Subclinical Hypothyroid: Do’s and Don’ts

Episode 53

Subclinical Hypothyroidism is an often over-treated or mistreated condition. This week, we take a look into the research to determine the best way to treat this misunderstood condition.

Episode Intro

Dr. Michael Ruscio, DC: Hey, guys, this is Dr. Ruscio with your fast facts on this episode on subclinical hypothyroid, which I think was a great episode, and I hope you guys really enjoy it. Subclinical hypothyroidism is defined as high TSH and normal T4, according to the conventional ranges. Many cases will normalize with time. Subclinical hypothyroidism correlates with conditions like cardiovascular disease, cholesterol and lipid abnormalities, infertility and miscarriage. Subclinical hypothyroidism can be treated with thyroid hormone. Treatment of subclinical hypothyroidism is controversial. The highest-level evidence shows minimal benefit from treatment with thyroid hormone. It lowers cholesterol and lipids but does not appear to have any effect on heart disease risk or quality of life. In my opinion, subclinical hypothyroidism should be re-evaluated after you have improved your diet and lifestyle and treated any other health problems, especially including digestive problems. Some other guidelines suggesting when treatment may be indicated: The younger someone is, the more likely treatment may help. Also, the less responsive someone has been to other therapies, the more likely treatment may help.

There is some evidence suggesting that treatment may help with infertility—probably the most well suggested, high cholesterol levels, cardiovascular disease, and cognition problems in children. Treatment is least supported for inflammation, cognition problems in the elderly, fatigue, mood, and weight loss.

OK, that’s it, guys. Now we will jump into the show.

[Continue reading below]

Dr. R’s Fast Facts Summary

  • Subclinical hypothyroid (Subclinical Hypothyroidism) is defined at high TSH and normal T4, according to the conventional ranges.
  • Many cases will normalize with time.
  • Subclinical Hypothyroidism correlates with conditions like:
    • Cardiovascular disease
    • Cholesterol and lipid abnormalities
    • Infertility and miscarriage
  • Subclinical Hypothyroidism can be treated with thyroid hormone.
  • Treatment of Subclinical Hypothyroidism is controversial, the highest level evidence shows minimal benefit from treatment with thyroid hormone:
    • It lowers cholesterol and lipids but does not appear to have an effect on heart disease risk or quality of life.
  • In Dr. Ruscio’s opinion, Subclinical Hypothyroidism should be re-evaluated after you have improved your diet, lifestyle and treated any other health problems, especially including digestive problems. Some other guidelines:
    • The younger someone is with Subclinical Hypothyroidism the more likely treatment may help.
    • The less responsive someone has been to other therapies, the more likely Subclinical Hypothyroidism treatment may help.
  • There is some evidence suggesting treatment can help: infertility, high cholesterol, CVD risk and cognition problems in children.
  • Treatment is least supported for inflammation, cognition problems in elderly, fatigue, mood and weight.
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In this episode…
Fast Facts … 00:00:42
Episode Intro … 00:04:13
Subclinical Hypothyroid Defined … 00:07:59
Meaning of High TSH and Normal T4 … 00:10:51
Risks Associated with Subclinical Hypothyroidism … 00:11:18
Treatment of Subclinical Hypothyroidism … 00:16:44
Research on Treating Subclinical Hypothyroidism with T4 … 00:20:36
How to navigate Subclinical Hypothyroidism … 00:34:30
Episode Wrap-Up … 00:43:57

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DR: Hey, folks. Welcome to Dr. Ruscio Radio. I am back with the lovely Susan McCauley of Evolve Nutrition. Hey, Susan, how are you?

Susan McCauley: I’m doing really well. How about yourself, Dr. R?

DR: I am admittedly running on fumes today. I’ve been pushing nonstop ever since coming back from London, and we were talking off air about how this weekend, I think, for me is going to be a zombified weekend of a lot of lying on the couch, watching crappy television, and just letting my brain turn off for a little while. It should be fun.

SM: Are you a football fan? Are you going to be watching the Super Bowl?

DR: I will be watching the Super Bowl. I don’t watch much TV, in general, so I haven’t really gotten too into sports. I love playing sports. I’m just not a huge, huge sports fan, but of course, this weekend I’ll be watching the game somewhere with a bunch of my buddies who will be way more excited about it than I will be, but I’ll pretend!

SM: Well, then there’s all the good stuff that goes with it. The good food, the beer, and all that other stuff, right?

DR: Yeah, it’ll definitely be fun. And it’s right here in our backyard, so that’s nice.

SM: It’s really in my backyard.

We’re hiding out. We’re about 25 minutes south of the stadium, and with the Silicon Valley traffic and then you add the Super Bowl on top of that, we decided to just hang out at home and not venture up around there for the week.

We will watch it on TV. I’ve been to the stadium. It’s a beautiful stadium. Everyone will have a wonderful time, but I’m not a big fan of either of the teams. If your team’s not in it, to me, it’s not as fun, but then I’m not a guy and I’m not an avid sports fan!

So you have a great topic for us today.

Episode Intro

DR: Yes, I thought we could talk today about subclinical hypothyroid. This is something that we discussed during the practitioner training in London, and I thought it would be important to talk about this with our audience. With thyroid, there are a lot of symptoms that can look like a thyroid problem, and because of that, when people start on the road of not feeling well, one of the first things they are suspicious of is hypothyroid.

thyroidCertainly hypothyroid is a fairly common condition, and it needs to be treated with hormone replacement if the thyroid gland is damaged to the extent to where optimum or necessary thyroid hormone levels can’t be achieved or can’t be manufactured by the gland, yes. However, at the same time, in my clinical observation, many people that are either being treated with thyroid hormone and their levels are in the normal range or people that have no thyroid hormone abnormalities on lab testing but still exhibit symptoms, get pulled into what I think is a bit of a fictitious world of trying to have these super-tight, super-meticulous lab values regarding their thyroid levels, and people get super into this T4:T3 ratio or T3:reverse T3 ratio. I ran all these markers on all my patients for a few years, and I didn’t really find they made a huge difference. What I did find was that once we got thyroid hormone production—either through getting them on a thyroid hormone or by treating underlying gut and/or autoimmune conditions that helped decrease inflammation in the gland—once we got the thyroid hormone levels kind of in the ballpark, any more improvement that was needed was usually found by cleaning up an inflammatory issue, and that inflammatory issue oftentimes came from the gut or diet or lifestyle.

Most of what I found was if someone is not responding and thinking that the answer to their problem was a subtle imbalance in something like the T3:reverse T3 ratio, what it typically was in my observation was there was some underlying inflammatory issue that was missed, and that was what was resulting in the hormones not working well. Once we identified something like a Blastocystis hominis infection in their gut, once we identified that, cleared that, we saw patients feel much better, and the change that we would see in things like reverse T3:T3 didn’t seem consistent. In fact, sometimes there were patients that would have high T3 and high reverse T3 because they were taking too much thyroid hormone, and they still felt terrible. Or there were people that felt great and they had a T3 level that was just above the lower end of the cutoff.

So I started to find that once your hormones are in the ballpark of where they should be, it’s not this meticulous, “Let’s force this down and push this up.” It was, “Let’s take a lateral look or a deeper look as to why even though your hormone levels are about normal, you’re not feeling well.”

Subclinical Hypothyroid Defined

DR: That’s a very long kind of prelude into this topic of subclinical hypothyroid, which is a little bit different because subclinical hypothyroid is where you look like you’re hypothyroid, truly hypothyroid, not the functional medicine super-narrow ranges, which I think are a bit misguided if I may be honest because I don’t think that meticulous of a range is needed. Subclinical hypothyroid is where you are high according to the conventional range in TSH and you are normal according to T4. This is a very perplexing position for both patient and doctor because what do you do in this situation? Do you prescribe a thyroid hormone or do you not? There’s controversy regarding this, and so I thought we could outline this issue, look at both sides of the data as we do, and I think that will help people see what the most reasonable way to navigate subclinical hypothyroid, which is, according to the conventional ranges, again, high TSH and normal T4.

SM: Right, because if you have high TSH and normal T4 and you go to a conventional endocrinologist or your general practitioner, they won’t prescribe you anything. They won’t do anything. They’ll just say you need to wait; it’s either going to get worse or it’s going to get better. Right?

DR: Well, I don’t think we can make that blanket of a statement because it depends on a number of factors. It depends on the progressiveness of the conventional doctor, and it also depends on the patient. The younger the patient is, the more likely they are to receive treatment for that. The older they are, the less likely.

And if someone is infertile or trying to get pregnant or pregnant, they will almost certainly be treated for that. I know that many in functional medicine are not huge fans of conventional medicine doctors, but I think that oftentimes they do have a reasonable approach in some things, and this is one of the areas where I think there is a reasonable approach at least in some of the thinking in conventional medicine, and we’ll outline where some of that comes from.

Hair LossSM: OK, so you have high TSH, your T4 is normal, but you feel the symptoms. You have fatigue, thinning hair and nails… I can go on and on.

DR: Let’s not even talk about the symptoms just yet because that’s part of how we interpret this.

Let’s just start with getting some of the basic definitions down and what this tends to correlate with. You’re asking a very important question, Susan, which is, what do the symptoms of the person look like, and I want to work our way into that.

SM: OK, cool. I’m ahead of us, as usual!

DR: Yeah, but you’re going to a very intelligent place, so I will meet you there in just a minute!

SM: OK, I’ll be here!

Meaning of High TSH and Normal T4

DR: All right, so we see this high TSH. We see this normal T4. Does this actually mean anything? One of the quarrels I have with functional medicine, as much as I love it, is sometimes creating a disease where there is none. We want to know, does this high TSH actually correlate with any kind of disease or does it not? Let’s look at some of this. There are a number of references here, which we will include in the notes for this podcast.

Risks Associated with Subclinical Hypothyroidism

DR: Subclinical hypothyroid subjects have been shown to have a higher risk for cardiovascular disease due to having higher blood pressure, total and LDL cholesterol, and CRP, so we see an observation there (1). We also see the observation from other studies that subclinical hypothyroid is associated with infertility (2). However, it’s also important to mention that another study showed that most women with elevations of TSH ranging from 4.5 up to 10 do not progress to overt hypothyroidism and even normalize their TSH (3), not a bad rationale that may be embodied by your conventional doctor, knowing that according to some of the research, most women, when they have an elevation of TSH, will actually revert back to normal with time, or at least not progress any further.

Thyroid MedicationHowever, there’s a caveat there, and this is where the context is important. The initial value of the TSH seems to be an important predictor for further progression and even more important in the presence of antibodies or ultrasound findings. What that means is that if you have a mild elevation of TSH, between 4.5 and 10, you have a higher likelihood that you will not progress to overt hypothyroid and that you will even normalize. So chances are in your favor that if there is an elevation of TSH, watch it, it’ll go back to normal. However, the initial value if your TSH is an important predictor of if you will progress to hypothyroidism. It’s more important, again, with the antibodies or the ultrasound findings. So if you got your labs back and they came back at 18 or 23 but your T4 was normal, there’s a much higher likelihood that you’re going to progress from that point.

Does that make sense, Susan?

SM: Yeah, so the further you are out of the range, the more likely it is that you’re not going to revert to being in the range.

DR: Right, which would make sense.

Oftentimes with these things, when we just step back and think about them practically, that’s usually the way these things play out.

SM: If you think about the function of thyroid-stimulating hormone, it’s your brain’s way of telling your body that you need more thyroid hormone.

DR: Exactly, so maybe that’s a nice reminder for me to just reiterate or kind of cover the basic thyroid hormone function or signaling. The brain tells the thyroid gland, which is in the base of the neck, to make thyroid hormone with the signaling hormone called TSH. TSH travels from the brain to the thyroid and signals the thyroid to then make T4. Then T4 is produced by the thyroid gland, and then T4 peripherally in your body is converted into T3, and it’s the T3 that kind of has the cellular effect, but it’s the T4 that has an effect on the TSH levels or what the brain is kind of seeing. That’s why most of this discussion is centered around TSH and T4 because they are the two that communicate back and forth.

So continuing, one systematic review with meta-analysis—so this is our highest-level scientific evidence—showed no association between subclinical hypothyroidism and cognition in the elderly. So older people that were subclinical hypothyroid, there doesn’t seem to be an association between subclinical hypothyroid and cognition, according to the highest-level scientific data available.

AdobeStock180645195WEB Memory Brain OldContinuing along with that, treatment of subclinical hypothyroid in the elderly does not help with cognition. So we’re seeing here, and as I said a moment ago, this may be part of the reason why when an older population presents with subclinical hypothyroidism, there’s less of a likelihood for treatment to be rendered.

However, the treatment of subclinical hypothyroidism does help with cognition in children. This has led some researchers to conclude that perhaps we should have an age-adjusted normal level for TSH, just like we do for many other hormones.

SM: That makes a lot of sense.

Because as you age, all your hormones change, it seems.

DR: Yeah, the brain tends to have to yell more loudly at the endocrine organs to get production, so you’ll see all of the brain hormones—like TSH, LH, FSH—you will see those start to increase normally as you age. Of course, again, this is a very logical conversation where it’s likely that a creeping upward of the TSH—within reason—as we age is probably normal.

That’s what we see in terms of some of the observational data. We see some associations with cardiovascular disease, we certainly see associations with fertility, and we see quasi-associations with cognition, but probably more important in children.

Treatment of Subclinical Hypothyroidism

DR: Now, the more important question is treatment, because it’s one thing to show an association, it’s another thing to show treatment. If you do have the diagnosis of subclinical hypothyroid, what treatment might be intelligent, and what might you want to do?

Well, the first thing we should really do is we need to verify that this is actually present. Like we talked about a minute ago, this may be just a transient, meaningless elevation, so the first thing one should really do is wait a couple of months and then retest because some of the literature has shown that you will go back to normal within a few months. That’s why it’s important not to just rush right into treatment right out of the gate. Coming back to our “minimal intervention for maximal improvement” philosophy that we try to embody, we don’t want to rush right into treatment at the first sign of dysfunction.

SM: Right, and then while you’re waiting for that retest those couple of months, I would look at sleep, lifestyle, diet, and make sure that all those things are dialed in because that’s only going to have a benefit if it’s transient to get you back in the range.

DR: Exactly. That’s a nice segue into my point kind of after next. The next point, if that does stay consistent, so if the TSH remains elevated, the next thing you would want to do is try to figure out where might that be coming from. Testing for autoimmunity certainly may make sense or testing for iodine deficiency or excess. Iodine deficiency is very rare. Iodine excess is also rare unless you’ve been reading some stuff on the internet and you’ve been taking multiple milligrams—not microgram, milligram—doses. High milligram doses have been shown to actually induce hypothyroidism as we discussed in our series on iodine several months ago. Someone could be really freaking themselves out about this constant subclinical hypothyroidism, and it may be totally induced by taking too much iodine.

AdobeStock180191805IodineSM: Right, and a lot of people that don’t know about the effect of iodine, they hear it and they tell their friend, and then their friend tells their friend, “Oh, yeah, you need to take iodine.” Then somebody picks up the 12.5 mg—I think that’s a dose—tablets online, and now they’re in subclinical hypothyroidism!

DR: Right. Exactly. So you’d want to look at these things first. If there’s autoimmunity present, then treating the autoimmunity, which consists of a number of things—vitamin D, selenium. Of course, your diet is going to be very important. Your stress, your sleep, and then any underlying gut infections. Like we’ve discussed, we have a lot of observational data here clinically that shows that improving the health of the gut helps with autoimmune conditions, and we have one peer-reviewed published trial, placebo-controlled, showing that by treating H. pylori infections, that actually had a significant Hashimoto’s or autoimmunity-lowering ability. So you’d want to start with just coming back to what it might be that’s driving that.

Then once you have gotten someone as healthy as you can reevaluate. Once you’ve addressed any issue with iodine if there’s an imbalance there, once you’ve addressed any diet, lifestyle, or autoimmunity as best you can, then reevaluate. If there are still symptoms present and/or if there’s still this subclinical hypothyroid present, then a thyroid prescription is a consideration.

Research on Treating Subclinical Hypothyroidism With T4

DR: Let’s use that now as a transition point to discussing what the studies treating subclinical hypothyroidism with thyroid hormone show. Again, it’s probably best practice to address the diet, lifestyle, autoimmune, and gut things first because you have a very good likelihood of not needing to go any further after you do that. It’s not uncommon that we see patients that need to greatly decrease their thyroid hormone dose or even come off thyroid hormones once we’ve really done a good job with diet, lifestyle, and especially with gut.

If all those things don’t work or don’t work fully and you’re still subclinical hypothyroid, what do we do next? Remember a few things that help contextualize how important thyroid hormone replacement may or may not be. The severity of TSH elevation is going to be important. Usually, if it’s over 10 consistently, that’s going to be a stronger indicator for treatment. Now, age also factors into this. If you’re over 10 in an 18-year-old, that’s very strongly suggested, whereas if you’re over 10 in an 85-year-old, it’s less strongly suggested.

SM: OK, that makes sense.

DR: Now, also their symptoms. In my opinion, this is not really published, but once we’ve gone through diet, lifestyle, everything you can do to treat autoimmunity, gut health, if someone is still having symptoms, it’s much more likely there’s a true thyroid hormone deficiency present. If you’ve gone through all the steps to increase someone’s health and they still haven’t really responded much, that also is a favorable consideration suggesting that treatment may be a good idea. So we’ll look at the severity of the TSH elevation compared to age, and we’ll also look at how many of their initial symptoms are still present.

17636722Now, looking at what happens when we treat people with thyroid hormone who have subclinical hypothyroid: There was a meta-analysis (4) of 12 randomized controlled trials, so this is the highest-level scientific evidence because we’ve taken 12 clinical trials and summarized them in a meta-analysis, so this is the best level of scientific evidence that we have. Treatment did not result in improved survival or decreased cardiovascular morbidity, so there was no effect on survival or cardiovascular morbidity or cardiovascular events. Also, regarding health-related quality of life—like general symptoms, energy, mood, things like that—there was no demonstrable significance between either the treatment group or the placebo group. However, there is some evidence that suggests that the treatment with thyroid hormone will improve some parameters of lipid profiles. So the best level of data that we have shows you have a chance of seeing an improvement in your lipid profiles; however, that doesn’t seem to correlate with a decreased cardiovascular morbidity, meaning events, or with changes in quality of life.

This is what the best evidence shows, and this may run counter to, I think, what some people would like to believe or what some people have projected based upon smaller studies. It doesn’t mean I’m not open to treating subclinical hypothyroid with thyroid hormone, but it’s important that we know what the data shows when we’ve done 12 placebo-controlled trials and we’ve isolated for things like bias and we’ve really just run a real-world experiment. Here are 50 people with this condition. We will treat half. The other half we won’t treat, but no one knows who’s getting treated and who are not getting treated, so we can’t placebo this, and here’s what we see. This is where the conventional doctor, I think, is justified in their more conservative stance on how quickly to render treatment for subclinical hypothyroid.

Now, in reviewing some of this literature, there were a few trends that stuck out, where it seemed like treatment of subclinical hypothyroid was of greater or lesser value. I’d like to provide people with a quick outline on that because, again, I’m not saying that this condition should never be treated with thyroid hormone, but there may be certain conditions this is more or less indicated for. Again, why I think this is important is because some people may really not want to be on a thyroid hormone, and so we want to help them qualify, depending on what they have going on, when might it be the best idea or when might they really not need to do this.

SM: Right. I think it’s important because a lot of times people say, “OK, my thyroid’s out of whack. I need a doctor that’s going to give me a prescription for thyroid hormone,” and it’s good to set the expectations for those people that think it’s going to fix them when maybe it might not.

“What else is going on that’s looking like hypothyroid symptoms? That’s where we come back to a lot of the gut work that we do.”tweet e1540485375388

DR: Exactly. The past few years have been a very interesting experience for me, observing that a lot of the patients that make their way into my office went on a thyroid hormone or even tried a couple of different ones, thinking that that was going to be the thing that really, really helped them. And for some patients, it is. But for many patients, they don’t tend to feel a whole lot different, and then we come back to, “OK, your levels are in the ballpark. Now the question is, what is causing your body not to be able to use the thyroid hormone appropriately? Or what else is going on that’s looking like hypothyroid symptoms?” That’s where we come back to a lot of the gut work that we do.

Again, for people trying to sort this out, what might be the best case for this, based upon my looking through the literature and looking at where the studies show trends for maybe the most benefit?

Certainly, the most well-defined need is for infertility. I think this is probably pretty well agreed upon on both sides of the fence, both conventional and progressive or functional. Infertility subclinical hypothyroidism is something that should be treated, and I think there’s also more support for if people have high cholesterol, cardiovascular disease risk, and cognitive problems in children. Again, these are not definitive, but I think this is where we have the most support: infertility for certain, high cholesterol, cardiovascular disease risk, and cognition in children.

Where it is least well defined is if there is a chronic inflammatory issue, if there’s a cognitive problem in the elderly, if there are fatigue problems, mood problems, or weight problems. Let’s just transition quickly into a few of the studies that support that.

There was one clinical trial where they showed no change in C-reactive protein after treating subclinical hypothyroidism (5a), and as we discussed a moment ago, another trial showed that there was no change in cognition in elderly after treating subclinical hypothyroidism (5b). There was another study that showed there was no quality-of-life benefit in women after treating subclinical hypothyroid, and it actually may increase anxiety (5c). Of course, anytime I say the treatment of subclinical hypothyroidism, I mean treatment with thyroid hormone replacement therapy.

weight lossSM: The ones where it’s the least effective, two of those are probably what people come to see you the most for fatigue and either weight gain or inability to lose weight.

DR: Exactly. These are certainly legitimate concerns. It’s just that it may not always be a thyroid problem. Again, the thyroid symptoms, they’re so nonspecific. There are many different things that can cause inflammation, fatigue, and mood problems. The thyroid piece, again, is one I tracked closely for a while, and then I kind of became of the opinion, although I always remain open-minded, that these very robust thyroid assays were kind of much ado about nothing and we just needed to get the big picture right, which was getting the thyroid hormone in the general ballpark and then go to work on finding what else is going on in the body that’s causing these symptoms or causing this poor response to the hormone to begin with.

SM: You just said these large thyroid assays, so you have the lab ranges and then you have these super-narrow functional ranges that certain companies or certain doctors recommend. How do you view these really narrow ranges for, like, T4, free T3, and T3?

DR: I think we spoke to that a minute ago. I don’t think that we need to be that scrupulous in our ranges. As someone who still runs these assays to this day because a lot of patients want them and their insurance will cover them, I went through calculating the T3:reverse T3 ratio on every patient. I went through all these meticulous assessments on every patient for a while, and I really think that if we’re constantly asking ourselves the questions, is this really necessary, does this really make a large impact on treatment, we can weed out a lot of things that aren’t fully necessary.

That’s my opinion on those assays. Perhaps there’s a time and a place for it, but what I really think is more practical is once you have someone in the normal range, get them as healthy as you can from a broad sense, meaning, like we talked about, diet, lifestyle, gut health, maybe some vitamin therapy if there are deficiencies, and then if they’re still not fully responsive, I think a little bit of experimentation with dosing is going to be the best approach. Some people do better at the higher end of the range, and other people actually feel worse. Some patients feel better at the lower end of the range, and so do you need to do these incredibly meticulous tests to sort all that out? I don’t really think so. I mean, monitor the general parameters: TSH, free T4, and free T3. Monitor those just so you make sure that you’re not going into an overdose or overt underdose, but from there, it’s just kind of this basic clinical medicine point of treat empirically and uses the patient response to guide you within the acceptable ranges.

SM: Yeah, and I think we talked a couple of weeks ago about not just treating to the numbers, but looking at symptoms and looking at the history and the context.

DR: Exactly. The further I go into clinical medicine, I don’t see the need to be super analytical with testing and run a ton of testing. In fact, there are sometimes where I think you can have too much information and you can almost cripple your ability to think or your ability to see trends if you’re looking at so much information that you almost feel like you’re overwhelmed by it. That’s been a very freeing thing for me, being able to focus on less testing, but testing that I think is more important, and then getting a real mastery of how to look at those tests, how to treat those tests, and then when to know how to kind of leave the tests as your guideline and use the patient experience more so as a primary barometer.

26364311Before we lose some of our momentum from the other studies, I want to now go through these studies that have shown that treatment of subclinical hypothyroidism is helpful. We did talk about the studies showing that treatment of subclinical hypothyroid helps cognition in children (6a). There have also been two other trials—amongst many others—showing that treating subclinical hypothyroidism reduced infertility and miscarriage (6bi) (6bii).

There have also been a few studies showing improvement in serum lipids, one clinical trial (6c), and there’s been another clinical trial showing lipid profile has improved along with waist:hip ratio (6d). There are maybe seven, eight, nine, ten studies I found very quickly showing improvement in lipids (6ei) (6eii) (6eiii) (6eiv) (6ev), which was reinforced by our meta-analysis of the controlled trials; however, what degree these improvements in lipids correlates with chance or death or chance of morbidity is a bit ambiguous. That’s why I think there is not a super-fast reaction to treat this, because we see lab values improve, but we don’t always see those lab value improvements correlate with a lot of symptomatic improvement.

How to Navigate Subclinical Hypothyroidism

DR: I guess, in summary, how can we navigate this? Here’s what I think is a very plausible line of thinking when we are presented with something like this. We have a treatment that may or may not be helpful. It would be foolish to just rush right into treatment without trying to make the best case for that treatment possible. So how do we either justify or not justify a treatment that may or may not be beneficial? Well, we want to do everything we can to isolate that variable, so the first thing we’d want to do—amongst others—is making sure that this is actually a true problem. Retest one or two times. It may have been a transient, meaningless elevation. Also, do as much as you can to improve the health of yourself or the patient that you’re working with, and then reevaluate their symptoms or their other lab markers or whatever else you’re looking at. If everything seems to have improved, then the need for this treatment is probably much less suggested. If things are only partially improved or not improved at all, now you’ve made a much better case for this treatment being required.

Does that make sense, Susan?

Relationship with foodSM: Yes. Retest to make sure that it wasn’t just a blip on a screen. I told you about my reverse T3 that went through the roof and then has been normal ever since. Make sure that it wasn’t just some random thing or that your body rebalances itself out. Address health, diet, lifestyle, gut—all the things that we’ve talked about and have numerous podcasts about—and then if that doesn’t work—and you’re going to weed out, by this time, probably 80 percent of the people, right?

DR: Exactly.

That’s a really important process for people to think through because now we’ve been as responsible as we can—either if you’re a patient to yourself or if you’re a doctor or a clinician to the patient that you’re working with—now we’ve been as responsible as we can, and now it makes the most sense to undergo whatever treatment this is. This is just a really pragmatic kind of practical way of thinking, which is with some treatments that are controversial and there’s no consistency in the data, let’s focus on the things that are better established first and then reevaluate. If the person is not well, now this treatment that may or may not have benefit has the highest likelihood of having a benefit and we’ve done our due diligence to build up to that point and make a case for that treatment.

Hopefully, this narrative on subclinical hypothyroid helps. It’s definitely something that people will come across, and the way that you frame that and the way that you approach this will be very important to either prevent you from getting unnecessarily scared or from being under- or over-treated.

SM: Right. This requires patience. Just like we talk about for other things like SIBO and fixing the gut, it’s not an overnight thing. You’re talking about a couple of months in between retests. You’re talking about addressing the gut and autoimmunity. That takes some more months, and then you’re at a place, and a lot of people just want to feel better now. So any advice for people out there, Dr. R?

DR: Yes, definitely. This is where, especially as a clinician, we just have to know how to communicate effectively. There’s nothing saying that if someone comes in with subclinical hypothyroidism who’s eating like crap—and takes a crap twice a week!—there’s nothing to say that they are not going to feel better by addressing those issues and working on their diet or treating SIBO or whatever it is. Just because we’re not treating a lab marker right out of the gate doesn’t mean we’re not treating the patient. We always want to be moving the patient or ourselves in a forward direction, yes. Does that mean we have to treat every lab marker that’s found? No. That’s a very, very important thing to understand.

I think that’s one of the main reasons why there’s a lot of overtreatment in this field, because we feel the need to treat every marker under the sun, and I really think that a tenured, experienced clinician is much more reserved in action because, with time, you start to understand that many of the treatments that are discussed are not always needed. It’s a process of figuring out what are the vital few treatments that a patient needs, and that process takes a little bit of time, but it also doesn’t mean that you won’t start working on things right away. It’s just not that when you come in, we’re going to treat you for subclinical hypothyroidism, we’re going to start lead detox, we’re going to start methylation support, we’re going to be treating your SIBO, we’re going to be treating your adrenals, and we’re going to do female hormone treatment. That happens!

SM: And you can’t leave the house because you have so many supplements to take that you can’t go anywhere!

DR: Right. I always take pause when I say this because I’m sure there’s someone listening to this somewhere that may feel attacked by this. This is, again, in no way, shape, or form an attack. I just think that these are some conversations that need to be brought to the forefront because unfortunately, I think, a lot of functional medicine education has been permeated by labs and by supplement companies. Just like pharmaceuticals have really permeated into the treatment in conventional medicine, the same thing happens in functional medicine, and it’s really the job of the clinician to be educated enough to know what lab and supplement company resources to use and when. I don’t think it’s really the supplement companies’ fault. They’re providing you with lots of information and lots of options. As a clinician, it’s your responsibility to know when and how to use these, and I think the unfortunate thing is sometimes that qualifier is not made and the erroneous practice gets fallen into where we do everything at once, all the time in all people. It’s something I did more of in my earlier years and have learned my way out of. I’m hoping that by having this discussion and bringing these issues to the forefront and being able to talk through them will help the entire movement move to a more effective and efficient model of treatment.

AdobeStock163293447WEBdoctorpatienthealthpinkbluelaptopstethoscopeSM: Right, and then if you’re a patient, do your due diligence and research, but really find a provider that you trust and don’t go down the rabbit hole because there’s so much stuff on the internet, especially about subclinical hypothyroidism. There are entire websites that basically I’ve read that everybody should be on thyroid hormone. You can really go down that rabbit hole, but don’t do that. Don’t be Dr. Google! Dr. Ruscio, I know you’re still taking patients. Find a practitioner that you really trust, and go through the process with them.

DR: It’s important. The process of being able to read through science and the scientific medical literature with a discerning eye is very, very important because there are a lot of things when we look at low-level science that looks appealing, but looking at the higher-level science really helps filter the things that have merit from the things that don’t have merit, and that’s important.

Also, Susan, as you were saying that, it reminded me of something. I had a patient in the clinic the other day who saw an antiaging doctor and did the initial workup and they found a few different hormones low, and this doctor wanted a $5000 retainer just to treat the patient.

SM: Oh, I’ve heard of those types of doctors.

DR: I really struggle with that because it would be very hard for me to treat a patient in that way. My goal is always to fix the patient as quickly as possible, and when you ask for a $5000 retainer, it just seems like it’s more about a business than it is about putting the patient first. I’m sure that there are some clinicians that have found a way to do that in a very patient-centered way, but it definitely gives me pause, seeing that.

SM: I think we have a whole other podcast topic on that because I’ve seen a lot of doctors move to the concierge model as well, where you pay a certain amount per month. I don’t know. Something about that just rubs me the wrong way!

DR: Yeah, I think there are probably some that can do that effectively, and maybe one day I’ll bump into someone who’s doing that and I’ll be impressed with the savings, but unfortunately, I think, some of these practices happen because there are coaching models for doctors and clinicians, and of course, they’re looking at it from a business perspective. Hopefully, by us politely discussing this, we may help change some of that. Again, I’m open to the ability to do these things in an ethical and a cost-effective way, but I also have a bit of concern about them. Anyway, that might be an episode for the future.

SM: The business of medicine!

DR: Yeah!

Episode Wrap-Up

SM: We’re running out of time, so any last wrap-up words? Any last words of wisdom for everybody out there?

DR: I think that’s it. I think we covered that really well. If you guys have questions about this or concerns, the comments section of the transcript associated with these podcasts has really been growing. It’s nice to see people there, and I try to do my best to moderate and oversee and communicate, so if you have questions or thoughts, let me know, and I guess we’ll see you guys next time.

SM: Have a great week, everybody.

What do you think? I would like to hear your thoughts or experience with this.

Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.

Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!

20 thoughts on “Subclinical Hypothyroid: Do’s and Don’ts

  1. Hello Dr. Ruscio,

    Thank you very much for the very informative podcast. I wish I’ve known all that before I had initiated thyroid hormone supplementation unnecessarily several years ago. Unfortunately, I had done so by listening to the advice of some overzealous “practitioners”, recommending that everyone should be in the upper ranges for TSH, FreeT3 and Free T4 for optimal functioning and longevity.. For a few months now I’m trying to wean myself off of the Nature-Throid very gradually. Before supplementation my TSH was never higher than 4.5 and I never had any symptoms typically associated with hypothyroidism.

    Any thoughts on the study below?.
    http://www.ncbi.nlm.nih.gov/pubmed/24285689

    Thank you again very much for your thoroughness and hard work! You’ve grown tremendously as the presenter of information as well since you first appearances on Robb Wolf’s podcast a few years ago! Even your mixing of the word fixated with fixiated or even asphyxiated I find endearing. 🙂 Keep it on!!

    1. Thank you Daria, glad this was helpful! Very interesting study; looks like there may be similar, but inverse associations with sub-clinical hyperthyroidism. I was not aware of this previously but it certainly makes sense. 🙂

  2. Hello Dr. Ruscio,

    Thank you very much for the very informative podcast. I wish I’ve known all that before I had initiated thyroid hormone supplementation unnecessarily several years ago. Unfortunately, I had done so by listening to the advice of some overzealous “practitioners”, recommending that everyone should be in the upper ranges for TSH, FreeT3 and Free T4 for optimal functioning and longevity.. For a few months now I’m trying to wean myself off of the Nature-Throid very gradually. Before supplementation my TSH was never higher than 4.5 and I never had any symptoms typically associated with hypothyroidism.

    Any thoughts on the study below?.
    http://www.ncbi.nlm.nih.gov/pubmed/24285689

    Thank you again very much for your thoroughness and hard work! You’ve grown tremendously as the presenter of information as well since you first appearances on Robb Wolf’s podcast a few years ago! Even your mixing of the word fixated with fixiated or even asphyxiated I find endearing. 🙂 Keep it on!!

    1. Thank you Daria, glad this was helpful! Very interesting study; looks like there may be similar, but inverse associations with sub-clinical hyperthyroidism. I was not aware of this previously but it certainly makes sense. 🙂

  3. Hello Dr. Ruscio,
    Thanks for the great information you share in your podcats and website.
    I am a nutritional therapist studying Functional Medicine and I found a lot of conflicting information out there..
    You and Chris Kresser are my number one sources of health information online. Congratulations!

  4. Hello Dr. Ruscio,
    Thanks for the great information you share in your podcats and website.
    I am a nutritional therapist studying Functional Medicine and I found a lot of conflicting information out there..
    You and Chris Kresser are my number one sources of health information online. Congratulations!

  5. Great information! I really appreciate your research on these topics. How would you approach a patient with low end of the curve on TSH, T3, rT3 and T4? I’m assuming test for antibodies, urine iodine, salivary cortisol? Any other upstream thoughts on this? Seems a pituitary problem could be considered? Maybe a MR brain imaging study. Is this pan low thyroid scenario something that you have seen? I appreciate your wisdom! Eric

    1. Hey Eric,
      Thanks. Really hard to say because context is so important here. Low normal TSH, T3, etc… is normal for some. The sicker this person is the more I would consider an eval, the healthier they are the less I would. This could be subclinical Graves’ also, so consider running those antibodies with standard AIT antibodies. .
      Hope this helps!

  6. Great information! I really appreciate your research on these topics. How would you approach a patient with low end of the curve on TSH, T3, rT3 and T4? I’m assuming test for antibodies, urine iodine, salivary cortisol? Any other upstream thoughts on this? Seems a pituitary problem could be considered? Maybe a MR brain imaging study. Is this pan low thyroid scenario something that you have seen? I appreciate your wisdom! Eric

    1. Hey Eric,
      Thanks. Really hard to say because context is so important here. Low normal TSH, T3, etc… is normal for some. The sicker this person is the more I would consider an eval, the healthier they are the less I would. This could be subclinical Graves’ also, so consider running those antibodies with standard AIT antibodies. .
      Hope this helps!

  7. Hi doctor
    I am 18 and i recently got my thyroid profil tests done. Tsh was 5.8 t4 normal. This suggested subclinical hypothyrodism. I have no symptoms at all and no family history of thyroid disease. I am not suffering from any othrr disorder. I then went for tpo ab test which showed 315IU/ml. I actually enlisted for air force but they have referred me to a specialist due to that. Now they are seeing whether it ll progress or not. Can u kindly give your opinion on the case. I shall be v thankful

  8. Hi doctor
    I am 18 and i recently got my thyroid profil tests done. Tsh was 5.8 t4 normal. This suggested subclinical hypothyrodism. I have no symptoms at all and no family history of thyroid disease. I am not suffering from any othrr disorder. I then went for tpo ab test which showed 315IU/ml. I actually enlisted for air force but they have referred me to a specialist due to that. Now they are seeing whether it ll progress or not. Can u kindly give your opinion on the case. I shall be v thankful

  9. Hi doctor..
    Yesterday I measured my thyroid level
    My T3 (110. 2 ng/dl) , T4(6. 79 ug/dl) levels are normal and Tch 5.2 (ulu/ml)
    Kindly give me advice for the same..
    Daily I am doing cardio and body building exercises since last 4 years…
    Should I continue with these?

  10. Hi doctor..
    Yesterday I measured my thyroid level
    My T3 (110. 2 ng/dl) , T4(6. 79 ug/dl) levels are normal and Tch 5.2 (ulu/ml)
    Kindly give me advice for the same..
    Daily I am doing cardio and body building exercises since last 4 years…
    Should I continue with these?

  11. Hi sir my TsH level today is 24 iu I am in treatment with levothyroxine since 6 months initially 25 later on I was put on 50 LT4 weight gain is the only symptom

  12. Hi sir my TsH level today is 24 iu I am in treatment with levothyroxine since 6 months initially 25 later on I was put on 50 LT4 weight gain is the only symptom

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