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Bone Risk in Thyroid Treatment

Most women have probably already heard enough about osteoporosis to know whether they really need to worry about it.  Most women do have to worry, at least here in the United States.  Here's a reminder of the factors that affect your risk: good to the right, bad to the left as you go down.  Not having a "good" factor means you have risk on that basis.  

Here are three sets of information for evaluating the risk of hyperthyroidism for your bones: 

1. Literature search (July 2001)                  

• There two published studies of bone density in patients receiving thyroid hormone as a treatment for rapid cycling bipolar disorder.  The first shows that eight of 10 patients were maintained with a TSH <0.4, but these women  did not show bone loss.  This research group's recent report of 26 cases followed 1 year or more indicates the same result.  Even when TSH is suppressed into the "hyperthyroid" range, bone mineral losses were not observed, at least in premenopausal women. 
• In subtle hyperthyroid states, where symptoms are not present -- as opposed to "overt" hyperthyroidism -- bone loss was not evident if the woman studied was premenopausal.  After menopause, even subtle hyperthyroidism is associated with greater bone loss than would be expected for age.  
• With sustained overt hyperthyroidism (the woman has obvious symptoms), bone loss is worse than that associated with menopause.

2.  The opinion of Don Klein, an eminent psychiatrist who has reviewed this issue extensively -- and others.  

Here is Dr. Klein in an email discussion of the issue with colleagues ( if you want to read the whole thing, pretty technical but including the similar opinions of other doctors, click here) : 

Date: Sun, 11 Feb 1996 00:52:29 -0500 (EST)
From: Donald Franklin Klein <dfk2@columbia.edu>
Subject: Thyroid replacement

The major medical red herring is osteoporosis which is a problem in postmenopausal women correctable by estrogen. [italics mine; he's saying he does not regard osteoporosis as a problem in premenopausal women taking thyroid replacement, consistent with the research linked in section 1 above]

For useful medical references try:

Wartofsky L. Levothyroxine therapy and osteoporosis. An end to the controversy? Archives of Internal Medicine. 155 (11): 1130-1, 1995 Jun 12

Florkowski CM, Brownlie BE, Elliot JR, Ayling EM, Turner JG. Bone mineral density in patients receiving suppressive doses of thyroxine for thyroid carcinoma. New Zealand Medical Journal. 106 (966): 443-4, 1993 Oct 27.

There is a turf battle here but I handle thyroid myself rather than depend on an unstable alliance.

I use T3 + T4 and aim for .1 mg T4 + 50 mcg T3. For uselessness of thyroid indices once exogenous thyroid given, see Fraser WD et al. Are biochemical tests of thyroid function of any value in monitoring patients receiving thyroxine replacement? Brit Med J. 293:808-810, 27 Sept 1986.

3. Non-MD summary

Mary Shomon appears to have read more on the subject of thyroid conditions than many doctors.  She has also accumulated a great deal of experience listening to people with thyroid problems, which is how we doctors really learn.  Some people, including one inappropriate M.D. she quotes near the bottom of her summary, regard her as a "fringe" leader.  However, you can see from her summary that she is trying to help you evaluate risk in a very systematic way.  As she notes, even getting an opinion from an endocrinologist may not help you further:  it would depend on whom you saw, and his/her general stance on risk.