I’m looking for some information on whether a low / suppressed TSH is a factor of osteoporosis?
I’ve been to see an Endocrinologist- first time since my diagnosis of underactive thyroid 10 years ago. He wants to increase my TSH - its currently around 0.01 - by taking me off NDT, and back on to T4 with a small amount of T3. I’m presently taking 1 NDT, 20mcg of T3 and 25mcg T4. My T4 is a little low but I don’t do very well on T4 and feel alright at the moment - so I’m reluctant to change medication. His reasoning is the osteoporosis angle and that seems to take precedence over the rest of the symptoms. Should my TSH be higher - and does that happen with more T4 or just less NDT/T3.
I also wanted to say that since going back on NDT earlier this year - my Restless Leg Syndrome has mostly disappeared. Could also be the T3.
thanks in advance for any feedback 😊
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missrees
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Endocrinologists and GPs are often obsessed by keeping TSH with the laboratory reference range, not seeming to understand that if you take medication containing T3, it’s likely to be low in range or even suppressed.
If you aren’t over medicated, there’s no need to fix what actually isn’t broken.
But from what you’ve said so far, it’s not possible to tell. Do you have an FT3 result?
I keep meaning to find the articles the endos and GP always reference. From memory though they did not establish a causality or attribute a risk factor. Worth reading the Canadian thyroid patient articles on this subject.
healthunlocked.com/thyroidu... longterm-subclinical-hyperthyroidism-does-not-affect-bone-density-in-patients-having-had-thyroid-ablation-for-cancer (This post deals specifically with the alleged risk to bones.. it links to a recent long term study of patients whose TSH was kept deliberately supressed with levo, long term ( to prevent recurrence of thyroid cancer) ..... it found no significant increase in bone loss with a long term supressed TSH as long as T4 was kept in range.)
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pubmed.ncbi.nlm.nih.gov/367... Impaired sensitivity to thyroid hormone correlates to osteoporosis and fractures in euthyroid individuals (This very recent study (Feb 2023) shows that in euthyroid people over 50yrs old , a higher ratio of T3 to T4 is associated with a reduced osteoporosis / fracture risk. And that higher T4 levels are associated with increased risk ... which if you assume the same applies to those taking thyroid hormone, backs up the idea of giving a bit less Levo and adding a bit of T3 will REDUCE their risk of osteoporosis / fracture. ( i think ?.... it's a bit complicated to understand the results , but diogenes has clarified the findings in a reply to the post discussing it here : healthunlocked.com/thyroidu... another-study-on-bone-density )
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This post is worth a read on the subject of low TSH / Risk vs Quality of Life : healthunlocked.com/thyroidu... useful-evidence-that-tsh-between-0.04-0.4-has-no-increased-risk-to-patients-on-levothyroxine-updated-new-study-does-show-small-risk ~ It contains lots of links to further discussions )
and this one is worth a read too : healthunlocked.com/thyroidu.... /tsh-is-just-the-opinion-of-your-pituitary-about-your-dose-but-your-pituitarys-opinion-is-a-bit-warped-once-you-take-thyroid-hormone. ( the first reply to this post contains a list of references explaining why T3 lowers TSH relatively more than T4 does )
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If you previously did not function well on just levo, then there is a reasonable chance the same would happen again if you changed back now ... as for adding a bit of T3... well, they say that now , but if TSH is still too low for their liking on levo + T3 , then it is very likely they will use low TSH as a reason to take the T3 away from you as well... their ultimate objective is to get as many people back on just levo as they can , and they are unlikely to be bothered if you are made unwell and your quality of life goes down the pan during the experiment.
Ask this question of your endo ~ if your experiment reduces my quality of life to such an extent that i am not able to be as anywhere near as physically active as i am now .... what effect will that have on my bone strength ? isn't 'mostly on the sofa for the next 10 yrs' also a very real risk for my bones ?
why would he want to increase your tsh? What is his reasoning? You take t3 so it should be near zero (if you are taking the right amount - which you obviously are...). I believe that osteoporosis is worse with people who are too low or too high, so that isn't an argument for change. If he presses, please ask for a referral to an endo for a real check up. Or, print off info and hand it to him. Good luck
I’ve seen a paper on how people with suppressed T3 do have a higher rate of osteoporosis compared with those with an in-range T3, but and it’s an important but, the rate at which they have fractures is lower than those with an in-range T3 (There wasn’t any hypothesis as to why, but I would say if you have less brain fog and are more alert you are less likely to trip and fall.) I am very sorry but I haven’t got the link to it, but you may be able to find it with careful Googling - or searching here as I probably got it from this community.
I can only tell you that I had a bone density scan 10 yrs before I lost my thyroid or had thyroid issues and I was diagnosed with Osteopenia and 2 yrs after I lost my thyroid to cancer I had another Dexa scan because doctors were worried about my undetectable TSH due to combo drugs and the test revealed I was really no different from the first scan …. In my opinion it doesn’t at least for me .
I tried to have this conversation with my GP some years ago. I’ve been taking NDT for at least 8 yrs now. My Mum has taken Levothyroxine most of her life and has bad osteoporosis so that didn’t prevent it.
Maybe the links @greygoose posted talk about thisi have t had a chance to read them, but my understanding is that there is basically no research in to osteoporosis in people on NDT and the research showing the link between low TSH & osteoporosis is based on people who are not medicated. If I can find the research I looked at I will post it.
I decided that if my Mum got osteoporosis while on Levo I was not going to be scared in to switching back to something that did not help my symptoms. I do however now take HRT because lack of oestrogen does have a big impact.
I tried to argue with my endo when she wanted to reduce my dose due to low tsh. I had a Dexa scan and have osteoporosis. I'm on 75mg of t4 and 20mg t3. I was on 100mg of t4 as I was feeling great. Bit tired now to be honest. But I take vitamin D, magnesium and omega fish oils. Plus my tsh rarely moves from 0.01. Since 2018 it said 0.01 most tests and in that time I've had many dose changes, but endo was adamant that my osteis caused by the suppressed tsh and reduced my dose. Blood test tomorrow, I'm hoping tsh will still be 0.01 so I can argue that it doesn't change. Only when I'm under medicated and then it goes so high I feel awful. But hey, as long as I fit in their boxes, they don't care how I feel.
I finally got a copy of my results. Tsh 0.01, T4 10.3 range 9-19 and T3 5 range 2-6 and guess what, Endo is writing a letter to drop my T3 dose in the afternoon down to 5mg from 10mg. I am going to refuse that drop and ask why she told me that tsh picks up the slightest change in meds yet it hasn't moved. I told her my tsh is usually 0.01 and has been since 2018 unless I'm really hypo when I rises. Honestly so frustrating. She won't be happy until my tsh comes up but to do that she's going to make me ill.
Sorry to hear this! Your T4 is low - that should increase before she lowers your T3. Its so frustrating because you know that it will make you feel ill and worse. That's why people end up self-medicating.
The problem is that many physicians assume that your TSH feedback works in the same way than it does in a healthy person without thyroid disease. Sadly, this is not the case and this is where the problems start. Publications have shown that this feedback loop is not working and once you are medicating, you should rely on your free T4 and free T3 for guidance. So why should the TSH guide any health outcomes when it does not guide a healthy thyroid gland?
Early studies looking at this issue have mainly focused on UNtreated healthy individuals. And there was an increase in bone turnover in people with high levels of thyroid hormones and subsequently a low or suppressed TSH. However in thyroid disease, your TSH does not respond accordingly so you can have a suppressed TSH even though your free T4 and free T3 levels are within the normal range.
I have found an interesting publication that highlights that the relationship between thyroid hormones and bone mineral density is not entirely clear. And it should also be pointed out that a correlation / association does not necessarily mean causation.
Overall, the available evidences suggest that premenopausal women on chronic TSH suppressive treatment with L-T4 do not have adverse effect on bone mineral density (BMD). On the contrary, postmenopausal women on TSH suppressive doses of L-T4 are at risk of bone loss, particularly, when osteopenia or osteoporosis are already present. Finally, a very recent meta-analysis study on the influence of TSH suppression on BMD in patients with differentiated thyroid carcinoma suggested a possible association between L-T4-mediated TSH suppression and the lower BMD in postmenopausal women, but not in premenopausal women and men.
As there is a clear distinction between the risk in pre- and postmenopausal women, that would suggest to me that the driver of the increased risk could actually be more related to a difference in oestrogen levels and very likely not TSH alone.
I hope it will go well. In any case, you know best how you feel, and if you feel well on your dose of T3 then that should be taken into account, not the TSH, especially when both T4 and T3 are within the range. If he is so concerned about osteoporosis, he should arrange for a DEXA scan to check your bone density!
Interesting as Endo called to say Dexa scan shows Osteopenia and starting me on Alendronic acid, he attributes to low tsh and no hrt, I am post menopausal.
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