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The Use of Low Dose Estradiol to Ameliorate the Effects of ADT on Bone Mass Density

PhilipSZacarias profile image
16 Replies

I have been conducting a long-term n of 1 trial since January 23, 2021 using lose dose estradiol (E2) gel to counteract the effects of androgen deprivation therapy (ADT) on bone mass density (BMD). I believe that I now have sufficient data to report that low dose transdermal E2, along with exercise and diet, appears to be sufficient to stabilize BMD.

ESTROGEL®, a transdermal gel manufactured by Merck containing 0.06% E2, was used for the add-back trial. A product monogram for ESTROGEL® is available on the internet (1). According to the monograph, each depression of the metered-dose pump delivers 1.25 g of gel or 0.75 mg of E2. The gel was initially applied to both inner thighs over a consistent area (~264 cm2 per inner thigh) before bedtime and allowed to dry. Later in the trial I switched from applying 1.25 grams of gel to both inner thighs to one thigh, alternating thighs every other night. Applying the same dosage to a smaller area increases the dosage delivered (2), but surprisingly the circulating E2 concentration did not change as a consequence of the change.

The desired target range for E2 circulating concentration at 12 hours was 15 to 25 pg/ml. This target range was selected based on the need to be moderately above the minimum value of 11 pg/ml required to maintain bone density according to Russell, et al (3). Russell, et al further state that the average concentration of E2 in healthy older males is ~25 pg/ml, hence the rationale for selecting a maximum E2 concentration of 25 pg/ml. This range is similar to what our illustrious POShea has been recommending in his posts on HealthUnlocked. The actual average 12 hour (+/- 1 hour) circulating E2 concentration has been 14.7 pg/ml.

Bone density scans were performed 2 months after initiation of ADT with leuprolide in March 2016 and at 12, 24, 38 and 78 months afterwards. The time difference from initiation of transdermal E2 and the last DEXA scan was 20 months. There were two switches in testing laboratories, which were beyond my control that may have contributed to some variability in the data. The results are summarized in the attached figure.

It should be noted that abiraterone + prednisone, as a second line therapy, was initiated in August 2020, ~58 months after ADT with leuprolide was started. The dosage of abiraterone was initially 1000 mg/day without food, but was reduced to 250 mg/day with food (and prednisone reduced from 5 mg to 2.5 mg) – see NCCN guidelines. Furthermore, five+ hours of exercise (weight and cardio) per week and a Mediterranean type diet, on a time restricted feeding basis, doubtlessly contributed to the maintenance of the BMD. Calcium supplements (300 mg calcium citrate) were taken irregularly because of the consumption of cheese and soya based products. Vitamin D was initially 4000 IU but reduced to 2500 IU on August 2022 in order to reduce circulating levels of 1, 25 hydroxy VD. Lastly, I also take 10 mg slow release melatonin every night, which may have contributed to the maintenance of BMD (search PubMed for references), although this may be controversial.

With regard to side effects there was an initial nipple tenderness when starting transdermal E2 and a slight increase in breast size. When the same dosage of E2 was applied to one inner thigh, the nipples became tender again confirming exposure to a higher peak E2 concentration. Hot flashes appeared to decrease, but the frequency and severity of these were already waning after 5 years of ADT. There have been no adverse side effects to speak of. Quality of life has been very good during the trial.

Conclusion

At least in my case, low dose transdermal E2, exercise and diet was able to maintain BMD. For men with an initial BMD in the normal range (before or soon after initiation of ADT) and who see a significant decrease in BMD after a couple of years and would like to avoid taking bisphonates, then low dose transdermal E2 may be an option. It requires monitoring circulating E2 initially every 6 weeks until a target value is obtained, then decreasing testing to once every 3 months. A consistent application method, time of application and time of testing must be followed.

Obtaining a prescription through an oncologist may be difficult, or impossible. I was fortunate that my family doctor is open minded and prescribes E2 gel for many of his female patients. I guess a biochemically castrated male qualified (sorry, I could not resist).

There is abundant information in PubMed indicating that transdermal E2 is safe for men on ADT. It is truly unfortunate that there is no published literature that discusses bone medications for maintaining bone density that includes add-back E2 as an option. There is no profit in this alternative method for avoiding fractures.

References

1. merck.ca/static/pdf/ESTROGE...

2. en.wikipedia.org/wiki/Pharm...

3. Russell N, Cheung A, Grossmann M. Estradiol for the mitigation of adverse effects of androgen deprivation therapy. Endocr Relat Cancer. 2017 Aug;24(8):R297-R313. doi: 10.1530/ERC-17-0153. Epub 2017 Jun 30. PMID: 28667081.

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PhilipSZacarias
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16 Replies
maley2711 profile image
maley2711

thank you for the update.....leading edge!!!!!!!????

London441 profile image
London441

You have put a lot of effort into this. What exercise specifically are you combining with it?

PhilipSZacarias profile image
PhilipSZacarias in reply toLondon441

I do 4 - 6 km fast walks 1-2/week, hike during the summer, intense workouts on an elliptical bike (20-30 minutes, high resistance) every other day, I run up and down a flight of stairs fast 6 times most days, elastic bands, 10 and 25 lb hand weights, weighted vest, a steeper every other day (all while watching TV), occasionally do laps in a pool. Also 60 push ups, 60 bird dogs twice a week, running in place high stepping until exhaustion 2x week, six 30+ sec planks, etc... :)

j-o-h-n profile image
j-o-h-n in reply toPhilipSZacarias

Shoot I can do those in my sleep................ and that's usually where I do them....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 03/27/2023 12:55 PM DST

London441 profile image
London441 in reply toPhilipSZacarias

Love all the plyometrics. Add heavy weight leg work to further prevent osteopenia/osteoporosis if I were you.

HikerWife profile image
HikerWife

Wow. Thanks so much for this. Bone issues are one of the things that greatly concern me for my husband.

Atlpapa profile image
Atlpapa

Thanks for the post. I didn't see the attached figure showing you DEXA scan results. Can you share that.

PhilipSZacarias profile image
PhilipSZacarias in reply toAtlpapa

I just attached the figure. Had to be in jpg format.

Exrunner profile image
Exrunner

I have tried unsuccessfully for two years to get multiple Drs to give me a prescription for Estradiol patches to offset the SEs of ADT. Not SOC and thus far Drs have not been willing to give me a prescription. I have turned to using an OTC bioidentical estradiol cream that has, in my opinion, help with many of the SEs.

Carlosbach profile image
Carlosbach in reply toExrunner

Hey Ex, I just started with the E2 cream yesterday. Still lobbying for the patches, but fingers crossed on the cream's effectiveness.

Exrunner profile image
Exrunner in reply toCarlosbach

Life Extension came out with a simple guideline:

"We have recommended that ideal ranges for estradiol for most aging men are between 20 and 30 pg/mL of blood. Below 18 pg/mL increases osteoporosis risk, while levels greater than 32 pg/mL increase heart attack and stroke incidence." [2]

The difficulty with OTC is using just the right amount to stay within the recommended range. Prescription patches would help get the right dose.

The Drs I have see all know the SEs and would be happy to add an additional prescription medicine for bone loss, hot flashes etc. Not sure if they are concerned about a law suit or loss of revenue from using prescription medicines...or perhaps both.

Carlosbach profile image
Carlosbach in reply toExrunner

Thanks for the additional info. My SE's from Elligard have become untenable. If the E2 doesn't help before my next scheduled injection (early May), I'm going to have to switch meds, drs, insurance cos, or something. Fingers crossed

PhilipSZacarias profile image
PhilipSZacarias

My apologies, I forgot that the file had to be in jpg format. The figure has been converted.

This figure shows bone mass density data over 6 years and the effect of low dose estradiol
Carlosbach profile image
Carlosbach in reply toPhilipSZacarias

Thank you for the post

JohnInTheMiddle profile image
JohnInTheMiddle

Great report Philip! And dang I missed yesterday's Warriors group (Mar 27).

PhilipSZacarias profile image
PhilipSZacarias

Hello TalentedITGuy, I cannot disagree with you regarding having DEXA scans being performed at different locations and machines. I did the first two or so scans at a private clinic, but I started to have doubts about the proficiency of the tech and the age of the machine. I switched to the hospital where my I see my oncologist and get treatments. The machine there broke down and could not be repaired, believe it or not. I was referred to another hospital for the DEXA scan until a replacement was purchased. This was beyond my control. In a year or so I will have another DEXA scan on the same machine. In any case, there is sufficient published information that estradiol add-back slows BMD loss. Cheers, Phil

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