Diagnosis and treatment of Hypothyroidism: a patient’s perspective

Abstract

Hypothyroidism is caused by an inadequate supply of, or response to, thyroid hormones throughout the body. Hypothyroidism is the number one endocrine system problem and it affects hundreds of millions around the world. People with hypothyroidism typically suffer from a lack of energy and many other symptoms including cold intolerance, dry skin, weight gain, constipation, slow movement/speech, low sex drive, and dry, thinning or coarse hair.

When the hypothyroid condition is not adequately diagnosed and treated, more severe problems such as high cholesterol, cardiac issues, obesity, joint and muscle pain, gradual hearing loss, reproductive system disorders, depression, periodontal problems, carpal tunnel syndrome, sleep apnoea and diabetes will eventually appear; in extreme cases, it may even result in coma or death.

Why hypothyroidism is overlooked

Due to the non-specific nature of some symptoms, and the tendency of patients to downplay them, the possibility of hypothyroidism is often overlooked by both patients and doctors. When sufficient symptoms are present to warrant further investigations doctors will, in accordance with existing guidelines 1, 2, order a test for Thyroid Stimulating Hormone (TSH), the pituitary hormone that stimulates the output of hormone from the thyroid gland. If the TSH result is within the reference range, hypothyroidism is usually discounted.

If TSH exceeds the range, and the follow-up test for the thyroid hormone Free T4 (FT4) is within the range, then hypothyroidism is also usually discounted. Patients are told that their test results are ‘normal’ and that their symptoms must be due to something else. Free T3 (FT3), which is significantly more biologically active than FT4, is largely ignored.

Clinical evaluation has been largely superseded by TSH and FT4 tests, which will be shown later to be inadequate. For these reasons, the extent of undiagnosed/inadequately treated hypothyroidism is huge and frequently unrecognised. This is reflected in the American Thyroid Association’s (ATA) estimate that 20 million Americans have some form of thyroid disease and that up to 60% are unaware of their condition.

In addition to the problems discussed above, patients have not had easy access to the basic information necessary to realise that their symptoms are not normal, and to understand what testing and evaluation should be done. Doctors are not adequately informed on the benefit of combining clinical evaluation with biochemical tests.

These issues also adversely affect communication and cooperation between patients and doctors. Finally, although there are exhaustive scientific studies on all facets of hypothyroidism, no concise, comprehensive information for improved diagnosis and treatment, supported with scientific evidence, has been available to either group.

Suggestions for diagnosis and treatment of hypothyroidism

The intent of this paper is to meet the needs of both parties with the following suggestions for more effective diagnosis and treatment:

• The current diagnostic protocol based on TSH followed by FT4 is ineffective in reliably diagnosing a large proportion of hypothyroid patients and should be amended. The diagnosis must include a review of the full medical history of the patient.
• Diagnosis should include an evaluation of the patient’s signs and symptoms since they reflect both thyroid status and the patient’s concerns.
• Symptomatic testing and case finding should include FT4, FT3, arguably reverse T3 (RT3), TSH, TPO ab, TG ab (only if TPO ab is negative and TSH is high), cortisol , vitamin D, and ferritin. The interpretation of the test results is discussed in the Recommended Diagnostic and Treatment Procedures section below.
• If signs and symptoms are present, an ultrasound examination of the thyroid gland should be carried out, irrespective of the severity of biochemical abnormalities.
• If hypothyroidism is diagnosed, the patient’s FT4 and FT3 levels should be increased enough to eliminate signs/symptoms of hypothyroidism without creating signs/symptoms of hyperthyroidism . TSH should not be used to determine the medication dosage.