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Subclinical Hypothyroidism Treatment Challenges

Treating Mild Underactive Thyroid Conditions

Sep 17, 2009 Jim Lowrance

Subclinical hypothyroidism is a term meaning an under-active thyroid gland is not at full-blown level and knowing when to treat these cases can be difficult for doctors.

Some hypothyroid patients experience significant symptoms even when their diagnostic blood labs indicate that their thyroid hormones are only mildly deficient. In these type cases, symptoms should be a consideration in deciding whether or not to begin thyroid hormone replacement therapy as well as determining if the patient has thyroid autoimmunity. If auto-antibodies are the cause, starting treatment can help prevent antibodies from further increasing and causing inflammation in the gland which can contribute to goiter and other potential symptoms including rheumatic ones.

Mild Hypothyroidism Detected by TSH

Most cases of subclinical hypothyroidism are revealed by an elevated TSH level (Thyroid Stimulating Hormone). This pituitary hormone, coming from the brain-gland that regulates thyroid function, increases above normal when thyroid hormones begin to decrease (onset of hypothyroidism). The thyroid hormones, T4 and T3 will at the same time, fall within normal values, although they may be at lower-normal or even borderline-low.

Regardless of where the actual thyroid hormones fall within the normal range, if TSH is elevated even slightly above normal, this usually indicates that the thyroid gland is struggling to produce normal amounts of thyroid hormone to supply the body for normal metabolism. At this point, most patients do not experience noticeable symptoms, while a small percent of them do and for some they can be significant. Another factor in whether symptoms are beginning depends on how close a subclinical case is to becoming full-blown, or what is sometimes referred to as “overt hypothyroidism”.

What TSH Level Merits Treating Hypothyroidism?

This question has led to some controversy in medical circles because there are two concerns involved with this issue. One being, that not treating subclinical cases of hypothyroidism can lead to elevated cholesterol levels and can contribute to heart disease over time. The other being that by treating early, when a patient does not yet need replacement thyroid hormone administered, it could induce mild thyrotoxicity (abnormal elevations in thyroid hormones). If treatment does cause mild hyperthyroidism in a patient, it could contribute to osteoporosis and dysrhythmia in the heart (abnormal beats).

Some doctors want to see the TSH level elevated to a “10.0” or above before they begin treating hypothyroidism if thyroid hormones continue to stay within normal range. The normal values reference range at most blood testing labs is approximately “0.5 to 4.5” but some labs have normal cut-off ranges as high as 5.0 and 6.0. The AACE (American Association of Clinical Endocrinologists) however recently published recommendations in the year 2002, encouraging doctors to consider treating patients whose TSH levels reach levels above “3.04”. They also recommended narrowing the diagnostic TSH range to “0.3 to 3.0” which will detect more cases of developing thyroid hormone disorders.

Symptoms and Thyroid Autoimmunity

If a patient with subclinical hypothyroidism tests positive for thyroid antibodies, this may prompt a doctor to begin treatment due to the fact that thyroid autoimmunity increases the rate of progression to overt hypothyroidism. Some cases of mild under-active thyroid glands are age-related or may have no apparent cause and these can remain in a mild state, not causing a patient symptoms. These cases may not require treatment but will simply need to be monitored closely by blood retests of thyroid levels once or twice yearly.

If symptoms are present in mildly hypothyroid patients, this should be a consideration by doctors monitoring these cases because symptoms can affect quality-of-life in these patients. If additional blood testing reveals elevated cholesterol levels in these patients, this is an important consideration as well because treating with thyroid hormone replacement may be less difficult than treating with cholesterol lowering drugs (statins) which can produce a variety of potential side effects.

The copyright of the article Subclinical Hypothyroidism Treatment Challenges in General Medicine is owned by Jim Lowrance. Permission to republish Subclinical Hypothyroidism Treatment Challenges in print or online must be granted by the author in writing.

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