Is high TSH equal to immediate treatment? When to treat?

The results of some blood tests, when they are altered, scare patients a lot.

One of these tests is the TSH (thyroid stimulating hormone) which, when it presents a high value, brings discomfort and concern to the patient.

This justifies what Dr. Joachim Feldkamp, ​​MD, Ph.D., director of the University Clinic for General Internal Medicine, Endocrinology, Diabetology, and Infectious Diseases at the Central Hospital, Bielefeld, Germany, said recently at a conference.

Thyroxine and L-thyroxine are two of the 10 most frequently prescribed medications. Dr. Feldkamp commented that “a major health insurance company ranked thyroid hormone fourth on the list of best-selling drugs in the United States. It is possibly the second most commonly prescribed preparation.”

Typically, these medications are prescribed when the thyroid gland produces too little thyroid hormone. It is worth remembering that TSH is the hormone produced in the pituitary gland (a gland located in the brain) that stimulates the thyroid to produce its hormones T3 (triiodothyronine) and T4 (thyroxine).

An increase in TSH may initially indicate that too little thyroid hormone is being produced. And this increase in TSH, in simpler words, would be the body’s mechanism to make the thyroid “work harder”. Therefore, this thyroid-stimulating hormone (TSH) is used to assess thyroid function. TSH is used to quickly assess thyroid function.

Dr. Feldkamp indicates that not every elevated TSH value needs to be treated immediately. Broader investigations demonstrate that TSH values ​​are subject to fluctuations. This specialist comments that the results of individual assessments deserve caution, before making a therapeutic decision. He also recommends that slightly elevated TSH values ​​should be checked again after 2 to 6 months, and the patient should be asked if they have any symptoms.

Very important!

Dr. Feldkamp explained that “in 50% to 60% of cases, the TSH value normalized on the second exam without the need for any treatment.”

And what leads to elevated TSH values? The reasons are several.

There are fluctuations in TSH values ​​depending on the time of day. At night and early in the morning, the TSH value is much higher than in the afternoon. Furthermore, an acute lack of sleep can lead to higher TSH values ​​in the morning. So, if a patient is worried about the test to be carried out the next day and has a bad night’s sleep, this could be the factor for a specific change in the TSH value obtained from a blood sample taken that morning.

It is important to remember that, in winter, TSH values ​​are slightly higher (when compared to summer), due to our body’s adaptation to colder temperatures. Some research has already shown that people who live in colder regions have significantly higher TSH values ​​than those who live in warmer regions.

Age also leads to differences in TSH values. Children and adolescents have higher TSH values ​​than adults. Another important fact: TSH values ​​increase with age. In people aged between 70 and 80 years, slightly elevated TSH values ​​– initially — are not a reason for treatment.

Dr. Feldkamp advises caution when treating these patients, as overtreatment can cause cardiac arrhythmias and decreased bone density.

On the other hand, women’s TSH values ​​are generally a little higher than men’s.

Attention should be paid to obese patients. In obese patients, there is an increase in TSH and these values ​​are often higher than those observed in patients with normal weight. High TSH values ​​in obese patients do not necessarily mean low thyroid function and usually represent an adjustment mechanism for the body. This can be proven by the fact that when these patients lose weight, TSH values ​​drop without any specific treatment; there is a spontaneous drop in TSH with weight loss. Once again, it is worth highlighting that slightly elevated TSH values ​​in obese patients should not be treated with thyroid hormones.

Falsely high or low TSH values ​​may be observed in blood tests of patients who use some nutritional supplements, such as biotin. These supplements are recommended for some skin, hair, and nail growth disorders. It is recommended to take a break of at least 3 days and, more appropriately, a week in the use of these supplements, before collecting blood for TSH assessment.

But are there some “rushed” thyroid hormone prescriptions?

Courtesy — Freepik

Dr. Feldkamp points out that thyroid hormones are sometimes prescribed too quickly due to the assumption that any elevated TSH value is due to the presence of hypothyroidism.

Is there a sensitive determination for a TSH value?

Apparently no.

A doctor’s assessment is essential. Recent symptoms such as weight gain, impaired weight regulation despite reduced appetite, depression, increased need for sleep, reduced quality of life, cognitive dysfunction, memory deficit, fatigue, muscle weakness, cold intolerance, and constipation, may indicate a more in-depth investigation of thyroid function with the determination of free thyroid hormones T3 and T4. More specific tests may be necessary, such as the detection of antibodies against autologous thyroid tissue, TPO-Ab [antibody against thyroid peroxidase], TG-Ab [antibody against thyroglobulin], and TRAb [antibody against TSH receptor], and also an examination of thyroid ultrasound.

There are, however, many particular situations, where there are high TSH values, in which treatment must occur, such as in young patients, pregnant women, post-thyroid surgery, or treatment with radioactive iodine. However, this decision must be evaluated by your doctor.

Here, it is worth remembering that the doctor treats the patient properly and not the laboratory test.

But finally, it is true that faced with an abnormal (altered) exam, everyone is uncomfortable: patient and doctor.

When the patient has a slight increase in thyroid-stimulating hormone (TSH) and normal thyroid hormones (free T4 level), what is called subclinical hypothyroidism may be characterized.

In these cases, as we saw previously, the doctor asks himself: to treat or not to treat?

Subclinical hypothyroidism is a purely laboratory diagnosis. Subclinical hypothyroidism is a mild thyroid dysfunction and not all patients benefit from treatment.

The symptoms of subclinical hypothyroidism are present in a minority of cases and these symptoms are those that have been previously described and that the doctor seeks to identify during the consultation of the patient who has elevated TSH values.

The symptoms of subclinical hypothyroidism are similar, although milder, to those reported by patients with clinical hypothyroidism.

This reaffirms the need to always be close to our clinical doctor.

References

• SCUBEL J, FELDKAMP J et al — Deutsches Arzteblatt International — 23 Jun 2017
• FELDKAMP J — Deutsche Medizinische Wochenschrift — 01 Aug 2017
• FELDKAMP J — German Society of Endocrinology’s hormone week — Online Conference — 2023
• EPPINGER U — Medscape — Oct 05, 2023