't a lifestyle deficit. While estrogen can prevent further bone loss, it really cannot regain lost bone.
Do you have secondary cause. Low testosterone is one cause of rapid bone loss for men,
While it's good that you are preparing and making sure she is tested for secondary causes, and ensuring that she is prescribed bone markers, be careful to lay low during her consultation. You might record the conversation, and reserve your comments for last, recognize, accept and encourage her decision.
I'll be secretly hoping she opts for Forteo.

@gently She is willing to do whatever is needed. I will definitely play it cool at the appointment. I figured I will at least will understand the conversation and can ask some questions.

What about Evenity? It wasn't an option for me. A monthly shot doesn't sound too bad, but I don't know anything about it.

We checked her DEXA details, and her L3/L4 are a lot worse (-3.5) than L1/L2 (-2.7).

-, my personal choice would be Forteo over Evenity. Evenity is a medication that she should consider, because it lays down new bone fastest.
I think from your posts that you understand the differences between the bone from Forteo use, because it is the most similar to Tymlos-bone than Evenity-bone. It is remodeled bone as opposed to modeled bone. Restorative, integrated, more flexible articulated by communication channels. The pth 1-34 drugs restore the missing architecture creating the chondrocyte structure needed for calcium attachment, reforming spicules that make up trabecular bone.
Evenity bone is lost more quickly than most of the osteoporosis medications if not followed by another medication,
I haven't taken Evenity. Relying on our friends scribing here, almost everyone has a weighty increase in bone density with Evenity, many have arm swelling (it is actually two injection, on in each arm), most have joint and bone pain. Some are miserable, some are quite pleased. Read the package insert notably the black box warning about increased risk of cardiac events in some.
The impact of running places the most stress on the areas where she is most vulnerable. I don't know any runners who are willing to quit running, but she may be to avoid running on hard surfaces.
We have wider range of flexibility at L4-5 than at L3-4. At L3-4 she is at most risk of fracture in flexion and extension, the the forward and backward movement. It's clever to avoid exercises in the sagital plane until whichever medication increases strength at L3-4.
You'll want to do all of the lifting, heavy lifting for the next year.
NJX you must be almost at the end of your Tymlos run. Have you decided on a follow-up drug. I'm 2 years 7 months on Forteo and love the drug, hoping to stay on it endlessly.
Don't let her fracture. Best wishes.

@gently My wife has been running for 47 years. She's not stopping unless she physically can't do it. 🙂 She is not high-mileage, though. She's not training for a marathon or half-marathon or anything like that.

I'd like to start her off slowly with some basic exercises. Superman, light dumbbells, that sort of thing, There are many videos and other resources out there to guide us.

I have three months left on Tymlos. I don't know my T-score now- it was -2.0 in January, so I hope it is even better by now. I go to the gym regularly, and my back is definitely much stronger.

My doctor and I have discussed using Fosamax for a year, and then monitoring. I have no interest at the moment in a Reclast infusion, and I don't think I need it.

I’ll add a few thoughts to the discussion,

The Superman pose (spinal overextension) is not recommended for someone with severe osteoporosis, so double check on that.

HRT can help slow bone loss, but with a lowest T-score of −3.5, an anabolic-first approach makes more sense than an HRT → PTH or HRT → HRT + PTH sequence. Between the anabolic options, I’d lean toward a PTH analog as well. A TBS showing deteriorated microarchitecture would reinforce that choice.

@mayblin Yes, we're definitely leaning towards teriparatide at this point.

I'll cross that exercise off the list until later, when she has hopefully gained bone density.

Do people take HRT + anabolic at the same time? My wife hasn't had a hormone checkup, and I assume the doctor will be ordering that along with other tests.

@njx58, if your wife decides to add weights to her routine, she might want to see a PT trained in osteoporosis. Mayblin's caution about extension and flexion is really important. Just picking the weights up off the floor could become a life changing event.
Vertebral osteoporosis is actually multiple fractures without compression. https://www.researchgate.net/figure/Light-microscopic-views-of-normal-left-and-osteoporotic-right-cancellous-bone_fig3_230657347
Dxa warns a person that they have bone missing and because weight bearing exercise is good for bone we are advised to add weight to an already fragile structure before reinforcing the structure. not even giving the bone the possibility of restructuring itself. It is good to have strong muscle surrounding the bone, but the muscle may already be stronger than the bone at this point. I'd wait the weights. I stopped weights. back bends, crunches, anything bending forward. Even bending forward in a chair had to wait for Forteo to provide bone to the missing structure.
I'm a long time runner and don't think it wise to stop or even lessen the running routine. If possible, though, running on soft turf instead of cement or asphalt would be protective.
If she does decide to let you start her on weights, light weights. Be sure that it is her decision. She might look at https://www.youtube.com/watch
Of course, now that your healthy bones are doing alllll the lifting, vacuuming, (bending) making the bed, grocery shopping careful light weights might be necessary for her to get sufficient exercise.

@njx58
I’ve come across a few cases of PTH + HRT, but don't know how to read into the results. There is a published clinical study of teriparatide + HRT if you’re interested:
https://academic.oup.com/jbmr/article-abstract/16/5/925/7516026
To me, it’s hard to draw firm conclusions on the role of HRT in combination with teriparatide because the study didn’t include a teriparatide-only arm. In addition, the study investigated PTH added to established HRT, and the teriparatide dose was slightly higher (25 mcg), given for a longer duration (3 years) than the standard regimen. All these factors influence end results.

If the topic of HRT + PTH comes up, I’d ask the physician for supporting data/references.

If baseline btm indicates a low turnover state, I wouldn't throw HRT in the mix if I were the patient.

None of my care team physicians are particularly keen on checking hormone levels, although I insisted on a baseline, which was within the expected range. For follow-up, we mainly rely yearly DXA scans (or earlier if needed), and monitoring bone markers. I did a course of Forteo and followed with HRT as maintenence btw.

A good Dr will order blood work, urine vitamin D, magnesium, thyroid and others. So just look at DEXA and tell you you should be on drugs. I suggest if she can get HRT, do it. Also find a good personal trainer ( hopefully trained in liftmor) and start resistance, balance, posture, and impact training. A great Facebook group is Brick house bones. Dr. Lisa more is trained in osteoporosis exercises. She also has many exercises on her YouTube channel.

I would have her try Pilates. Wonderful work out and enjoyable.