How will patients with hypothyroidism typically present to clinical care providers, what are the guideline-endorsed protocols for laboratory evaluation, and how do we confirm our treatment strategy has been successful from the patient perspective?
who do we identify as needing a hypo thyroid work up? How do they come to us? Well, I like to pivot a little bit and ask, you are watching me. How many of you have thought at some point in the past that you had an under functioning thyroid. I was wondering about getting your thyroid levels checked. Well, what drove you to that is very common and many people feel even me a couple years ago. I thought so. So what brings them to you? I'm gonna tell you right now. It's one of those diagnosis that I have patients come to me and ask me to identify if they have. And one of those diagnosis that they almost feel disappointed they didn't get because they're looking for reasons for weight gain depression, fatigue, hair loss, things that menopause and many other conditions, but they're looking for a reason because then there's a way to treat now we take these patients seriously. Many of them will come with subjective changes and that's the biggest thing. Usually weight weight gain, depression, there's fairly new onset, maybe constipation, it looks like a b sc different kinds of things. There's many of them they're very ubiquitous and there's a whole list of them that look like so many other things and you're gonna have to work them up. But always keep hypothyroidism, safety, fatigue, hypothyroidism is a one of differentials and certainly if you have hypertension that's difficult to treat dis lipid denia, that's there. I keep pounding on the cardiovascular sick. Well yeah And those who might be an urgent care, I cannot tell you during my 20 years as an intensive in acute care nurse practitioner where I was identified patient was identified to me as a possible hypothyroidism with hypothyroidism undiagnosed because the thermometer didn't work temperatures down. So that's also when patients are feeling cold in the middle of the summer here and rural Virginia. This is very unusual. So they'll come to a different reasons and you work them up and that should always be one of the different rentals. And I think we we are doing that when we have a patient we're working up there. The main thing we do, I think when you're just doing annual workups people do a TSH And TSS has been for 40 years. The gold standard for identifying not diagnosing thyroid disorder. It doesn't diagnose, it identifies that you may have problems with circulating levels of thyroid hormone. That's important to understand. You do not diagnose it with just a TSH. So it can let you know the TSH is coming up. It means in response to having low circular circulating levels of T. Four. And so we then to a free T. Four level. That's general. With the guidelines are you look at a TSH if that's climbing up we will then see we expect to see That the TSS is kicking out thyroid stimulating hormone is being kicking out in response to low circulating levels of T. four, which is picked up by a genetic set point in our tissues and in the brain. So we do that to identify it and those are the main ones that we use. And and then if I suspect anybody has any other autoimmune disorders early on, if I see there is an impairment that the T four levels are low. TSH is high, I make sure I get thyroid antibodies. It's very important for a number of reasons. One is that people who have actual autoimmune thyroid itis, they progress faster or farther. Disease may progress faster and farther than those who have maybe non toxic natural gliders or other reasons for having a lower down regulation of thyroid function. So I'll look for T. P. O. Antibodies, this big one and that's gonna be over 95% will have a positive anti tipo tipo antibodies. There is a subset. They look for all the world to be say hashimoto's with a mild Goyer. Uh and they just by ultrasound you don't need an ultrasound for these. But but these pages look like they have hashimoto's or an auto autoimmune disorder. And for those people then I would look at thyroid globulin antibodies but you don't usually need that. It's usually just an anti Tapio which will take care of it. So that's laboratory diagnosis and hypothyroidism is diagnosed based on that. Currently that's what we look at. So you have elevated TSH decrease T. Four and so then you have to look for treatment before you go any further. What's the target? What are you aiming at? And sometimes we get so fixated on numbers and labs were missing, what's really going on? And that's so unique with this particular hormone more than insulin or any other endocrine hormone is how thyroid affects the body's in massive systemic ways. So when we're looking at the goal is and should be to alleviate symptoms of the disease. Number one eliminate subjective symptoms of hypothyroidism. This is a quality of life issue as well. Then this number two is being able to prevent or minimize the morbidity, ease and complications of hypothyroidism. Those are the first two goals because sometimes how patients feel and or present with the lab biomarkers we have, which is TSH three T. Four. And even looking at T or free T three does not show the whole picture.
