Symptoms of hypothyroidism persist despite taking medications, normal blood tests

About 10% of the 12-15 million people in the United States suffering from hypothyroidism comply with the treatment standards recommended by the American Thyroid Association, but doctors regularly prescribe levothyroxine, a synthetic thyroid hormone, the dose of which is adjusted until the level of thyroid stimulating hormone (TSH) in the blood stabilizes.

Despite routine TSH tests, these patients still have many nagging symptoms of hypothyroidism. Antonio K. from rush. “Patients complain of depression, slowness and heart problems,” says Bianco, MD, professor of medicine at Rush and an expert on thyroid diseases, former president of the American Thyroid Association.It is difficult for them to lose weight. They feel depressed and complain that they have less energy. But our doctors keep telling them, “I’m giving you the right amount of medication, and your TSH is normal.” You should feel great.””

A new study provides these patients, who often feel rejected and forgotten, with evidence that their persistent symptoms are not just in their head.

The study, conducted by Bianco and other Rush colleagues, was published in October. The Journal of Clinical Endocrinology and Metabolism (Journal of Clinical Endocrinology and Metabolism) showed that people who took levothyroxine with normal TSH levels were significantly more likely to take antidepressants than their peers with normal thyroid function. People taking thyroid medications are also less physically active and, in their opinion, have lower energy levels. They weighed about 10 pounds more than their peers of the same height, although they consumed fewer calories after adjusting their weight. In addition, they were more likely to take beta-blockers, drugs that are often prescribed to lower blood pressure, and cholesterol-lowering statins.

“These results are consistent with what the patients are telling us,” Bianco said. “This study objectively confirms for the first time that patients taking levothyroxine, despite normal TSH levels, feel worse and much less active than in the control group, which indicates objective violations of cardiac metabolism.”

The Current Treatment Approach

According to Bianco, women most often suffer from hypothyroidism, which occurs when the thyroid gland in the neck stops producing enough hormones, most often due to autoimmune diseases. Hypothyroidism also develops with surgical removal of the thyroid gland (for example, due to cancer or benign growths).

One of the main tasks of the thyroid gland is the regulation of metabolism, which affects almost all organs and functions of the body. If the level of thyroid hormones is low, for example, with hypothyroidism, the heart rate slows down, and the intestines slow down the absorption of food, which leads to constipation. The thyroid gland also affects the brain. “Your brain will be turned off,” says Bianco. “Patients may feel tired, drowsy and depressed. If left untreated, the course of the disease can dramatically slow down, gradually lead to falling asleep and eventually lead to coma.”

There are 2 types of thyroid hormones: triiodothyronine (T3) and thyroxine (T4). Until the 1970s, patients with hypothyroidism were given pills containing both T3 and T4 made from the dried thyroid gland of cattle or pigs.

But everything changed after scientists made two brilliant discoveries. 1. The thyroid gland mainly produces t4, which, when ingested, turns into T3. “It is important to understand that T4 is not an active hormone,” Bianco said. “Our body converts T4 to T3 using an enzyme called deiodinase.”

This discovery led to the widespread treatment of hypothyroidism with levothyroxine monotherapy, a pharmaceutical analogue of t4. As Bianco explained: “The medical community has come to the conclusion that patients with hypothyroidism should not inject t3 and T4 into the thyroid gland at the same time, but only T4, and then the body, in its wisdom, will produce sufficient amounts of T3.” This avoids potential side effects from the administration of the active thyroid hormone T3.

The second discovery concerned TSH, a hormone produced by the pituitary gland, a small organ at the base of the brain. Scientists have found that the pituitary gland and thyroid gland work together, providing the body with enough T3 to convert into T4. When T4 levels are low, for example in hypothyroidism, the pituitary gland releases TSH into the bloodstream, stimulating the thyroid gland to produce more T4. A high level of TSH in the blood is a sign that your doctor is diagnosing hypothyroidism, and you need to adjust the dose of T4 (or levothyroxine) until TSH levels return to normal.

“This is how patients with hypothyroidism are usually treated and monitored today,” Bianco said. “The goal of treatment is to improve the well-being of patients, but the symptoms themselves are not used to determine the effectiveness of treatment. There is a TSH level in the blood. In other words, the levothyroxine dose is adjusted depending on the TSH level, and not on whether the patient feels better.”

A Changing Paradigm

Since most patients with hypothyroidism tolerate levothyroxine monotherapy well, which is considered a safe medicine, the medical community considers this approach to treatment to be successful. However, in recent years, patient support groups have helped draw attention to the plight of hypothyroid patients who feel unwell despite taking levothyroxine and normal TSH levels.

Bianco sees many of these patients because he and his colleagues specialize in thyroid diseases. “They are looking for someone who believes in what they are saying,” he said. “When I say, ‘I understand and believe in you,’ many of my patients start crying. These patients are suffering, and the doctors are firing them.”

To find out more about why some patients feel unwell in a completely objective and unbiased way, Rush researchers turned to a wide-ranging public survey called the National Health and Nutrition Examination Survey (NHANES). More than 10,000 people are participating in the NHANES research program, designed to assess the health and nutrition of adults and children in the United States. The uniqueness of the study is that it combines interviews with medical examinations.

From this database, Rush researchers identified 469 adults who received levothyroxine monotherapy and compared them with 469 who did not take levothyroxine. Age, gender, race, and serum TSH levels were the same in both groups.

“We examined how 2 clinical indicators differed in 52 groups. People who took levothyroxine were more likely to take antidepressants than those in the control group,” said Sarah Peterson, Ph.D., first author of the study and a certified nutritionist at Rush University Medical Center.

Other results of the study included significantly increased use of statins and beta-blockers in the levothyroxine group, possibly due to high cholesterol and high blood pressure.

A Revised Dialogue

Patients with hypothyroidism who persist with symptoms of levothyroxine monotherapy consult with their doctor about trying combination therapy or pills containing both T3 and T4. Although trials of combination therapy are supported by the American Thyroid Association, there are mixed clinical studies on whether this approach works, Bianco said. Subjectively, some patients report an improvement in well-being, while others do not.

According to Bianco, more effective drugs are needed to treat hypothyroidism. In the meantime, he urges doctors to change the way they talk to patients about treating hypothyroidism. “The doctor should tell the patient, “We are going to normalize TSH levels, but you will have a higher risk of gaining weight, experiencing depression and fatigue.” In addition, it increases the likelihood of an increase in cholesterol levels.” Based on our research, this is exactly what we need to tell our patients. This conversation is especially important for all patients who are considering surgical removal of the thyroid gland.”