Tired? Always Cold? Think it’s hypothyroidism? Think again

With Mary Samuels, MD, James Hennessey, MD, and Deena Adimoolam, MD

MIxed messages persist regarding whether to treat subclinical hypothyroidism or not. You may be diagnosed with subclinical hypothyroidism if you have a thyroid function test indicating normal thyroxine (T4) concentration and mildly elevated serum thyroid stimulating hormone (TSH) level.

While symptoms like unexpected weight gain, depression and moodiness, sleeplessness, hair loss, and intolerance to cold temperatures are commonly associated with hypothyroidism, there are rarely any symptoms in individuals who have very mild subclinical hypothyroid disease so it is rarely detected. Then does it really matter?

Being cold all the time may be a sign of hypothyroidism.Symptoms like feeling fatigued, always cold, gaining weight are possible signs of hypothyroidism but subclinical hypothyroid disease often has no symptoms and rarely requires treatment. photo; 123rf

No Apparent Benefit in Treating Subclinical Hypothyroidism

This is a question that has plagued doctors—to treat or not to treat for subclinical hypothyroidism? The answer remains controversial. Having subclinical hypothyroidism may increase a person’s risk of cardiovascular disease so you might say, “treat me.

However, guidelines from experts found no benefit in treating individuals whose TSH falls between 5-10 mlU/L,1,2 unless you are planning a pregnancy or are pregnant and have confirmed subclinical hypothyroidism.  

Before you jump to the conclusion that everyone with subclinical hypothyroidism should be treated, findings from a pair of studies, published in the Journal of Clinical Endocrinology and Metabolism,3,4 may clarify the matter for you. Both studies were carried out by Mary Samuels, MD, professor of medicine, and her research team, at the Oregon Health Sciences University in Portland.

In the first study,3 the researchers wanted to know if changing the dose of levothyroxine has a noticeable effect on patients’ quality of life, mood, and cognitive reasoning. They used surveys to gather patient responses assessing their quality of life and mental health status, and a research assistant conducted tests to evaluate changes in memory, attention, and decision-making to develop a score for cognition.

According to Dr. Samuels, there was no improvement in participants' test scores based on dosing levels, even though the dosages were increased to bring the patient into line with recommended TSH levels.3 Furthermore, patients reported feeling their best when they thought they were being treated with the highest dose of levothyroxine. If they thought their dose had been lowered, they reported feeling better at the beginning of the study, whether they had actually had a change in their medication or not.

The research team looked at changes in energy expenditure and body mass index (BMI), in the second study of these same individuals,4 to assess whether a change in these parameters had any effect on the dose of thyroid replacement therapy needed. Again, the authors reported no differences found; yet, patients believed that the dose they did best on was the highest dose. 

“This means that even if you think you have a very mild form of hypothyroidism, you should not expect to gain any significant health advantages or benefits from thyroid replacement therapy,” Dr. Samuels tells EndocrineWeb.

 Unless You Are Pregnant, Approach Treatment with Caution  

James Hennessey, MD, an endocrinologist at Beth Israel Deaconess Medical Center in Boston, says patients often leap at the idea of hypothyroidism when they have certain symptoms because it is so easily treated; he reviewed the studies for EndocrineWeb but wasn't involved in them.

“It’s important to realize there are many other conditions which can produce similar symptoms, including depression, poor kidney function, or an autoimmune disease like systemic lupus,” he says. So pushing for treatment may be premature or even counterproductive.

If you have symptoms that are causing you to worry, or that you've noticed recently, the best course of action is to make an appointment with your doctor to share these changes so your health can be assessed, and your thyroid status can be properly evaluated.

Dr. Hennessey offers another note of caution—you should know that the TSH levels that are listed on websites as normal or abnormal may refer only to specific age ranges. “There is a big difference between what is acceptable for a 30-year-old than for a 60-year-old. And, while 2.5 mlU/L is a great TSH level for a younger person, a thyroid function at 6.0 mlU/L is equally fine for a more senior patient.

“Receiving [levothyroxine] treatment can even be dangerous," says Deena Adimoolam, MD, an endocrinologist and assistant professor of medicine at the Icahn School of Medicine at Mt. Sinai Hospital in New York City. It may be constructive to realize that there are symptoms of too much thyroid hormone; signs of overtreatment include anxiety, sweating, and insomnia but there are also “silent” effects that can result such as irregular heartbeats (arrhythmias) and even heart failure. 

Even when one doctor has treated you for years, Dr. Adimoolam says, “if you change doctors for any reason, you should expect to be screened by your new provider who is likely to recommend that you taper off your thyroid replacement medication before checking your TSH levels.”

Seek Treatment Based on Thyroid Function Status, Not Perceptions

"Patients should also know that the TSH levels that are on listed on websites as normal or abnormal may refer only to specific age ranges. There is a wide difference between what is acceptable for a 30-year-old than for a 60-year-old. While 2.5 mlU/L is a great level for the former, 6 mIU/L is fine for the latter," Dr. Hennessy adds.

 

“Age is only one of the factors that I rely on in evaluating whether or not a patient would benefit from thyroid replacement therapy,” says Deena Adimoolam, MD, assistant professor of medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York City. 

“We need to assess the patient based on her overall clinical situation —history of symptoms, physical examination, comorbidities, other meds—and lab values, specifically thyroid function tests, keeping in mind that these tests, specifically the TSH, will change with age in making a determination to treat or not to treat.”

While you might feel certain that you have hypothyroidism and insist that your doctor give you levothyroxine (thyroid replacement therapy), according to Dr. Hennessey, physicians must resist these entreaties and instead should offer you alternatives to address your concerns.

Should you experience a change your health status, such as taking new or different medications or doses, experiencing new life circumstances, such as pregnancy, these may warrant a fresh evaluation of your thyroid function levels,” Dr. Adimoolam says.

Of course, if you have symptoms that worry you, or that have occurred recently, the best course of action is to make an appointment to mention these changes with your physician who can assess the need for testing and possible treatment.

Dr. Hennessey offered another note of caution—it's important for patients to know that the TSH levels that are listed on websites as normal or abnormal may refer only to specific age ranges. “There is a big difference between what is acceptable for a 30-year-old than for a 60-year-old. And, while 2.5 mlU/L is a great TSH level for a younger person, a thyroid function at 6.0 mlU/L is equally fine for a more senior patient.

Receiving treatment can even be dangerous," says Deena Adimoolam, MD, an endocrinologist and assistant professor of medicine at the Icahn School of Medicine at Mt. Sinai Hospital in New York City. While lesser symptoms of overtreatment can include anxiety, sweating, and insomnia, “silent” effects can include irregular heartbeats (arrhythmias), and even heart failure.

More to Learn about Effects of Treating Hypothyroidism

Even when one doctor has treated you for years, Dr. Adimoolam says, “if you change doctors for any reason, you should expect to be screened by your new provider who is likely to recommend that you taper off your thyroid replacement medication before checking your TSH levels.”

“Remember—life is not static,” she says, “New medical issues, other medications, changes in life circumstances like an interest in pregnancy, even as you age, will warrant a reevaluation of your thyroid status, medications, and dosing.”

There is a lot more to study on the issue of who needs to be treated," says Dr. Hennessey. “Patients who are diagnosed with subclinical hypothyroidism who are not treated as well as those who are receiving levothyroxine need to be more closely evaluated.” Dr. 

“I would like to see longer term studies [in people with subclinical hypothyroidism] looking at the effect on quality of life as well as mortality rates,” says Dr. Adimolam. Until then, you can expect that there will be articles on the internet telling you that your hair is falling out not because you are aging, but because your thyroid is off. Chances are, your thyroid is not the problem, she says, so it's best to bring any concerns to your doctor and have an open mind.

These studies were conducted with grants from the National Insitute of Diabetes and Digestive and Kidney Diseases, the National Center for Advancing Translational Sciences, and an OSHU Clinical and Translational Science Award.

Only Dr. Hennessey offered the following disclosure-- he has been a consultant to Allergen Pharma, and AbbVie.

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Some Pregnant Women Should Be Treated for Subclinical Hypothyroidism

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