Sudan Journal of Medical Sciences
Volume 17, Issue no. 2, DOI 10.18502/sjms.v17i2.11460
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Review Article

Thyroid-stimulating Hormone Suppressive
Therapy and Osteoporosis: A Review and
Meta-analysis
Hyder Osman Mirghani1* and Albaraa Altowigri2

1Associate Professor of Internal Medicine and Endocrine, Faculty of Medicine, University of
Tabuk, Saudi Arabia
2Assistant Professor of Orthopedics, Faculty of Medicine, University of Tabuk, Saudi Arabia
ORCID:
Hyder Osman Mirghani: https://orcid.org/0000-0002-5817-6194

Abstract
Background: Osteoporosis is a common morbid and mortal disease; thyroid-
stimulating hormone (TSH) suppression is the state-of-the-art for postoperative
differentiated thyroid carcinoma (DTC). However, its association with osteoporosis
remains controversial. The current meta-analysis assessed the relationship between
TSH suppressive therapy and osteoporosis among patients with DTC.
Methods: We systematically searched PubMed, Cochrane Library, EBSCO, and the
first 100 articles in Google Scholar for relevant articles published in English during
the period from 2008 to November 2020. The keywords differentiated thyroid cancer,
TSH suppression, osteoporosis, low bone mineral density, osteopenia; fracture risk,
disturbed bone micro-architecture, bone loss, and trabecular bone were used. One
hundred and eighty-four articles were retrieved; of them, fourteen were eligible and
met the inclusion and exclusion criteria. The RevMan system was used for data analysis.
Results: We included 36 cohorts from 15 studies, the studies showed higher
osteoporosis and osteopenia among TSH-suppressed women, odd ratio, 2.64, 1.48–
4.68 and 2.23, 0.33–14.96, respectively. High heterogeneity was observed, I2 = 68%
and 96%, respectively). The sub-analysis showed a lower bone mineral density among
postmenopausal women at both femoral neck and lumbar spines, odds ratio, –0.02,
–0.07 to 0.04, and –0.03, –0.06 to 0.01, I2 for heterogeneity, 69%, and 51% in contrast
to men and premenopausal women who showed normal or higher bone density.
Conclusion: TSH suppression for DTC was associated with osteoporosis and
osteopenia among postmenopausal women but not premenopausal women or men.
Studies focusing on trabecular bone scores are needed.

Keywords: TSH suppression, differentiated thyroid carcinoma, osteoporosis

1. Introduction

Thyroid carcinoma is among the most common malignancies with an incidence of 1.7
to 4.1/100.000/yr in men and 4.5 to 8.7/100.000/yr in women [1]. DTC is on the rise
worldwide due to the increasing age. Patients diagnosed with thyroid carcinoma are

How to cite this article: Hyder Osman Mirghani* and Albaraa Altowigri (2022) “Thyroid-stimulating Hormone Suppressive Therapy and Osteoporosis:
A Review and Meta-analysis,” Sudan Journal of Medical Sciences, vol. 17, no. 2, pp. 263–278. DOI 10.18502/sjms.v17i2.11460 Page 263

Corresponding Author: Hyder

Osman Mirghani; email:

s.hyder63@hotmail.com

Received 16 November 2020

Accepted 21 May 2022

Published 30 June 2022

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Hyder Osman Mirghani

and Albaraa Altowigri. This

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Editor-in-Chief:

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Sudan Journal of Medical Sciences Hyder Osman Mirghani and Albaraa Altowigri

usually hypothyroid or euthyroid. However, thyrotoxicosis may be observed in 3.38%
of metastatic thyroid diseases [2, 3]. Endogenous hyperthyroidism shortens the bone
turnover cycle, accelerates bone turnover, and leads to low bone mineral density (BMD)
[4]. Supra-physiological doses of thyroxine are the mainstay of therapy to suppress
the TSH among postoperative patients with DTC for >60 years [5]. Whether TSH
suppression can lead to osteoporosis is a matter of controversy. On the other hand,
hypoparathyroidism observed among patients with DTC was shown to increase BMD
[6]. The relationship between osteoporosis and DTC is complex and when coexist may
lead to deleterious consequences. Although thyrotoxicosis is well-known for its effects
on BMD, the supraphysiological doses of thyroid hormone and their exact contribution
to bone turnover are not well-established [7, 8]. The literature on this important health
problem is scarce. Given the above, we conducted this meta-analysis to assess TSH
suppression effects on BMD among patients with DTC.

2. Materials and Methods

2.1. The selection criteria according to PICOS

2.1.1. The included studies

We included cross-sectional, prospective and retrospective cohorts, and controlled
trials. Studies must assess thyroid-stimulating hormone (TSH) suppression on BMD
among patients with differentiated thyroid carcinoma (DTC).

2.1.2. Outcome measures

To be included, the studies must investigate osteoporosis, osteopenia, BMD, or bone
loss as primary or secondary outcomes. No specifications were applied for subgroups
(pooled females, premenopausal, men, and postmenopausal were included). DTC is
affecting all age groups, males and females. Besides, osteoporosis risks are not limited
to postmenopausal status. Thus, including all the patients and controlling for possible
risk factors might be appropriate. Case reports, animal studies, and experimental studies
were not included.

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qualitative synthesis 

Figure 1: The effect of long thyroid-stimulating hormone (TSH)-suppressive therapy (following surgery for
differentiated thyroid carcinoma) on bone mineral density (osteoporosis).

2.1.3. Patients

The patients who underwent TSH suppression following thyroidectomy for DTC (males,
and females, premenopausal or postmenopausal) were included. Patients with other
thyroid disorders that need TSH suppression including toxic goiter and thyroid cancer
other than DTC were excluded.

2.2. Literature search and articles selection

A systematic electronic search was conducted in Pub Med, Cochrane library, EBSCO,
and the first 100 articles in Google Scholar for relevant articles published in the English

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Sudan Journal of Medical Sciences Hyder Osman Mirghani and Albaraa Altowigri

language. The search engine was set to include studies from the first published arti-
cle up to November 2020. The terms “differentiated thyroid cancer,” “TSH suppres-
sion,” “osteoporosis,” “low BMD,” “osteopenia,” “fracture risk,” “disturbed bone micro-
architecture,” “bone loss,” and “trabecular bone” were used. The protean ”AND” and
”OR” were applied. The two authors independently screened the titles and abstracts.
One hundred and eighty-four articles were retrieved, the number stood at 88 after
duplication removal. Of them, 32 full-texts were screened, and only 15 were eligible
after applying the inclusion and exclusion criteria (nine texts were excluded due to
missing information, and another eight needed subscription). The authors resolved any
discrepancy among the articles by consensus. The data were exported into an extraction
sheet detailing the author’s name, year, country of publication, the study type and
period, the T and Z-scores of bone densitometry (DEXA scan), and the number of both
the interventional and control groups. The study’s risk of bias and quality was assessed
using the Ottawa Newcastle scale (Table 1). The different phases of the literature search
are shown in Figure 1.

2.3. Statistical analysis

The authors used the RevMan version 5.4 for data analysis, data were entered manually,
the fixed effect was used unless a significant heterogeneity was observed (>50%). The
funnel plot was used to test for sensitivity (lateralization). P-value < 0.05 was considered
significant.

3. Results

Out of the 184 studies included, 15 articles were included in the meta-analysis, 6 were
cross-sectional, 5 were prospective cohorts, and 4 were case–control studies. Most
of the included studies also have a retrospective arm. Seven studies were published
in Europe, five in Asia, one in South America, one was from the USA, and one from
Canada. The study periods ranged from14.93 ± 2.17 months to 12.2 ± 6.6 years, and
the total number of patients was 2180 versus 2707 controls.

In the current meta-analysis, six studies assessed osteoporosis among women
(menopausal status not uniform); of them, five studies showed a higher rate of osteo-
porosis in the interventional group [9–13], while one showed lower osteoporosis [14].
However, due to the significant heterogeneity observed (I2 = 68%), the random effect

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Table 1: Ottawa Newcastle assessment for the included studies.

Author Selection Compatibility Outcome Score

Franklyn et al. (1992) [16] 3 2 4 9

Kung et al. (1993) [18] 3 2 4 9

Muller et al. (1995) [9] 3 2 4 9

Fujiyama et al. (1995) [17] 3 2 4 9

Goerres et al. (1998) [22] 3 2 4 9

Eftekhari et al. (1998) [23] 3 2 4 9

Reverter et al. (2005) [20] 3 2 4 9

De Melo et al. (2015) [11] 3 2 4 9

Wang et al. (2015) [10] 3 2 3 8

Tournis et al. (2015) [21] 3 2 4 9

Moon et al. (2016) [19] 3 2 3 8

De Mingo Dominguez et al.
(2018) [15]

4 1 2 7

Vera et al. (2016) [14] 3 2 3 8

Mazziotti et al. (2018) [12] 4 1 3 8

Zhang et al. (2018) [13] 4 2 3 9

showed a net effect favoring high osteoporosis among the TSH suppression group,
odd ratio, 2.64, 1.48–4.68. The funnel plot showed significant lateralization (Figure 2).

Regarding osteopenia, among the three studies included, two [11, 12] showed more
osteopenia in the control group, and one reported a marked rate of osteopenia in
the interventional group [13], the overall effect is more osteopenia among the TSH
suppression, odd ratio, 2.23, 0.33–14.96 (Figure 3).

Regarding the effects of TSH suppression among postmenopausal women, no dif-
ferences in BMD was observed in lumbar spines [11, 15–21], and femoral neck [11, 16,
18–21], odd ratio, –0.02, –0.07 to 0.04, and –0.03, –0.06 to 0.01, respectively, I2 for
heterogeneity, 69% and 51%, respectively, P-values, 0.52 and 0.1, respectively (Figures
4 & 5). A higher value of BMD was observed among premenopausal women compared
to controls in both the lumber spines [11, 16, 19, 21, and 22] and femoral neck [16, 19,
21, and 22], odd ratios, 0.05, 0.0–0.09, and 0.03, 0.0–0.06, P-values, 0.04 and 0.03,
respectively (Figures 6 & 7).

No difference in BMD was evident between males with suppressed TSH and their
counterparts, no heterogeneity was observed, odd ratio, 0.0, –0.7 to 0.06, P-value, 0.87
(Figure 8).

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Table 2: The effect of long thyroid-stimulating hormone (TSH) suppressive therapy (following surgery for
differentiated thyroid carcinoma) on bone mineral density.

Author Year Country Type Patients
(interventional
vs controls)

Study
period

Results

Muller et al. [9] 1995 Canada Prospective 25 DTC
(matched for
menopausal
status, BMI, and
age), 0/25 vs
13/25 for EXT,
0/25 vs 1/25 for
other sites

11 years Cancer patients showed
insignificant reductions of
2–5% in BMD of LS, FN,
and TK and a significant 5%
reduction in BMD of EXT
(DTC, higher T4, same TSH
suppression)

Wang et al. [10] 2015 USA Prospective
comparing
TSH < 0.4
mU/l and 0.4

125/537 vs
29/537 for
premenopausal
and
postmenopausal

66
months

Osteoporosis increased, with
no change in the recurrence
rate. No increased risk of TSH
level around 1 mU/l

de Melo et al. [11] 2015 Brazil Cross-
sectional,

21/109 for
osteoporosis
and 44/109 for
osteopenia
vs 17/109
and 49/109,
postmenopausal

88 ±
70.6
months

Not significant

Vera et al. [14] 2016 Italy Case–
control

62/74 hip,
49/74 lumbar vs
92/120, 75/120,
women

36
months

No relation of T4 dose, level,
or duration of therapy to
osteoporosis Mean ± SD
available

Mazziotti et al. [12] 2018 Italy Cross-
sectional,
TSH < 0.05
and >1

35/83 vs 9/46
for osteoporosis
and 35/83
vs 21/46 for
osteopenia,
women

5.5 years Vertebral fractures were com-
mon among patients on long-
term T4 and TSH levels <1
mU/l

Zhang et al. [13] 2018 China Prospective
cohort

90/152, 13/152
vs 23/68,
9/68 for
osteopenia and
osteoporosis,
respectively,
post-
menopausal
women

2 years Osteopenia was observed, no
osteoporosis. (TSH > 0.3 &
TSH < 0.3 μIU/mL)

4. Discussion

Osteoporosis is common among men and postmenopausal women in contrast to pre-
menopausal women; therefore, much less interest is observed regarding this morbid and
mortal disease in this age group [23]. TSH-suppressive therapy is on the rise due to the
increasing diagnosis of DTC mirrored by improving diagnostic and screening tools [24].
We found a higher rate of osteoporosis among women (pooled and postmenopausal).

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Table 3: TSH suppression for differentiated thyroid carcinoma and bone mineral density among women.

Author Year Country Type Premenopausal Postmenopausal Study
period

Franklyn et al. [16] 1992 UK Prospective 18 vs 18 controls
0.760 ± 0.140 vs
0.780 ± 0.150 Lum-
bar spines and 1.000
± 0.110 vs 0.970 ±
0.130 femoral neck

26 vs 26 controls
0.540 ± 0.170 vs
0.540 ± 0.220 lumbar
spines and 0.810 ±
0.080 vs 0.830 ±
0.130 femoral neck

7.9 years

Kung et al. [18] 1993 Hong
Kong

Cross-
sectional

34 vs 34 controls
0.749 ± 0.147 vs 0.917
± 0.161 lumbar spines
and 0.622 ± 0.123 vs
0.708 ± 0.127 femoral
neck

12.2 ±
6.6 years

Fujiyama et al. [17] 1995 Japan Prospective 12 vs 12 0.849 ± 0.605
vs 0.849 ± 0.605
lumbar

Goerres et al. [22] 1998 SwitzerlandCross-
sectional

7 vs 7 controls 1.006
± 0.143 vs 0.903 ±
0.128 lumbar spines
and 0.892 ± 0.141
vs 0.861 ± 0.094
femoral neck

Reverter et al. [20] 2005 Spain Cross-
sectional

44 vs 44 controls 1.094
± 0.248 vs 0.978 ±
0.355 lumbar spines
and 0.927 ± 0.124 vs
0.921 ± 0.148 femoral
neck

de Melo et al. [11] 2015 Brazil Cross-
sectional

109 vs 109 1.09 ± 1.43
vs 1.11 ± 1.3, lumbar,
0.12 ± 1.1 vs 0.37 ± 1.06
femur

88 ±
70.6
months

Tournis et al. [21] 2015 Greece Case-control 40 vs 29 1.200 ±
0.100 1.100 ± 0.100
lumbar 0.940 ±
0.100 vs 0.900 ±
0.100 femoral

40 vs 60 1.100 ±
0.100 vs 1.100 ± 0.100
lumbar and 0.840 ±
0.100 vs 0.870 ± 0.100
femoral

Moon et al. [19] 2016 South
Korea

Case–
control

25 vs 75 1.210 ±
0.110 vs 1.180 ± 0.120
Lumbar, and 0.930
± 0.100 vs 0.900 ±
0.090, femoral

74 vs 222 1.050 ±
0.150 vs 1.070 ± 0.140
lumbar, and 0.830 ±
0.110 vs 0.830 ± 0.100
femoral

36
months

De Mingo
Dominguez et
al. [15]

2018 Spain Case–
control

14 vs 84 1.00 ±
0.12 vs 0.98 ± 0.11,
lumbar

14 vs 84 0.86 ± 0.12 vs
0.84 ± 0.15, lumbar

10 years

BMD was higher among women with DTC who received thyroxine for TSH suppression,
no difference in BMD was observed among males compared to their counterparts
without TSH suppression. The current findings were similar to Ku and colleagues who
conducted a meta-analysis and found similar results [25]. The current findings supported
the conclusion of a recent meta-analysis that included only 11 studies and focused on

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Sudan Journal of Medical Sciences Hyder Osman Mirghani and Albaraa Altowigri

Table 4: TSH suppression for differentiated thyroid carcinoma and bone mineral density among men.

Author Year Country Type BMD Study period

Franklyn et al. [16] 1992 UK Prospective 5 vs 5 controls 0.710 ± 0.270 vs
0.750 ± 0.280 Lumbar spines and
0.890 ± 0.110 vs 1.000 ± 0.210
femoral neck

7.9 years

Goerres et al. [22] 1998 SwitzerlandCross-sectional 17 vs 18 controls 0.965 ± 0.173 vs
1.003 ± 0.132 lumbar spines

Reverter et al. [20] 2005 Spain Cross-sectional 33 vs 33 controls 1.253 ± 0.156 vs
1.238 ± 0.171 lumbar spines and
0.948 ± 0.128 vs 0.997 ± 0.151
femoral neck

Eftekhari et al. [23] 2008 Iran Cross-sectional 11 vs 11 controls 1.110 ± 0.210 vs
1.040 ± 0.090 lumbar spines

14.93 ± 2.17
months

 

 

 

 

Figure 2: The effect of long thyroid-stimulating hormone (TSH)-suppressive therapy (following surgery for
differentiated thyroid carcinoma) on bone mineral density (osteoporosis).

the site of BMD, our study assessed additional women with osteopenia and a broad
category of women without specification of menopausal status. A recent meta-analysis

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Figure 3: The effect of long thyroid-stimulating hormone (TSH)-suppressive therapy (following surgery for
differentiated thyroid carcinoma) on bone mineral density (osteopenia).

[26] concluded the negative effects of TSH suppression on BMD (the study assessed
postmenopausal women only). A broader insight for TSH suppression, which might be of
minimal contribution to mortality and morbidity was suggested [27, 28]. A previous study
based on American Thyroid Association has categorized patients into nine categories
including the patient’s character, the aggressiveness of the tumor, the duration and
levels of TSH suppression, and cardiovascular adverse effects [29]. Besides, the time
to develop osteoporosis was found to be shorter in postmenopausal women and
those with a family history of the disease [30]. Recent studies have suggested that
trabecular bone score combined with BMD measurement might be more useful than
the current practice of depending on BMD alone [31]. The contradicting findings of
a higher BMD in premenopausal women might be explained by estrogen effects or
lifestyles. The strength of this analysis is that we investigated both osteoporosis and
osteopenia. The study limitations were: including studies with different methods of

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Figure 4: TSH suppression and bone mineral density among postmenopausal women lumbar spines.

outcomes assessments, the unlimited period of database search, and the heterogeneity
observed in the meta-analysis.

5. Conclusion

TSH-suppressive therapy was associated with increased osteopenia and osteoporosis
risk in postmenopausal women, no association was found between TSH suppression
and osteoporosis in premenopausal women and men. Further studies investigating
the combined use of trabecular bone score for bone quality in addition to BMD are
recommended.

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Figure 5: TSH suppression and bone mineral density among postmenopausal women femoral neck.

6. The implications for research, policy, or practice:

Extreme caution is needed regarding the use of TSH suppression in low-risk DTC in
patients at risk of/with osteoporosis. If needed, TSH suppression may need careful
follow-up to keep the TSH levels at the recommended levels (<0.1 mU/l for aggressive
malignancies and [<21 mU/l for low-intermediate grades) follow-up by the indicated
techniques DEXA-Scans or qualitative computed tomography) at shorter periods may
be needed.

Acknowledgements

The authors would like to acknowledge the Saudi National Library for granting access
to the databases.

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Figure 6: TSH suppression and bone mineral density among premenopausal women lumbar spines.

 

Figure 7: TSH suppression and bone mineral density among premenopausal women lumbar spines.

Ethical Considerations

The current meta-analysis did not include any research on humans or animals published
by the authors.

Competing Interests

The authors declare that they have no competing interests.

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Figure 8: TSH suppression and bone mineral density among men lumbar spines.

Availability of Data and Materials

The dataset used in this meta-analysis are available upon request.

Funding

The research is self-funded and not supported financially by any institute or organization.

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	Introduction
	Materials and Methods
	The selection criteria according to PICOS
	Proxima-Nova-Bold-Italic.otfThe included studies
	Proxima-Nova-Bold-Italic.otfOutcome measures
	Proxima-Nova-Bold-Italic.otfPatients

	 Literature search and articles selection
	Statistical analysis

	Results
	Discussion
	Conclusion
	The implications for research, policy, or practice:
	Acknowledgements
	Ethical Considerations 
	Competing Interests
	Availability of Data and Materials
	Funding
	References