All the Proposed Causes for Bone Loss

**This page is to highlight that it is NORMAL to see your TSH fall due to the effectiveness of T3 in your treatment. How do we as patients know the latter, even on lower doses before we have raised to get an optimal free T3)? Because it has been consistently “observed and experienced” for over two decades now.

And that TSH fall is NOT the same as the low TSH from hyperthyroidism, aka Grave’s disease—the latter which can cause bone loss if it’s uncontrolled.

And contrary to what you are told, that low TSH from the power of the active hormone T3 is NOT the reason for bone loss. We have had thyroid patients on NDT (20% is T3), or on T4/T3, or on straight T3 for years and in some cases decades, who have reported NO BONE LOSS (unless one of more of the below occurs).

Hormonal and Age-Related Causes

• Natural aging (peak bone mass typically in the 20s–30s, with gradual loss thereafter)
• Menopause / estrogen deficiency
• Premature menopause or early oophorectomy
• Hypogonadism (low sex hormones in men or women)
• Low testosterone (andropause or other causes)
• Hyperthyroidism aka uncontrolled Graves’ disease
• Being underdosed with T3 over time; not getting an optimal free T3
• Being on nothing but T4 over time
• Hyperparathyroidism (primary or secondary)
• Cushing’s syndrome
• Growth hormone deficiency
• Diabetes mellitus (Type 1 and Type 2)
• Pregnancy- and lactation-associated bone loss (usually temporary)
• Amenorrhea (e.g., from extreme exercise, low energy availability, or hypothalamic causes)

Nutritional and Gastrointestinal Causes

• Calcium deficiency or chronically low dietary calcium
• Vitamin D deficiency or insufficiency
• Vitamin K deficiency
• Magnesium deficiency
• Protein-energy malnutrition or low protein intake
• Phosphorus imbalance
• Malabsorption syndromes (celiac disease, inflammatory bowel disease such as Crohn’s or ulcerative colitis, short bowel syndrome, bariatric surgery consequences)
• Chronic liver disease
• Anorexia nervosa, bulimia, or other eating disorders
• Chronic alcoholism (nutritional and direct toxic effects)
• Excessive vitamin A intake
• High sodium diets (increased calcium excretion) in susceptible people
• Very low-calorie or highly restrictive diets over long periods

Lifestyle and Behavioral Factors

• Sedentary lifestyle / lack of weight-bearing or resistance exercise
• Prolonged immobilization, bed rest, or cast immobilization
• Paralysis or neuromuscular conditions limiting movement
• Smoking / tobacco use
• Excessive alcohol consumption
• Excessive caffeine intake (modest contributor in some contexts)
• Low body weight or low BMI
• History of extreme athletic training with energy deficit (female athlete triad / relative energy deficiency in sport)
• Low vitamin D (common with being poorly treated for hypothyroidism)

Medications and Treatments

• Long-term systemic glucocorticoids (corticosteroids) — a major cause (we do use use cortisol long-term–only until we can raise our free T3 without pooling)
• Aromatase inhibitors (used in breast cancer)
• Gonadotropin-releasing hormone (GnRH) agonists or antagonists
• Certain anticonvulsants / anti-epileptic drugs (e.g., enzyme-inducing ones)
• Long-term proton pump inhibitors (PPIs)
• Selective serotonin reuptake inhibitors (SSRIs) and some other antidepressants
• Thiazolidinediones (certain diabetes medications)
• Long-term heparin (especially unfractionated)
• Some chemotherapy agents and cancer treatments
• Pushing our frees way above range via thyroid hormone replacement
• Certain immunosuppressants (e.g., after organ transplant)
• Medroxyprogesterone acetate (Depo-Provera) with prolonged use
• Some antiretroviral therapies
• High-dose or prolonged methotrexate in some contexts
• Calcineurin inhibitors

Medical Conditions and Systemic Diseases

• Rheumatoid arthritis and other chronic inflammatory arthritides
• Ankylosing spondylitis and other spondyloarthropathies
• Chronic kidney disease / renal osteodystrophy
• Multiple myeloma and other plasma cell disorders
• Other cancers with bone involvement or cachexia
• HIV/AIDS
• Chronic obstructive pulmonary disease (COPD)
• Organ transplantation (and associated medications)
• Mastocytosis
• Homocystinuria and certain metabolic disorders
• Osteogenesis imperfecta and related genetic connective-tissue disorders
• Marfan syndrome, Ehlers-Danlos syndrome (certain types), and other heritable disorders of connective tissue
• Idiopathic juvenile osteoporosis or other rare genetic bone diseases
• Hypercalciuria
• Paget’s disease of bone (can involve abnormal bone remodeling)
• Thalassemia and some other hemoglobinopathies
• Chronic inflammatory or autoimmune diseases more broadly
• Severe prolonged illness or critical illness with immobility
• Low stomach acid due to hypothyroidism or other medical causes

Genetics, Demographic, and Other Factors

• Family history of osteoporosis or hip fracture / genetic predisposition affecting peak bone mass or bone quality
• Female sex (higher lifetime risk on average)
• Caucasian or Asian ancestry (higher statistical risk in many populations)
• History of prior fragility fracture
• Low peak bone mass achieved in young adulthood
• Certain chromosomal or developmental disorders
• Spaceflight / prolonged microgravity (extreme disuse osteoporosis)
• Radiation exposure affecting bone in some settings

Additional or Overlapping Contributors

• Chronic inflammation from any source
• Oxidative stress and advanced glycation end-products (relevant in aging and diabetes)
• Zinc or other micronutrient deficiencies in some cases
• Secondary hyperparathyroidism from various causes
• Acid-base disturbances (e.g., chronic metabolic acidosis)
• Vascular or marrow changes affecting bone remodeling

So what do we do if a Dexa scan has revealed bone loss?? Below has evidence…

• Progressive resistance training of our muscles against the bone. Bone responds to strain. And it seems to be the most consistently supported interventions. Squats, deadlifts, presses, rows. Go to the Pubmed website for evidence for “resistance training bone mineral density meta-analysis”
• Even running, fast walking, jumping, etc can create ground-reaction forces that stimulate bone. Studies show impact loading improves hip and spine density, especially in younger and premenopausal people, but can help even menopausal and older. (Be careful with jumping if you already had a scan that shows osteoporosis)
• You need adequate calcium levels from your diet. (Janie loves her Greek yogurt, cheeses, cottage cheese in recipes, some meats, protein powder in recipes, etc.) For evidence, some studies about calcium in the diet might use “moderate” to describe bone improvement. But the study didn’t test calcium intake long enough! Be careful with some pronouncement in studies. Calcium probably gives even better results the longer you focus on your calcium intake.
• Same with adequate vitamin D. Check those levels. We are mainly looking for 70-90 in ranges. If you do genetic testing and have the VDR mutation (Janie does) which causes levels to fall, you will probably need to be taking 10,000 IUs at least 4-5 times a week or so. Do an internet search for “vitamin D supplementation bone density”. Lots of evidence.
• We need higher protein in take in our diet, and especially as our bodies age. Do a search for studies that consistently demonstrate that dietary protein works synergistically with calcium to improve bone mineral density (BMD) and reduce fracture risk.
• Yes, there are medications to consider to build density and fracture reduction. They include the following but always research them before using:
  • Bisphosphonates (alendronate, etc.)
  • Denosumab
  • Anabolics (teriparatide, romosozumab) — actually build new bone
• And get that free T3 optimal, because every cell in our body needs T3 for its health.

But what you need to face–the following with hurt your bones

• Smoking
• Heavy alcohol
• Being underweight
• Long-term high-dose corticosteroids (unavoidable sometimes, but managed). We don’t do long-term cortisol use. We only use it when saliva testing proves we are low, and we stay on until we get out of our hypothyroid state. Then begins a low wean.

Find a good doctor, too, when you need help.