Association of Thyroid Hormone Therapy With Quality of Life and Thyroid-Related Symptoms in Patients With Subclinical Hypothyroidism: A Systematic Review and Meta-analysis.
I know alot of people on this forum would have what is classed as subclinical Hypothyroidism and after starting medication have had no improvements of symptoms so I'd love to know your views on the Review here.
Seems that treating subclinical subjects does not always yield results and could set them along a path of medication that may never give them any benefits.
I think reviews like this are important before we recommend to anyone who has results just outside of range or with a slightly higher tsh but an in range T4/T3 to push for Thyroid replacement therapy from their Doctor.
Would love to start a discussion about this as this is what the forum is designed for
(side note: please don't reference some Thyroid guru who wrote a book but is not medically qualified in any way because I believe these people exist to extort money from sick people. Kind of like Dr Dr.e.w in the US )
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Karenk13
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Unless you know WHAT the 'quality of life' questions were, ......( i have filled in some of these in the past , and they often manage to NOT ask about any of the Thyroid related things that were ruining my quality of life!)
And, unless you accept that 'anywhere in range TSH' = adequately compensated Hypothyroidism ,( which most of us don't)
Then in my opinion this collection of 'evidence' has to be taken with a very large pinch of salt.
"After treatment (range, 3-18 months), thyroid hormone therapy was associated with lowering the mean thyrotropin value into the normal reference range compared with placebo (range, 0.5-3.7 mIU/L vs 4.6 to 14.7 mIU/L) but was not associated with benefit regarding general quality of life"
I would say that a TSH between 0.5 and 3.7 is very much normal for being on Thyroid replacement therapy most people aim for under 2 on this forum so I can't see a problem with their range they are very specific about it compared to the placebo group whose tsh remained above 4.6 at the lowest.
The point is even in the lower TSh group there were little reported improvements to their quality of life. This applies to people with Subclinical Hypothyroidism only not to be confused with other types.
"I would say that a TSH between 0.5 and 3.7 is very much normal for being on Thyroid replacement therapy"
Indeed it is, because Thyroid Replacement Therapy is currently carried out without any attention to; detail, logic, listening to, or examination of, patients ........ but 3.7 is of no use to the person who's individual 'set point' prior to disease was 0.5, and 0.5 is of no use to someone who was 3.7 before........... they will both feel no improvement on Levothyroxine if the dose is arrived at by using only TSH.
'Subclinical Hypothyroidism' is a bit of an oxymoron , literally it would mean 'without symptoms' but with 'out of range' blood test's.......but who get's a TFT done because they feel good ?
I think in thise context they are reffering to subjects who had symptoms along with slightly raised TSH just out of range but in range T4 and T3 which is why they were classed a subclinical.
Its a meta analysis which means it looks at the results of multiple studies to draw a conclusion not one single study you would have to look at all individual studies to verify that.
Anyway I think that this discussion is getting away from the point it is not based on people wth Hashimotos or autoimmune Thyroid disease if it states all levels were normal bar TSH you can "assume" and I mean that loosely that they are not positive for antibodies. They are only examining the patients who fit the criteria of subclinical and not autoimmune causes
" if it states all levels were normal bar TSH you can "assume" and I mean that loosely that they are not positive for antibodies."
That would be a very dangerous assumption to make.
I had TPOab's of >3000. with an in range FT4 and a TSH of only 6.8.
The TPOab's were only checked months later , on my insistence.
Many post's on this forum do not have TPOab's or even Tgab's done by GP, so how would they know?
The absence of this information does not prove a lack of autoimmune cause , only that it wasn't checked for , or recorded.
Any collection of evidence taken from subjects who do not have autoimmune thyroid disease should not be used as a basis of treatment decisions for autoimmune thyroid disease patients.
The vast majority of Hypothyroidism in the UK is currently caused by Autoimmune disease.
"Any collection of evidence taken from subjects who do not have autoimmune thyroid disease should not be used as a basis of treatment decisions for autoimmune thyroid disease patients"
Nowhere did I say it was. Again if you drill into the linked studies you'll see the criterias of all used studies they analysied . This is posted here for discussion I never stated if I agreed or disagreed with the study itself
I don't disagree with the result's as reported in this meta analysis.
But we must always remember when interpreting statistics ,the old maxim "Rubbish in=Rubbish out"
I do agree with the idea that caution should be exercised before committing someone to a lifelong diagnosis of Hypothyroidism based on TSH alone, because some peoples 'normal' IS above the Lab Ref Range. And also you must allow for Non Thyroidal Illness fluctuations in Thyroid Function Tests.
(Also , this could prevent finding a correct diagnosis of another complaint. At least in theory , if the GP then stopped looking for other causes.)
To encourage Thyroxine Treatment without taking these facts into account is irresponsible.
However,
I fail to see much harm in a 'trial of Levothyroxine' to see if symptoms improve. Levo is safe and cheap, and has nowhere near the amount of potential side effects of many other Drug's routinely prescribed for 'non specific symptoms'
The problem i have with the studies used in this meta analysis is that they do not properly conduct the said 'trials' of Levo , and so cannot give a good representation of whether in fact Levo would improve quality of life if it was dosed correctly for that individual.
Here is one of the studies and sets out the status of the patients but a bit of digging on the study will give you more information. This was a double blind randomized trial which is one of the most accurate forms of clinical trials.
I'm going to discuss the above paper rather than the one you've linked, just because it is the one I've read and thought about. It didn't give me any confidence in any of their thyroid research.
This paper was trumpeted in the health pages of some mainstream media when it first came out, as if it was a major advance in medicine. It was clearly designed to cut costs because they concluded that older adults got no benefit from thyroid hormones if they developed subclinical hypothyroidism, so I would guess that doctors galore will have removed treatment from older people and refused to treat them when they first present with thyroid problems.
The "cheat" that got the researchers the result they appeared to be looking for is that they treated their research subjects with just enough Levothyroxine to get the subject's TSH just into the top of the reference range.
From the results section of the abstract of the paper I linked to :
The mean age of the patients was 74.4 years, and 396 patients (53.7%) were women. The mean (±SD) thyrotropin level was 6.40±2.01 mIU per liter at baseline; at 1 year, this level had decreased to 5.48 mIU per liter in the placebo group, as compared with 3.63 mIU per liter in the levothyroxine group (P<0.001), at a median dose of 50 μg.
So, the people who were treated with Levo had their TSH reduced from an average of 6.4 (when untreated) to an average of 3.63 (when treated).
Anyone who reads this forum will know that few people with thyroid problems ever feel well with a TSH of 3.63.
and study the table in the picture, you can see that healthy people with no known thyroid disease aged in their 70s have the following median TSH :
Males : 1.60 (0.58 - 3.5)
Females : 1.70 (0.39 - 3.7)
So the male research subjects on Levo in the first paper that I linked, at the end of the research, had a TSH that was higher than 97.5% of healthy males with no known thyroid disease. I realise I'm mixing up reference ranges from different research, but the point I'm making is still valid.
The female research subjects on Levo in the paper that I linked, at the end of the research, had a TSH that was only 0.07 lower than 97.5% of healthy females with no known thyroid disease.
So, the people who carried out the research I linked to above were only interested in getting TSH to a level which was roughly the top of the level found in healthy people, and no lower. They weren't even slightly interested in lowering TSH to the median level of healthy people, nor were they interested in seeing if they could maximise quality of life or reduce or eliminate symptoms.
The other thing to point out is that Free T4 wasn't measured, and one can assume that Free T3 wasn't measured either.
...
Having read the paper (the one I linked first) by this research team I consider the way it was conducted to have been a deliberate attempt to deny older people any treatment of their thyroid problems. As a result it makes me less likely to read anything else they wrote.
This is what I'm looking for a logical discussion it doesnt have to be all emotional and dimissive when we talk about research and having constructive conversations . The point of the post was to see differing points of view in relation to the meta analysis so I'm glad you chimed in
What are your views on the following statement as they seem to use a lowee range as low as 0.5 in the review overall?
After treatment (range, 3-18 months), thyroid hormone therapy was associated with lowering the mean thyrotropin value into the normal reference range compared with placebo (range, 0.5-3.7 mIU/L vs 4.6 to 14.7 mIU/L) but was not associated with benefit regarding general quality of life"
I find this very interesting as I myself would have thought a lower tsh like that could yield some relief for patients
You are aware, are you not, that the TSH itself has nothing to do with quality of life? TSH does not cause symptoms whether it's high or low, and does not make you feel good if it's euthyroid. You can have a suppressed TSH and still have thyroid hormone levels that are too low to make you well. I cannot understand why this discussion is around TSH levels, when it's the actual thyroid hormone levels - especially T3 - that affect quality of life. The TSH in hypos is not a good indicator of thyroid status.
So you agree with the conclusion of the study as being correct. This is exactly the point they are making that a reduced tsh does not equal improved symptoms.
My above comment was in response to Humanbeans statement that one if the studies had a set point deemed too high tsh wise.
I ask questions around this because it is often stated on this forum that people should have a tsh below a certain number and are told a tsh for example of 3-4 (just an example) is too high when they post their blood results but yet we can agree that the real indicator is T3. So I suppose I posted this to start a debate and raise awareness tgat tsh is not the deciding factor of health.
I have seen multiple times posters with mid/upper range t3 and t4 being told they need an increase because their tsh is still above 2 and would be better under 1.
Like my original post said..
"I think reviews like this are important before we recommend to anyone who has results just outside of range or with a slightly higher tsh but an in range T4/T3 to push for Thyroid replacement therapy from their Doctor."
Glad to open discussions like this as they are important.
The point though , is that you will not see recommendations here based on a TSH result in isolation, but discussed in context of FT4 result and usually a recommendation to get an FT3 done too. And of course , in relation to symptoms.
The studies used above are only interested in TSH, so they offer a very incomplete picture of any individuals situation.
Well, I think the majority of people on here know that the TSH is not the deciding factor of health. And, if they don't when they arrive, they soon find out.
The reason we talk about the TSH coming down to a certain level is because very often doctors only test the TSH. So, it's no use asking people what their FT3 level is. They have a TSH result and that's all. But, we know that euthyroid people have a TSH of around one; not higher than 2. Over 2, we know that the thyroid is beginning to struggle to keep levels up - if it is keeping levels up. And, then, at 3 you are hypo. But, the ranges are hopelessly unrealistic. And, doctors do not understand ranges, but use them to suit their own ends. They ignore the ranges when it suits them - such as the dictate in the UK that the TSH must go up to over 10 before they will diagnose!
We also know that once a TSH goes below one - hence the cut off - it doesn't give you much useful information. Above that, thyroid levels are probably too low - but even that's not sure - but with a TSH below 1, they could be just about anywhere. That's when you really, really need the FT3 to know how you're doing.
I suppose it's good that there is a meta analysis to point that out - sorry, haven't had time to read it yet - and we all sincerely hope that doctors read it. But, on here, it's really a case of preaching to the choir. So, yes, I suppose you could say I agree with it.
just looking at the comments above, and it’s a bit of a blind spot that they didn’t reference the tpo antibodies as a cause of poorer quality of life. Funny enough I’m beginning a thesis and have been wading through a whole stack of questionnaires for qol or ‘wellbeing’ - and I’m honestly not sure if different studies have used different methods - how u can standardise them after the event. Also often they’re meant to be general but that means the questions for qol assessments miss the issues that affect us. But then if you made up your own - it’s not going to relate to anything.....
I’d be interested to know, if anybody here were filling in a well-being questionnaires, would they feel it more relevant to fill in a 14 question WEBMWS, where some questions might not feel relevant - or the global quality of life assessment that asks just one question which is what’s your quality of life - and you put a number between 1 and 100?
I have problems with all these questionnaire approaches.
For example, if I answer how much something hurts, it will depend not only on the level of pain, but whether the sun is shining, something good is anticipated, I've just had a really good laugh, and everything else that goes to make up our lives. Miserable rain, dark clouds, really annoying building works nearby, bad sleep last night, would raise that pain hugely!
True, but then if you use no measures that are recognised or accepted, then your research ends up in a ghetto of qualitative research that’s not taken quite as seriously as the quantitative stuff. sometimes I feel we r shouting up saying ‘there’s something wrong here with our quality of life, and then medical research is creating reports that shout down ‘nope, nothing showing up here...
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