Hypothyroidism / Hashimoto's Thyroiditis: Treat or Not?

[echo]

This is a new thread started off the tails of BlizzardBoy's CompSa etc thread. I started talking about my own journey with Hypothyroidism in that thread, which got SleepingUgly interested in something I said (that if you have Hashimoto's Thyroiditis it doesn't matter what the blood tests say, you should probably get treated). I've extracted SU's question; the original posts are here: viewtopic.php?f=1&t=51063&st=0&sk=t&sd= ... 80#p500748 .

I actually consider this topic very On Topic because there seem to be a lot of people who have both OSA and Hypothyroidism... and in my mind there is a very clear link with untreated OSA and the development of thyroid problems.

I was diagnosed with Hashimoto's Thyroiditis a few years ago, and, as determined by my TSH, I remain euthyroid. They don't test anything besides my TSH anymore (although I have some older numbers for T4, T3 Uptake, Free Thyroxine Index, etc.). I get tested every 4-6 months. Examples of some of my last TSH's were 1.49, 1.35, 1.56, 1.89, 2.65, (others in the 2's), 2.99, etc... The highest ever, never to be repeated, was 3.78, and that was more than 2 years ago. All the rest since have been 2's and 1's. Once (or twice?) I had a low PTH, but nothing was made of that in the absence of other abnormalities.

With these very low numbers, is it even possible for hypothyroidism to be an issue? Isn't that more of an issue in the 4's, and higher (and maybe in the 3's), but certainly not the 1's?

First I will make the standard Disclaimer (again): I am not a doctor in any way, this is only based on extensive reading and my own personal experience! FWIW & YMMV.

There are two separate issues here:
(1) Do you treat Hashimoto's Disease when the lab values all show "normal"
(2) Do you treat someone that has all the symptoms of hypothryoidism when all lab values show "normal"

So,
(1) Now, based on a number of articles I read, it seems that some doctors suggest treating Hashimoto's Thyroiditis even in the absence of non-normal lab values for TSH, T4, T3, because in the long term it prevents/delays the development of hypothyroidism.
"Treating Antibodies When TSH is Normal" : http://thyroid.about.com/od/hypothyroid ... tative.htm
The references are from 2005, I haven't checked any new references but that would be easy enough.

(2) Then there is the issue that your lab values are all within the lab's "normal range" yet you still feel like crud. Everything else checks out ok too (e.g. no diabetes, heart is OK, blood vitamin and mineral levels are OK, etc). Yet you still have many of the symptoms of hypothyroidism (again one must tread with caution since these symptoms can be caused by other things, but in this case the false negative rate in detecting hypothyroidism is probably higher than other health problems, due to the currently used threshold for TSH).

The problem with the "normal" ranges are that the recommended thresholds have changed, yet not all blood labs have changed THEIR ranges.
In January 2003, the American Association of Clinical Endocrinologists (AACE) stated that doctors "consider treatment for patients who test outside the boundaries of a narrower margin based on a target TSH level of 0.3 to 3.0. AACE believes the new range will result in proper diagnosis for millions of Americans who suffer from a mild thyroid disorder, but have gone untreated until now."
Read more at
"The TSH Reference Range Wars: What's "Normal?", Who is Wrong, Who is Right..." : http://thyroid.about.com/od/gettestedan ... stwars.htm
and "Is Your Hypothyroidism UNDERtreated?" : http://thyroid.about.com/cs/hypothyroid ... reated.htm
Most labs have set the thresholds for TSH at 0.5 to 5.0, some are even higher at 6, 7, or even 10. In this case, MANY people who SHOULD probably start getting treatment DO NOT.

---
Then there is the question, if you are being treated, what is the optimal TSH to target? Most doctors try to get it <3, (sounds like AHI, anything <5 is fine!), but in fact the ideal target range for TSH may be 1-2. There is also the controversy of whether to include T3 together with T4 (like Armour thyroid or other sources of T3), rather than only T4 (like levothryoxine).

In my case, it took a long time to get started on the meds because none of the doctors would accept that I had hypothyroidism. I finally found one doc willing to work with me. Then I had the second problem with her, she stopped me a low dose because the TSH was pretty low, but i still had symptoms. On these low doses I *did* feel a lot better than before, but still not 100%. I manually titrated myself to a higher dose, and literally overnight I felt like a new person. I went from needing 10-14 hours to only 7-8 hours. So I am now skeptical about cases where the symptoms match the disease, but the person gets a negative diagnosis because the blood values are "normal". Am still waiting to hear back from last week's test as to whether i have the antibodies... but this is SU's thread so that's for another day.
---

In the case of Hashimoto's Thyroiditis, In My Humble Opinion only, if it was me, and I had the symptoms of hypothyroidism and tested positive for thyroid antibodies, I would want to start on levothyroxine, even if the lab values were "normal" or on the edge of "normal". I agree that the 1's are pretty low and probably do indicate that there's no problem, on the other hand treatment with levo might stop the attack on the thyroid (as those studies seem to indicate). And especially if you have the symptoms, then I personally would want to get started on treatment. Also look at the FT3 and FT4 levels, even when the TSH is average you might be able to detect a trend where the T4, and especially the T3, are in the very low range of "normal".

Here is an interesting, sort of anecdotally written article about how to go about finding the right dose of medications when you have Hashimoto's Thyroiditis, since you apparently cannot depend on the blood labs to determine this: Understanding Thyroid Lab Tests : http://www.thyroid-info.com/articles/woliner.htm .

Comments???

[Emilia]

I've been diagnosed with hypothyroidism for several years now. I started out only needing 25 mcg a day, but now I need to take 88's 5 days a week and 100's 2 days a week to keep me in the <2 range. My last test was 1.65. The American Thyroid Association, which has been in existence since 1923, has wonderful resources. This web booklet is filled with great information. They believe a normal range should be .5 - 2.5, with most patients feeling best at 2.0 or below. http://www.thyroid.org/patients/brochur ... ooklet.pdf

Now I have just been through a sleep study, and I get my results later today. It is interesting that you mention these two often appear together. I also have been told I have fibromyalgia, but I see that CPAP can often alleviate those pains. This is going to be an interesting journey!

[who]

Complicated question.

Hypothyroidism can interact with OSA. The tissue swelling in the throat that can come with overt hypothyroidism is the issue there. Some doctors now contemplate a trial of treatment for an "asymptomatic" subclinical hypothyroid patient who also has OSA, for that very reason.

TSH is the test used to monitor treatment, so if a patient has a TSH that moves around and dips low, no doctor will want to take the risk of overtreating (to the point of hyperthyroid), which would be a very real risk in that instance.

In the case of an asymptomatic subclinical hypothyroid patient with antibodies present that would indicate looming Hashimoto's, some doctors may choose to treat based on a patient's preference and for prevention purposes. But routine treatment of those whose TSH has not reached 10 remains controversial and is not considered a mainstream approach. Yet. And that is so even if antibodies are present. Doctors differ greatly on how to make that call. Some doctors feel asymptomatic sublcinical hypothyroidism should always be treated if antibodies are present. I think the official statements are that it is "reasonable" to decide to treat. The lack of good studies proving benefits to subclinical hypothyroid patients from treatment is what is pointed to by those doctors for their hesitation to treat.

Europe tends to put people on trial-treatment for subclinical more than the US does, in my opinion. But that still should only happen if a patient has a stable TSH. If the results of that test regularly dip down below 3 without treatment, I believe a doctor and patient would be foolish to attempt to treat because of the very real risks of overtreatment. Sometimes a TSH level will rise temporarily, so most doctors want to see a TSH that is consistently high (although the definition of "high" may differ for some doctors) before deciding treatment is more likely to help than harm.

[elena88]

well count me as someone who has OSA and hypothyroidism..


I had not been to the doctor in years, and my husband dragged me in six months ago and my level was 8.5
Ive been on armour thyroid since then and it has dropped in half. I didnt really have any symptoms though, save
my hair was getting thinner, and my body temp was lower. ( I got dragged in for the heart arythmias which I found out was caused by the osa)

I have seen many friends struggle with the actual symptoms, and have their doctors refuse to treat them because
their numbers were "normal" Since then, I have heard that some physicians feel that many people are slipping thru
the cracks, that the tests and numbers dont apply to everyone, and the symptoms should be treated.

[who]

Some sources:

http://www.mayomedicallaboratories.com/ ... 09/03.html
http://www.aafp.org/afp/2005/1015/p1517.html
http://www.umm.edu/patiented/articles/h ... 0038_7.htm

Some interesting statements:

"In rare instances, OSA may be improved or even cured by treatment of underlying endocrine disorders: this is the case of hypothyroidism and acromegaly, situations in which OSA is mainly related to upper airways narrowing due to reversible thickening of the pharyngeal walls. However, when irreversible skeletal defects and/or obesity are present, OSA may persist despite treatment of endocrine disorders and may thus require complementary therapy." -- http://jcem.endojournals.org/cgi/conten ... 009-1912v1

"Treating clinical hypothyroidism can result in marked improvements in the AHI, particularly if the TSH is very high, and treating subclinical hypothyroidism appears to improve sleepiness more so than AHI." -- http://icmr.nic.in/ijmr/2010/february/0214.pdf

[BlackSpinner]

My daughter has hypothyroidism. Last fall her symptoms flared even though the labs came back "Normal" - symptoms like memory or "stupidness" as she calls it, she began failing her classes. Luckily the doctor has this herself so she treated the symptoms not the lab results.

[Songbird]

Thanks for this info, Echo. I recently learned that I, too, have hypothyroidism. SA related? Don't know. I'm on 25 mcg of Synthroid, but we're just in the beginning stages of getting my TSH levels down. However, I've never heard about Hashimoto's. Looks like I have some reading to do. Thanks!!

Marsha

[SleepingUgly]

Thanks for starting this thread, Echo. I'll have to read those links when I'm more alert.

Who, how do you define "subclinical hypothyroidism"? I've seen that term used, but my impression was that it meant slightly/somewhat below the "abnormal" cutoff, but not so low as mine (recently 2's and 1's--see above in Echo's post for my recent #s -- Thanks for posting that, Echo).

Tomorrow I'll look up my T4, T3, etc., although I think it's been a few years since they were measured.

[LoQ]

For every disease except hypothyroidism, "subclinical" means that a disease is present without clinical symptoms. With hypothyroidism, the opposite is true--"subclinical" means that clinical symptoms (fatigue, weight gain, etc.) are present, but the disease is not considered to be "official" yet. I think officially subclinical has come to mean that TSH is between 5 and 10.

[araminta]

My understanding of hashimoto's is that it is a "syndrome" not a disease, per se.
Translation: it's a condition that for some people could go away on its own, as ones hormones continue to change.

If you're at all able to wait it out, it might be worth it. But it's a very individual decision.

[who]

Who, how do you define "subclinical hypothyroidism"? I've seen that term used, but my impression was that it meant slightly/somewhat below the "abnormal" cutoff, but not so low as mine

I believe that it usually refers to those with no symptoms with a TSH that is slightly elevated but below 10. However, many doctors use the term to refer to those with an elevated TSH, but below 10, and don't factor in symptoms at all, since, to them, the symptoms are too vague and variable to be useful for actual diagnosis. That is because the thyroid affects all organ systems, and no one has all organ systems operating at perfect efficiency, so many doctors latch on to the test numbers exclusively and ignore symptoms. That may be a logical thing to do scientifically, but a good doctor has to think in terms of individual patients or what good is he? Right?

Conn’s Current Therapy—2007 states: “Many patients with mild subclinical hypothyroidism may experience unexpected symptomatic benefit as well as lowering of serum lipid levels following the initiation of T4 replacement therapy. In this sense, subclinical hypothyroidism may represent a misnomer.”

An article in American Family Physician stated in 1998: “The term ‘subclinical’ may not be strictly correct, since some of these patients may have clinical symptoms. . . . Studies suggest that some patients with subclinical hypothyroidism do indeed have clinical manifestations.”

If a patient complains of symptoms, a SCREENING TSH is given. If the test comes back out of range high (different cut-off points for different labs), then a repeat TSH test and FT4 and auto-anitbody DIAGNOSTIC tests needs to be done, according to most guidelines. If the TSH is elevated, but below 10, and T4 is in range, treatment is not routine, but a doctor/patient team may decide to try treatment anyway. (Results from studies show a placebo is just as likely to help the patient "feel better," though.) If auto-antibodies are significant, then there seems to be more evidence of treatment serving a purpose. If T4 is out of range low, than a diagnosis of overt hypothyroidism is made, even if TSH is below 10. Once treatment begins, TSH-test information is used to keep the results of the treatment within a target range to make sure the right amount of T4 is being prescribed. Overtreatment is the biggest risk.

So, I believe there is widespread confusion about the TSH test, since it can be used at least four different ways in which the results all mean different things: (1) It is used to routinely screen people who do not complain of any symptoms. (2) It is used to screen people who DO complain of symptoms. (3) It is used in conjunction with other tests for the purpose of DIAGNOSIS, once a screening test comes back out of range. (4) It is used to measure results of treatment. The information from the TSH test means very different things in those four different circumstances.

The above is for information purposes only, and is not meant to be medical advice in any way.

[M.D.Hosehead]

For every disease except hypothyroidism, "subclinical" means that a disease is present without clinical symptoms. With hypothyroidism, the opposite is true--"subclinical" means that clinical symptoms (fatigue, weight gain, etc.) are present, but the disease is not considered to be "official" yet.

I think LoQ has correctly identified source of confusion, not only for patients but also for doctors: a paradoxical and contradictory use of the term "subclinical".

Therefore, I propose new terminology. Those who have hypothyroid symptoms, but whose numbers don't qualify officially for the diagnosis should be called "pseudoeuthyhroid." If their symptoms fluctuate, they can be termed "intermittently pseudoeuthyroid." Give both terms diagnosis code numbers, so doctors feel more comfortable treating them.

That should clear things up.

[tongue-in-cheek smiley needed here]

[who]

Those who have hypothyroid symptoms, but whose numbers don't qualify officially for the diagnosis should be called "pseudoeuthyhroid." If their symptoms fluctuate, they can be termed "intermittently pseudoeuthyroid." Give both terms diagnosis code numbers, so doctors feel more comfortable treating them.

That should clear things up.

[tongue-in-cheek smiley needed here]

That terminology should be particularly appropriate for all the nonendocrinologists for whom thyroid is their primary pseudosubspecialty.

[M.D.Hosehead]

pseudosubspecialty.

LOL. There sure are a lot of those around. Think of all the Forensic Pseudosubspecialties. Like Forensic Meditation.

[echo]

I like this new terminology!

I did find references to both 'types' of subclinical hypothyroidism in the literature, and was very confused as to the actual definition!

Thanks very much for all those references & info, who(s on first)! Lots of great info here from everyone, thanks!

So SleepingBeauty, does this help at all? You could always try to the body temp method too if you're still not sure whether to treat or not. What about your symptoms?