Beyond Bisphosphonates: An Orthopedic Surgeon on Overlooked Osteoporosis Therapies

Why People Look Beyond the Usual Drugs

Most osteoporosis medications weren’t built for the long haul—evidence tends to run out by the 10-year mark. If you’re in your 40s, 50s, 60s (or even beyond), your time horizon is likely longer than that. Osteoporosis is fundamentally a metabolic dysfunction of bone, which means pills alone won’t fix the engine. Still, when side effects or limited durability make people hesitant, it’s reasonable to ask: Are there lesser-known options worth discussing with my doctor?

“Muscle health and bone health are intrinsically tied together—what helps one often helps the other.” – Dr. Doug

The Forgotten FDA-Approved Option: Nandrolone

At a recent performance and men’s health conference (Silverback Summit), a familiar name popped up: nandrolone—an anabolic steroid that, yes, holds historic FDA approval for osteoporosis.

What the studies show

• Across 17 studies, nandrolone increased bone mineral density (BMD) and lean mass.
• Trials were not long enough to confirm reductions in fracture risk (a common limitation across many bone drug studies).
• Side effects were frequent—up to ~50% in some cohorts: acne, facial hair (in women), and voice changes (androgenic effects).
• Weight gain occurred (good for some, not all).

Why it’s rarely used now

• Not commercially available today in most settings and largely out of favor.
• Side-effect burden is high, especially for women, making it a last-ditch option rather than a front-line strategy.

Bottom line: Nandrolone can move BMD and muscle, but the trade-offs are steep, and availability is limited.

A More Practical Anabolic Alternative: Testosterone (Context Matters)

In Men

Multiple randomized trials show that testosterone replacement in men with deficiency:

• Improves BMD and lean mass
• Enhances insulin sensitivity and other metabolic markers
• Improves mood, cognition, and quality of life
• Reduces adiposity and symptoms commonly associated with aging

Fracture data remain limited due to study duration, but the overall health-span signal is strong.

In Women

• In the U.S., testosterone is FDA-approved only for HSDD (hypoactive sexual desire disorder)—a psychiatric diagnosis.
• There’s no commercial female testosterone product, so treatment (when used) is typically compounded. Many clinicians shy away due to regulation, comfort, or training gaps.
• Existing research in women suggests benefit to BMD and sexual function; trials are fewer and smaller than in men.

A key physiology point people miss
Women carry ~5× more testosterone than estradiol (unit-adjusted) across most of adult life. Testosterone is not a “male-only” hormone; it’s a dominant sex hormone in women too. Yet the aging conversation for women often centers only on estrogen, overlooking how testosterone loss may contribute to decreased muscle, energy, cognition, and bone signals.

Safety, Side Effects, and Sensible Use

• Women: Androgenic effects (acne, hair changes, scalp thinning) are dose-related. Pellets often deliver high peaks you can’t “turn off.” Dr. Doug prefers topical creams (testosterone ± estradiol) with physiologic dosing, allowing quick dose adjustments. If needed, DHT-blocking strategies can help manage skin/scalp conversion.
• Men: Replace to physiologic levels and monitor labs routinely.
• Everyone: Use biomarkers and clinical response to guide therapy. Hormones aren’t zero-risk—but neither is muscle/bone loss, frailty, or fractures. The goal is optimal, not supraphysiologic.

Clinical stack Dr. Doug often favors (individualized):

• Estradiol (patch or cream) when appropriate
• Oral micronized progesterone (avoid synthetic progestins)
• Topical testosterone (physiologic dosing) when indicated
  Rationale: support symptoms of aging, muscle, metabolic health—and by extension, bone.

So…Should You Use These “Alternatives”?

• Nandrolone: Historically positive for BMD, but high side effects, poor availability. Not a first choice.
• Testosterone:
  • Men: Stronger evidence base for broad health benefits that also support bone.
  • Women: Off-label; discuss with a bone-savvy HRT clinician. Combine with estradiol/progesterone when indicated, dose physiologically, and monitor.

“There’s risk in everything—from calcium to water—so make the risk/benefit discussion specific to you and measured by outcomes.”

Standard disclaimer: None of this is medical advice. Discuss options with your own clinician—especially if you have cancer history, cardiovascular disease, or other complex conditions.

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Don’t Go It Alone

👉 Want a guided way to weigh these options alongside training, protein, and labs? Join me inside the OsteoCollective. You’ll get step-by-step frameworks, live guidance, and a community walking the same path. Prefer to start lighter? Attend our free masterclass and bring your questions to the live Q&A.

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