Hypothyroidism: What guides who should get treated, what type of treatment and when to see an expert?

Endocrinologists, who are experts in thyroid disease, recommend considering hypothyroidism treatment in the following situations:

  • When thyroid stimulating hormone (TSH) exceeds 10 because of the increased risk for heart failure and heart disease resulting in death when levels are in this range
  • When TSH levels are between the upper limit of a given laboratory’s normal range and 10, particularly if there are symptoms of hypothyroidism, positive thyroid antibodies (TPOAb), heart disease or risk factors for heart disease
  • Women in the first trimester of pregnancy or who are planning a pregnancy, including assisted reproduction in the immediate future, when TSH is between 2.5 and the upper limit of normal for a given laboratory’s reference range or they have TPOAb antibodies
  • Women who are pregnant or planning a pregnancy, including assisted reproduction in the immediate future if they have or have had positive levels of serum TPOAb and their TSH is greater than 2.5.

The goal of treatment is a normal TSH if the patient is not pregnant. If pregnant, the target TSH is more restrictive. Ask your endocrinologist what these TSH values should be for you. Also, TSH should be promptly checked after conception and thyroid hormone dosing adjusted as needed.

What Are the Treatment Options?

Following a 1999 report which suggested a benefit of T4 and T3 combination therapy, a number of studies have attempted to additionally support this benefit. However, these studies have not shown an advantage to the combination thyroid hormone approach. Treatment of hypothyroidism is best done with synthetic T4 as the single thyroid hormone preparation. Additionally, T4 and T3 combinations should not be used by pregnant women or those planning pregnancy because of the potential for harm.

To get the best results from your thyroid hormone medication, T4 is best absorbed when taken with water 60 minutes before breakfast, or at bedtime four hours after the last meal on an empty stomach. It is easier for many to consistently take it with water between 30 and 60 minutes prior to eating breakfast, although absorption of the medication is best if the 60-minute spacing can be used.

Results of Hypothyroidism Treatment

Some features of hypothyroidism, such as skin changes, may take anywhere from three to six months to return to normal after serum TSH has returned to normal. fast and/or irregular heart rhythms, lead to bone loss and create emotional difficulties such as anxiety. So how best to know if treatment doses are just right?

The most reliable way of figuring out when treatment of primary hypothyroidism is effective is the TSH value. The expert panel recommends thyroid tests should be repeated 4-8 weeks after starting treatment or after a change in dose. Once your TSH goal has been reached, repeat testing should be done after six months and then at 12-month intervals, or more frequently if your health changes or your clinician feels the thyroid level should be rechecked. In pregnancy, your thyroid levels should be checked more frequently!

When to Consult an Endocrinologist

Although many physicians can diagnose and treat hypothyroidism, consultation with an endocrinologist is needed with the following patients and/or in the following situations:

  • Children and infants
  • Patients in whom it is difficult to get to a stable thyroid level
  • Pregnancy
  • Women planning conception
  • Cardiac disease
  • Presence of goiter (thyroid enlargement), nodule (lump) or other structural changes in the thyroid gland
  • Presence of other endocrine disease such as adrenal (the gland that sits on top of the kidney that produces life-sustaining stress hormones) and pituitary disorders