I read somewhere that in the pre-Lupron days when DES (Diethylstilbestrol) was commonly used, bone loss was not a major issue.
My 19-year history falls into three phases:
i) continuous testosterone [T]
ii) alternating 3-month periods of ADT & T
iii) my version of BAT (LongBAT) - a single T injection every 3 months + oral DES (3mg) days 8-90.
I am castrate between days 31-90 (roughly) & began to think that I should get a Dexa scan. Besides, at 75, I might have age-related bone loss. Plus, I do not exercise.
Yesterday was the end of a LongBAT cycle & I had the test in the morning. The results were in the portal that afternoon. Everything normal.
With DES, my estradiol [E2] is <5 pg/mL (the lowest that LabCorp measures. At <8 pg/mL, bone loss would normally be rapid.
Conclusions:
Having been tested after 2 months of castrate T, I can safely say that T itself is not required for bone health.
DES is a synthetic estrogen & seemingly used as an E2 substitute in the body for bone health.
For those on conventional ADT, add-back E2 should reverse ADT-related bone loss. i.e. if one had normal bone density before ADT, a low-dose E2 patch twice-weekly should restore normal density.
IMO, the target for E2 should be 12-20 pg/mL.
Apparently, I do not have age-related bone issues. These emerge much later than in women. Could they be diet-related? At 75, I eat far less than at 55. But I take vitamin K2, vitamin D, magnesium, boron, etc. I do not take calcium. Or perhaps the cause is E2<12 pg/mL. I have that covered too.
But doctors persist in prescribing harmful Bisphosphonates & Denosumab (Prolia / Xgeva).
(Given that my results were all "normal", I don't know what significance I should place on the T- & Z-scores.)
-Patrick
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Up until my dx 16 months ago I took no prescription meds, had no operations. With the exception of colds, flu and Covid. I have had no serious illness.
Beat a lot of 30 and 40 year olds at singles tennis by out running and out lasting them for the last decade.
Sorry to hear about your dilema. For me with 5 or 6 bomne nets I have been on Xgeva initially for 6 years, then after a DEXA bone scan in 2018 that showed my bones are within normal range 1.1 I think, the old Onc let me keep off Xgeva for almost one year. I was started back on it in 2019.
I switched to City of Hope and the new Oncologist. Dr Tanya Dorff did not precribe it in January, but sceduled me for another DEXA Bone scan next month, and may give me the Xgeva shot again, a bit of a roller coster. I convinced mysef my bones "fell" better witht he xgeva shots, and was told by my prior oncologist, beside keeping bomes from losing calcium, it may also help fight new formmtions of mets! (if only that was true)
"The HALT-prostate cancer trial (also known as NCT00089674) included 1468 non-metastatic prostate cancer patients who were currently receiving androgen deprivation therapy.[23] Randomly selected patients were given either 60 mg of denosumab or calcium and vitamin D supplements. This was done to measure the effectiveness of preventing treatment-induced bone loss.[21] The patients who received 60 mg of denosumab showed a +5.6% increased in bone mineral density and a 1.5% decrease in bone fracture rates.[21]
"Another clinical trial (NCT00321620) was established to determine the safety and effectiveness of using denosumab compared to zoledronic acid.[24] In this trial, they used 1901 bone metastatic prostate patients whom were also suffering with other complication of bone diseases. Again, patients were randomized and some were given either 120 mg of denosumab or 4 mg of zoledronic acid.[21] Patients who were given 120 mg of denosumab (in comparison to those who were given 4 mg of zoledronic acid) showed a greater increase in hypocalcemia, a greater resistance to bone turnover markers uNTx, a delay response in both pathological fractures and spinal cord compression.[21] However, survival rates for both clinical groups were comparable.[21]"
I thought the optimum E2 range was 20 - 30. At a minimum high teens. Not sure I understand... did you expect some bone loss with such a low E2 or is the DES preserving bone health?
I had never been concerned about possible bone loss, but I am now at an age where such things happen to unwary men. One wouldn't like to find out after a fall - or a spontaneous fracture.
I hoped that DES would compensate for <5 pg/mL E2, but wanted to verify.
It's true that LEF advises men to aim for E2 between 20-30 pg/mL. Over 30 pg/mL, bad things happen. Below 20 pg/mL? All I know is that bone studies seem to show <12 pg/mL as the tipping point. Are there other risk factors in the 12-19 pg/mL range? I don't know.
How much E2 did you have at age 21? That's probably a good target.
The 1998 paper from Giovannucci/Willett [1] was an influence. I felt that vitamin D was very important & PCa cells inhibit the creation of the hormonal form, so we are at the mercy of kidney production. I began using fructose in my coffee & I avoided calcium supplements.
I had long been leery of high-dose calcium. First, there is the general problem with high-dose minerals: supplementation comes at the expense of other minerals. The calcium:magnesium ratio is very important:
"Low blood Mg levels and a high Ca/Mg ratio were significantly associated with high-grade prostate cancer. These findings suggest Mg affects prostate cancer risk perhaps through interacting with Ca." [2]
Then there is the futility of treating bone loss with calcium, as though a bucket with a hole can be fixed by topping up with water.
I wondered how much calcium was needed when bones were healthy? How did pre-farming ancestors get their calcium? The RDA of 1,000-1,200 mg seems an impossibly high target for a hunter-gatherer. 3oz meat has only 5mg. The soft bones of small animals would have more. I doubt that my ancestors would have been on the lookout for fields of wild spinach. lol But who knows?
My diet 19 years ago was higher in calcium than today. I noticed that some of my supplements included a small amount of calcium (I have no idea why), so I did get a small amount from them. These days, that might not be enough. And yet, my Dexa results turned out to be "normal".
With circulating calcium homeostasis, calcium is taken from bone temporarily, while some is taken up from the gut, to be returned to bone. If we can avoid the situations where calcium is plastered onto arterial walls or ditched by the kidneys, how much calcium actually gets used up each day?
Thanks for sharing what does seem like an interesting historical profile of your E2 levels vs DEXA results.
Years back, your perspective (and that of your nearby lunch companion) clued me in on the need for balanced nutrition and supplementation to aid in calcium uptake in the bones - and, as you note, notin the arterial walls, kidneys, and joints. BTW, like you, I do not supplement with Ca and assume I get around the 900=1200 mg I need from my diet. I also believe the advice of many/most MDs for men on ADT and all women over 50 years old to supplement with only D3 and Ca is more likely doing more harm than good. (Most recent studies using just these two supplements indicate no benefit to bone health/density.)
From two series of CT+bone scans done back in 2017, I took note of arterial calcification, scattered pelvic pleboliths, and widely diverse calcium uptake in joints. Add in a visit to the ER for a kidney stone in 2014 and I didn't need much more incentive to get on a regular program of Mg + Bo + K2 + D3 (with Natto-Serra thrown in for good measure) to make sure I was sending Ca to my bones where it would do me some good vs other places likely doing harm.
I have a reply with additional information on the issue of bone health and DEXA scans that I will add later today. Even without the bone issues caused by treatments for PCa, we need to engage all methods to support the normal decline in bone density as we age. Unsurprisingly, exercise seems to be to single most important way to do that. (Sorry, Patrick.)
Hope all is well on your end of the state. Enjoy the return of spring for the next several days. Later On,
I agree that DES can replace or substitute E2. Continuous T results in the production of E2 (unless you were also taking an aromatase inhbitor, which I think you have mentioned using in some of your past posts). BAT and Long-BAT may also result in the production of some E2. It appears that you have been exposed to DES or E2 (from continuous or intermittent T) often enough and od sufficient concentration to maintain your bone density. It would appear that sustained E2 may not be necessary to maintain bone density. My take on the results you shared. Cheers, Philip
I stopped using Arimidex some years ago and it doesn't really fit in with my current LongBAT protocol.
True, E2 might spike after the T-cyp shot - if aromatase is over-expressed in the PCa cells. A blood test isn't going to tell me what is going on in those cells, but the ratio of E2:T will presumably be low & maybe that helps.
It would be nice to have a daily picture of what is going on, but I'm content with end-of-cycle PCa, so long as there isn't an upward trend. My concern is that I keep within a 3-month cycle, but nothing lasts forever.
is there a RT trial that covers low dose e-2 patches for bone health when on ADT (Lupron and Zytiga) that I can show to my MO to get a prescription. He has been very open to my suggestions in the past.
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Bone Health issues re:Bisphosphonnates, etc. ????
Making a Case for Intermittent ADT in Metastatic Hormone Sensitive Prostate Cancer 
T or E2
