Differentiated thyroid cancer is the most common form of thyroid cancer and its prognosis is favourable in most cases. Suppression of thyroid stimulating hormone (TSH) by supra-physiological thyroid hormone replacement has been the mainstay of long-term management for over 60 years. However, evidence for a beneficial outcome of TSH suppression is conflicting and intervention must be balanced against adverse effects, particularly affecting the cardiovascular system and skeleton. Here we discuss the role of TSH suppression in the long-term management of differentiated thyroid cancer in the context of risk stratification for disease recurrence and the latest clinical guidelines. (C) 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.