Published April 28th 2014
Thyroid hormone is important for normal skeletal development and bone mass. As a result, people with hypothyroidism and Hashimoto’s Thyroiditis have an increased risk of developing osteoporosis and fractures. However, the same is true with hyperthyroidism and Graves’ Disease. As a result, whether someone has a hypothyroid or hyperthyroid condition, they need to take certain precautions to ensure proper bone health.
As I just mentioned, having normal levels of thyroid hormone is important for healthy bone development. Hypothyroidism in children results in growth retardation with delayed skeletal development, whereas high levels of thyroid hormone accelerates bone maturation (1). Population studies indicated that hypothyroidism and hyperthyroidism are both associated with an increased risk of fracture (1). What I’d like to do is take a look at both hypothyroid and hyperthyroid conditions and how bone density is affected in each of these. However, before I do this I’d like to briefly talk about some of the basics of bone density.
What You Need To Know About Bone Density
Everyone knows that healthy and strong bones are important. However, most people don’t think much about doing things to help improve their bone health, or consider factors which might have a negative effect on their bone density. Some causes of low bone mass include genetics, low bone mass as a child, vitamin and mineral deficiencies, deficiencies of the sex hormones, smoking, taking certain medications, lack of physical activity, carbonated soft drinks, and of course an imbalance in thyroid hormone.
Both osteopenia and osteoporosis are very common. Osteopenia is a term used to define bone density that is not normal but also not as low as osteoporosis (2). Osteoporosis is the most common type of bone disease, and about half of all women over the age of 50 will have a fracture of the hip, wrist, or vertebra during their lifetime due to osteoporosis (3). So my goal isn’t just to educate you about the causes of decreased bone density, but in this article I’ll of course provide some information to help prevent osteoporosis from developing.
One of the big problems is that there usually are no symptoms associated with a decrease in bone density. In fact, what frequently happens is that a person will feel fine from a health perspective, but then will experience a fracture, and then find out they have osteoporosis. I think it’s safe to say that many people reading this have low bone density and don’t realize it. As a result, for those with a hypothyroid or hyperthyroid condition it might be a good idea to get a bone density scan once the thyroid hormone levels normalize in order to determine whether you have a decrease in bone mass. Another option is to just assume you have a low bone density and follow the recommendations given at the end of this article.
The Impact Of Estrogen and Progesterone On Bone Health
Both estrogen and progesterone can be factors when it comes to bone health. Estrogen plays an important role in the growth and maturation of bone as well as in the regulation of bone turnover in adults (4). It does this by controlling the activity of osteoblasts, which form bone, and osteoclasts, which break down bone (5). Although estrogen seems to play a greater role in bone health than progesterone, there is evidence that it also is important for proper bone mass, and might help with the prevention of pre- and perimenopausal bone loss, as well as increasing bone mineral density and possibly decreasing fractures in postmenopausal women (6).
However, there is also evidence that an immune mechanism might be involved in the pathogenesis of post-menopausal osteoporosis (7). Estrogen deficiency leads to an increase in the immune function, which in turn leads to an increased production of tumor necrosis factor (TNF) by activated T cells (8). TNF in turn increases osteoclast formation and bone resorption. Although in past articles I’ve spoken about how estrogen dominance can potentially trigger an autoimmune response, normal amounts of estrogen help to prevent bone loss by regulating T cell function.
The Truth About Calcium, Dairy, and Bone Health
There is no question that calcium is important for strong bones. As a result, it would seem to make sense that taking calcium supplements and/or consuming dairy products would be two good ways of increasing bone density. However, recent studies have shown that calcium supplementation might not have as big of an impact on bone density as we once thought, and at the same time seems to improve the risk of cardiovascular disease and heart attacks (9) (10). However, another study showed that high intake of supplemental calcium is associated with an excess risk of cardiovascular disease death in men but not women (11). Perhaps supplementing with calcium on a short term basis can provide some benefits, but even if this is the case you don’t want to take calcium alone, as you always want to take calcium with magnesium, and you also want to make sure you have healthy vitamin D levels. Other nutrients can also be important for healthy bones, such as vitamin K, magnesium, and boron (12) (13).
Can consuming dairy products help to reduce the incidence of osteoporosis? Although I commonly recommend for my patients to avoid dairy products, the truth is that dairy can be a good source of calcium. This is especially true in children, as consumption of dairy products in childhood and adolescence may improve bone mineral density and reduce the risk of osteoporosis in adult women (14). Keep in mind that I’m not completely anti-dairy, although we of course are the only species on earth that drinks the milk of other species. But besides this fact, many people are sensitive to the proteins of dairy. Some people do better when consuming raw dairy, but some people react to this type of dairy as well. Just remember that you don’t need to consume dairy in order to have healthy bones. For more information about dairy I would check out my blog post entitled “Should People With Graves’ Disease and Hashimoto’s Thyroiditis Avoid Dairy?“.
Hyperthyroidism and Bone Health. Overt hyperthyroidism is associated with accelerated bone remodeling, reduced bone density, osteoporosis, and an increase in fracture rate (15). These changes in bone metabolism are associated with negative calcium balance, high calcium levels in the urine, and, rarely, high serum calcium levels (15). As a result, calcium intake is important, but as I mentioned earlier, other nutrients are important for healthy bones. Vitamin D is arguably just important, as it helps with the absorption of calcium. However, many people are deficient in vitamin D.
What’s also important to understand is that if someone has overt hyperthyroidism, but then normalizes the thyroid hormone levels through medication, natural treatments, or another method, this won’t necessarily correct the bone density problem. In other words, if some has high thyroid hormone levels for a prolonged period of time, this can lead to osteoporosis. If this person’s thyroid hormone levels eventually normalizes, this won’t necessarily correct the bone density problem. In addition, the person might not suffer from a fracture until many years after the normalization of the thyroid hormone levels. What this means is that if someone has a history of hyperthyroidism, even if this has been corrected, osteopenia or osteoporosis might be a factor.
In fact, one study evaluated bone mineral density in people with hyperthyroidism and found that most people have a decreased bone mineral density (16). The study involved 50 people with overt hyperthyroidism, and out of these 50 patients, 16 had osteopenia, and another 30 patients had osteoporosis. Another study involved 127 patients with hyperthyroidism, and the study showed that after an average of 7.5 months of being euthyroid, this recovery was insufficient to normalize the bone density in the lumbar spine, although the femoral bone mass wasn’t different from the control group (17).
Hypothyroidism and Bone Health. Fracture risk is also increased in people with hypothyroidism (18). There does seem to be an increase in bone density in adult subjects with hypothyroidism, but the bone quality is poor which is responsible for the possible increase in fracture in these patients (19). The reason for this is because normal amounts of thyroid hormones are important for bone mineral homeostasis.
How To Prevent And Reverse Osteopenia/Osteoporosis
So what can you do to make sure you have healthy, strong bones so that you don’t have to worry about osteopenia or osteoporosis? Or if you already have a decrease in bone mass, what can you do to reverse this problem? Here are a few things I recommend:
1. Correct the thyroid hormone imbalance. As I mentioned in this article, both hyperthyroidism and hypothyroidism can have a negative effect on bone mass. However, this is more true with hyperthyroid conditions. And so if someone has high thyroid hormone levels it not only is important to normalize these in order to decrease the cardiac symptoms associated with hyperthyroidism and Graves’ Disease, but it’s also important for the health of the bones. With regards to hypothyroidism, it’s also important to correct this condition. However, most people with hypothyroid conditions have Hashimoto’s Thyroiditis. And many times what I see is the TSH levels high, but the thyroid hormone levels normal, although they might be on the low side. This doesn’t mean that you don’t want to address this problem, but with regards to optimizing bone health, in most cases it’s more urgent to lower the elevated thyroid hormone levels in hyperthyroidism than increase the hormone levels in hypothyroidism.
2. Eat a healthy diet, and make sure you consume the nutrients important to bone health. This not only includes calcium and vitamin D, but other nutrients such as vitamin K, magnesium, and boron. Of course with vitamin D you ideally should get most of this from the sun, although some people have such low levels that they need to take a vitamin D supplement. While dairy can be a good form of calcium and therefore can help with bone mass, many people are sensitive to the proteins of dairy, and there are other foods which are good sources of calcium, including kale, almonds, Chinese cabbage, collard greens, broccoli, and blackstrap molasses..
3. Exercise regularly, and do some weight bearing exercises at least a few times per week. Doing some light weight lifting can help to increase the bone mass, and prevent or reverse conditions such as osteopenia or osteoporosis. However, if you are not already doing weight bearing exercises you might want to consider working with a physical trainer, even if it’s only for a few sessions.
4. Make sure you don’t have a deficiency of either estrogen or progesterone. Both of these can play an important role in proper bone health, although estrogen seems to play a greater role than progesterone. And so if you have either an estrogen or progesterone deficiency you want to correct this.
In summary, both hyperthyroidism and hypothyroidism are associated with an increased risk of fractures. However, the risk does seem to be greater in those people who have hyperthyroid conditions. Either way, for those people with a thyroid hormone imbalance it might be a good idea to get a bone density scan after the hormones are back in balance, and if the bone density is low you of course need to do some of the things I discussed to help improve the bone density. On the other hand, even if the there is no osteopenia or osteoporosis present, you still want to eat a healthy diet and do what is necessary to maintain healthy bones.