Making a choice between HRT to try to improve bone density post-menopause (after you have come out the other side of perimenopause and are feeling whole again) and medication for osteoporosis is a bit like being stuck between a rock and a hard place. (For perspective, it is also a privileged position to have access to either… but that’s another blog.)

What were my options?

• Continue as I had been with nutrition, and make the small increase in my strength training I knew would be sustainable for me (I could also have bought a vibration plate, but the evidence for them is mixed).
• Give up the strength training I had been doing (because it hadn’t improved my scores) and just hope.
• Take medications for osteoporosis, knowing I might not be able to take them lifelong and that they can have difficult side effects and health risks associated.
• Take HRT, known to improve bone density, but knowing that the longer you wait after menopause to start, and the older you get, the higher the risks, and that side effects are not uncommon.

A little more about medications available may help you understand my choice.

• Most osteoporosis meds have similar result rates.
• Some work through reducing bone breakdown (anti-resorptive), some others are anabolic (promoting bone building) through endeavouring to balance cellular activity related to breakdown and remodelling.
• You don’t always get a choice to try a medication you prefer the sound of (some are only available if you have tried others, and some are not suitable if there is low calcium levels in the blood, for example).
• Though many articles say that side-effects are rare, many people report them. Side effects such as bone, joint and muscular pain, and nausea, difficulty swallowing, heartburn, irritation of the oesophagus, and gastric ulcer (1).
• They may induce complications: osteonecrosis of the jaw, or atypical femur fracture (1) (though these are less common than osteoporotic fractures themselves of course). They can also be hard on the kidneys.
• These risks are higher the longer we take some types of osteoporosis drugs (bisphosphonates), and though there is no definite cut off, 5 years seems to be a safer bet.
• Another type of medication can increase the risk of spinal fracture after you stop taking it, so it has to be continued for life.

I am 54.

I could maybe take bisphosphonates (if they are suitable for me and I can tolerate them) until I am just under age 60.

Then what?

If bisphosphonates are too uncomfortable, or don’t work (one of my students was on them for 5 years only to then be told “they aren’t doing a thing for you”), maybe I could try Prolia (denosumab). That may induce pain, and with a heightened risk of spinal fracture after stopping it, I would feel stuck on it for life. (2)

I have a tendency to osteoporosis, so it is likely that it would return in subsequent decades after the medications benefits have worn off.

I might have 30+ years left with my kids, life, and this beautiful world.

But. IF I can handle oestrogen and progesterone supplementation (medicine known as HRT), I could rebuild my bones. I could take it for 5 or 10 years, then, when I feel it’s time to stop (even though my BMD will decrease after stopping) I could continue to work on my bone density from a better starting point, better density, than when I first had my diagnosis, while still having the option of osteoporosis drugs in my 70s or 80s as necessary.

It felt like the first bridge to burn.

But I am still not happy about it.

My friend said “Niamh, you know too much!” This was after my telling her of my fears:

• HRT can destabilise mood
• It can negatively affect cardiovascular health especially started years after menopause.
• It has its own huge list of possible side-effects.
• It carries an increased risk of stroke and breast cancer.
• After recalibrating to low levels, my body will need to recalibrate again. We know little about how the body might do this. A second perimenopause weirdly in reverse?
• When I stop it will have to recalibrate a third time. A third perimenopause?

Then there are the possibilities:

• Some people have little or no side effects.
• Some people do fine on it.
• It DOES improve BMD.
• I might get lucky and feel the miraculous effects some women report!

With concerns and hopes, I felt the likelihood of nocebo and placebo effects were fairly even…

I was also lucky to have the help of an esteemed endocrinologist (who contributes to my Yoga for Menopause Teacher Training) to reach out to, to discuss my own risks, and what the best option would be for me.

Asking her for my best options for two major concerns, I wrote: “What’s the lowest dose and preparation that has research showing improved bone density?” Then I told her I was most concerned about feeling emotionally destabilised after I had done so much and arrived at a steady place! She gave me great pointers. I knew what to ask for from my doctor, who obliged.

When I left with a prescription for HRT through the combined patch (50mcg estradiol and norethisterone for uterine protection), I felt pretty freaked out.

I didn’t fill it for a day or two.

Then I filled it and held it in my hand, and I felt pretty freaked out.

I didn’t use it.

Then, after a few days, I used it, and… nothing happened!

The relief I felt on day one, the calm, the anti-climax in fact, showed me that I must have somehow though I would die right there, or feel transcendent the moment I put it on!

That was day 1.

It didn’t stay so easy.

My next blog is a look at the surprising reactions in my body and mind…

If you would like to join me for your own care, I work one-to-one helping people WITH osteoporosis (and/or other common movement issues 50+) or via my Yoga and More for Menopause and Beyond membership. Click the bold text to see the relevant options.

1: Side Effects of Bisphosphonates, bonehealthandosteoporosis.org.

2: Prolia Side Effects, Medical News Today