No surprise, attending ENDO2021 virtually wasn’t my hope. No, my ideal conference experience is not sitting at my computer focusing through the din of usual distractions until gluteal numbness demands movement. But, despite my heavy sighs thinking about the prospect of sightseeing and communing with colleagues at a conference destination, the ENDO2021 conference delivered tremendously. Attendees may have had to log on, but we still made it out. The sessions I saw on thyroid disease exemplified this. What was the secret sauce that made these explorations of clinical thyroid care so fulfilling? The answer is speakers who brought the data as well as their views on tackling tough clinical problems. Accumulating data have challenged previous paradigms and informed updated guidelines, such as those from the American Thyroid Association (ATA), ushering in more nuanced views of thyroid management. But steering in new waters can be hard, and hearing how an expert would handle those uncomfortable currents was excellent.
Now, whenever I see a session on patient complaints and thyroid hormone replacement, I am eager to see if there is anything promising on the horizon. Fortunately for me, ENDO2021 thoughtfully included this topic, so let’s jump in.
Patients with hypothyroidism often experience ongoing symptoms. While the reduced quality of life scores have been observed in hypothyroid patients compared to controls, these have not correlated well with thyroid hormone levels in some studies. The relationship between thyroid hormone levels to symptoms is an area of uncertainty, and patients are often left frustrated. In an online survey of patients treated with thyroid hormone, over half of respondents reported changing physicians more than twice because of dissatisfaction.
Patients may speculate that the inadequacy of thyroid hormone has not been uncovered or correctly managed because of limitations in our testing. This is the “it’s not normal for me” explanation, and it comes up in the assessment of other hormones as well (I’m looking at you testosterone). There are some reasons to consider this possibility. Thyroid hormone profiles measured in patients after thyroidectomy indicate that higher free T4 and lower TSH concentrations are necessary to normalize serum T3. Anecdotally, I see many patients who know when their thyroid levels are off or have an ideal TSH level even within the reference range. Should we be convinced? Well, in elegant studies by Dr. Mary Samuels’ group from Oregon Health & Science University, randomized and blinded subjects received levothyroxine to achieve TSH levels that were either low-normal, normal, or slightly elevated, and no differences were found between groups in measures including mood, mental function, metabolism, or weight. Preference for their assigned treatment was only found when the subject believed they were on the high dose, but participants were unable to accurately determine what group they were actually in.
The need for T3 supplementation is another topic that may be raised by patients and be uncomfortable for physicians. These can be troubled waters indeed! Here again, data are suggesting that serum TSH and T4 do not reflect euthyroid status in all tissues, which may require additional T3 to be normalized. Randomized, controlled trials, however, have not indicated a clear advantage to administering T3 in addition to levothyroxine, though studies remain heterogeneous and limited.
How do we approach these perhaps more trying patient encounters with patients who seem convinced that the thyroid is to blame? A comprehensive assessment for conditions that could be responsible for non-specific symptoms, such as fatigue or poor mood, should be performed and include common entities such as anemia, obstructive sleep apnea, or depression. Equally, if not more important, is the empathetic approach to these patients. To provide a partial quote of what the speaker offered, “Communication lies at the heart of managing patients whose health problems cannot be explained.” Many patients will find greater insight and alliance with their physician when the facts about thyroid hormone testing and dysfunction are explained. And when they don’t, we have done our best for our patients when we can provide this compassionate honesty.
Brava to Dr. Anne Cappola from the University of Pennsylvania who spoke for this session. Expert summaries and clinical insights were on display throughout the meeting, including Dr. Kristien Boelaert for thyroid disease and pregnancy, Dr. Cari Kitahara and Dr. Brian Kim debating the risk of cancer after treatment of hyperthyroidism, and many others. In a year that demanded it, the virtual ENDO2021 helped advance a current and evidence-based practice of medicine.