Patient Resources - Is it My Thyroid?

IS IT MY THYROID?

Thyroid Gland

The specialists at the Nevada Thyroid Institute treat thousands of patients with thyroid disorders every year. We take pride in the care we provide, as well as our high approval ratings on patient satisfaction surveys.

We see many patients that come to us with persistent symptoms of hypothyroidism despite “normal thyroid function tests” according to their healthcare provider. Similarly, many patients have symptoms of hypothyroidism when their thyroid tests are interpreted as “normal” by their healthcare providers. This is one of the most frustrating situations any patient will ever encounter. In some cases, after a careful review of the patient and in-depth thyroid testing, we are forced to conclude “it’s not your thyroid.” However, in many cases it is the thyroid. Still, in other situations it is another unrecognized endocrine disorder.

Several issues may contribute to misdiagnosis and suboptimal management of thyroid disorders.

Lab Values vs. Symptoms

It is increasingly common for healthcare providers to rely more on laboratory testing than on a medical history and examination. This relates to the pressure healthcare providers are under to see more patients in a shorter period of time. In such cases, compelling symptoms are dismissed if the thyroid function tests are “normal” and the patient is sent on their way. There is no room for discussion; no time to dig into the problem beyond a superficial assessment.

Optimal care of thyroid patients demands that close attention to how the patient feels is given. The patient is the foremost authority on how they feel. Likewise, it is very important to make proper use of the laboratory results. The combination of listening to the patient, examining the patient and scrutinizing the laboratory results is required to provide the best care. Good thyroid care goes beyond the science of reviewing laboratory data, and balances it with the art of listening, recognizing and understanding the subtleties of thyroid disease. The Nevada Thyroid Institute treats patients, not lab values!

Normal vs. Optimal Thyroid Function Tests

The reference range for thyroid hormone is very broad. Tiny fluctuations in thyroid hormone levels-even within the normal range-may cause clinically meaningful changes in how the patient feels and functions. The thyroidologists at the Nevada Thyroid Institute are strong advocates of aggressive thyroid hormone therapy that results in optimization of thyroid chemistry. In many cases, patients with normal TSH levels show significant clinical improvement when thyroid hormone replacement is modified and TSH is brought in to the “optimal” range.

Unrecognized Thyroid Disease

Thyroid disease often results in clinical symptoms before there are abnormalities in thyroid function tests. This is particularly true if old-fashioned thyroid function tests are ordered (i.e.- thyroid panel, T4, T3RU, etc.) Detection of thyroid nodules or changes in the texture and size of the thyroid with a physical examination is difficult, especially if the healthcare provider is not experienced in the diagnosis of thyroid disorders. Such subtle findings, which often indicate early thyroid disease, will further delay diagnosis and treatment if not recognized by the treating healthcare provider. Use of high-resolution ultrasound (by the treating thyroidologist as opposed to a technician) and measurement of advanced biochemical markers of thyroid disease often reveal unrecognized thyroid disease that warrants therapy.

Thyroid Hormone Replacement Regimens

The vast majority of patients with hypothyroidism do very well with levothyroxine therapy-if it is optimized. In general the Nevada Thyroid Institute uses levothyroxine as the sole treatment for hypothyroid patients. Many patients will not do well on the generic products that are so commonly substituted by health plans and pharmacies. In exceptional circumstances, combination therapy with other preparations of thyroid hormone will be necessary for some patients. We do not advocate use of compounded formulations of thyroid hormone. Additional factors such as timing of thyroid hormone therapy, coexisting medications, coexisting health problems and other factors which influence absorption of thyroid medications may influence the success of therapy.

Experience and Clinical Acumen

Most patients with a history of thyroid disease have had the unpleasant experience of being treated by a rookie that simply doesn’t understand how to correctly interpret thyroid function tests or how to appropriately adjust medication. Since it takes 5–6 weeks for thyroid levels to stabilize after any changes are made, this often translates into months of symptoms and frustration that stem from inadequate thyroid care. The more complex or refractory the individual patient with thyroid disease is, the more likely they are to require a thyroid specialist to manage their condition. In these cases, there is no substitute for advanced endocrine training that comes from managing thousands of thyroid patients in all their variety.

Non-Thyroid Endocrine Disorders

There is an old medical saying that says “When you hear hoof beats, think of horses, not zebras.” It means that common things are common, and doctors should look for common conditions to explain symptoms first. However, when a patient’s symptoms persist and multiple healthcare providers are unable to provide relief, it’s time to look for zebras! It is not sufficient to conclude “it’s not your thyroid” without systematically evaluating a patient for other endocrine disorders first. This kind of evaluation often requires consultation with an experienced endocrinologist. We routinely diagnose endocrine disorders such as polycystic ovary syndrome, metabolic syndrome, pituitary disease, hypogonadism or other uncommon conditions in patients that present for evaluation of their presumed “thyroid disease.”

Summary

It is an over-simplification to suggest that every patient with fatigue or inability to lose weight has a thyroid condition. Similarly, it is incorrect to attribute these types of symptoms to the thyroid in every patient with an established thyroid disorder. However, a significant number of these patients really do have a problem—and we feel we can help! The specialists at the Nevada Thyroid Institute/Desert Endocrinology would welcome the opportunity to evaluate you if you find yourself in this frustrating dilemma.