Op-Med is a collection of original articles contributed by Doximity members.
The recently concluded 2023 Endocrine Society Annual Conference in Chicago brought together a diverse range of attendees from across the world and showcased cutting-edge research across various disciplines of endocrinology.
Most sessions were standing-room only, and presentations related to thyroid disorders were extremely popular. This year's overarching theme in thyroid disorders was the concept of de-escalation of therapies to provide effective outcome-based treatment to our patients. Both overdiagnosis and overtreatment contribute to increased health care costs and place our patients at risk of potential harm.
Deprescribing is defined as a patient-centered process to taper or stop medications with the intention to achieve improved health outcomes by reducing exposure to said medications that can be either harmful or no longer required. Levothyroxine is one of the most prescribed medications. Dr. Maria Papaleontiou from the University of Michigan discussed the appropriate use of thyroid hormone replacement in older adults. Aging is associated with an increase in serum TSH levels, and most laboratories lack age-adjusted reference ranges for clinicians. This has led to inappropriate use of levothyroxine in older adults, which carries the risk of bone loss and atrial fibrillation, among other detrimental effects. Approximately 6-25% of elderly patients taking levothyroxine develop iatrogenic thyrotoxicosis. Dr. Papaleontiou advocates for the judicious use of levothyroxine in older adults and consideration of deprescribing to reduce potential complications in the elderly.
Overdiagnosis is defined as detection of a medical condition that, if left undiagnosed, would cause no harm. Dr. Naykky Singh Ospina from the University of Florida, Gainesville, discussed the inappropriate evaluation of many thyroid nodules, resulting in overdiagnosis of low-risk thyroid cancer. American Thyroid Association (ATA) guidelines for the evaluation and management of thyroid nodules are not consistently followed, and a recent study looking at Physician Perspectives in the work-up of thyroid nodules showed that 64% of clinicians recommended evaluation that led to overdiagnosis of low-risk thyroid cancer. The potential harms of cancer overdiagnosis extend beyond unnecessary surgeries and possible complications, encompassing emotional and financial tribulations incurred by the cancer diagnosis.
In 2012, the Endocrine Society, under the auspices of the Choosing Wisely initiative, recommended against ordering thyroid ultrasounds in individuals with subclinical or overt hypothyroidism and a normal neck exam. Despite clear guidelines, studies have shown that thyroid ultrasounds continue to be ordered inappropriately and result in further medical encounters, repeat ultrasound, biopsy, thyroid surgery, and subspecialty consultation, all increasing cost of care. Dr. Juan Brito from the Mayo Clinic addressed the overuse of thyroid ultrasound in practice and emphasized that there is a limited or no role of ultrasound in patients with thyroid dysfunction.
Thyroid cancer is a common endocrine malignancy, and most patients are diagnosed with low-risk differentiated thyroid cancer. Neck ultrasonography and serum thyroglobulin measurements are the mainstays in long-term thyroid cancer surveillance. Dr. Megan Haymart from the University of Michigan addressed the uncertainties regarding optimal surveillance in patients with low-risk differentiated thyroid cancer. She argued for tailoring our follow-up strategies to individual patients and de-escalating ultrasonographic surveillance in patients at low risk for recurrence.
Multiple factors influence the adoption of any new guidelines and recommendations. Barriers to adherence are multifactorial: encompassing clinician knowledge and attitudes as well as patient behavior and resistance. Clinician knowledge barriers include lack of awareness of, or familiarity with the guidelines. Clinicians may disagree with specific guidelines based on individual experiences and motivations. Clinician behavior may also be related to a perceived increase in malpractice liability. Enhancing the clarity of guidelines and providing adequate clinician education may help facilitate meaningful changes in the future.
Overall, the 2023 Endocrine Society conference provided valuable insights into thyroid disorders, with a focus on the de-escalation of therapies to ensure value-based treatment for patients.
I - 😱 - am speechless. 🤯 Where to even begin. Maybe the title. "De-escalation" ... Am i in an Orwell novel??
Where do they get these numbers from. How do they even define overmedication. How do they know the bone loss & af weren't from undertreatment. Or ok they mention "risk" but are they comparing low TSH to Grave's again. I guess I should read the full text but i don't need a stroke right now.
Wasn't it the same US Endocrinology Society that 15 years ago recommended reducing the TSH top range from 4+ to 3.something? I will have to find that opinion paper back. It may have been a different org.
Indeed. It would take at least a week to go through it all point by point and write a rebuttal.
It's due to nonsense like this that my poor FIL of large build with a.f. is stuck on 75 mcg levo & doctors aren't worried that all his minerals & vitamins are under the lab's ranges. (I try my best but there are other inlaws to deal with). /end rant.
I was thinking of the American Association of Clinical Endocrinologists. I couldn't find the original paper back in my records but this is an interesting overview. aacc.org/cln/articles/2013/...
Nobody even discusses why TSH is still the first-line test when actual thyroid hormone tests have matured significantly in the last years. I had uptake and converted free thyroxine levels tested for many years, but FT4 and FT3 are now widely (and often the only tests) available, and they are reliable. Sorry I am going off on a tangent now.
And ten years after that paper and we seem to have made no progress on harmonisation of TSH assays, recognition of the multiple isoforms, identifying assays properly in papers, etc.
"and showcased cutting-edge research across various disciplines of endocrinology....."
oh yes , it's SO cutting edge that even though ......
"Aging is associated with an increase in serum TSH levels, and most laboratories lack age-adjusted reference ranges for clinicians."
.. they STILL haven't bothered to get off their asses and make any 'age - adjusted TSH ranges' Why might that be ? ....is it that if they did , it would show there is only a very slight increase in TSH in older age groups .. and that if they don't bother doing it , they can carry on trotting out this line about "older people have 'higher' TSH anyway" (so we won't bother treating subclinical hypo if they are old)
"Clinician knowledge barriers include lack of awareness of....."
Don't tempt me .. it would take so long to finish this sentence adequately , that by the time i'd finished , my TSH might be '9 and three quarters'
Because we'd overmedicate ourselves past the trembling, jitteryness, and profuse sweating, right into osteoporosis and atrial fibrillation, obviously. Didn't you know, thyroid meds are more dangerous than insulin and we can't possibly be observant, responsible patients, pffffttt.
It is possible to buy thyroid hormones without prescription in a few countries around the world. I wonder how often people there get themselves in trouble with excessive intake.
I suspect that for many, access to levothyroxine and liothyronine, in any doses wanted, at reasonably low cost, would be safer.
Obviously, we would tend to think of adding in regular testing. But the primary issue is having understanding. Realising excess and insufficiency are both poor choices. And seeing what to do to reach a personal optimum dose.
When I was put on T3 because the T4 just didn't work I was given a lecturer by my gp about over use of the drug, he went on to tell me it must not be used as a weight loss drug🙄 as some people do, also do not buy it from the Internet or abroad as you don't know the ingredients. HO yeah like I've gone through hell this last year (2017/2018) with hyperthyroidism (graves) that you couldn't Diagnose😠 leaving my heart doing a marathon everyday, with tremors, big loss in weight, sweating all the symptoms of an overactive thyroid, so what about my poor body then doctor?
Even when I eventually got the diagnosis by a more competent gp you failed to apologise for you blatant miss diagnosis, not even doing a routine check on my heart.
These so called specialist's at that convention have no real insite to thyroid conditions and the treatment of such, it's a jolly outing for them... Nice hotel, food and a usless talk😠
Wonder what they think of these stars who are using that insulin pen to loose weight????
If you read the official documentation for Greece, not easy when - like me - you can't read Greek!, there are many references to levothyroxine and liothyronine needing to be prescribed.
I suspect that there is simply widespread poor or no enforcement. Or there is some pharmacist discretion (as we have with some medicines such as antibiotic eye drops).
The end result is, it appears, often that people can obtain them without prescription.
Good catch. And after clicking on the link i see this is an op-ed piece. Thus the lack of references and opposing research.
The full list of conference abstracts is here eppro02.ativ.me/src/EventPi... i looked through a few and they seemed balanced, did not get the feeling it was all about de escalation. Maybe a keynote speaker was harping on about it.
Astonishing! Why do they think less of thyroid conditions than say pancreatic problems, or stomach issues, or liver malfunction? No doctor would withhold treatment for most other conditions just on the grounds of cost, which is what this seems to be stating. Hopefully the other presentations were more balanced and knowledgeable.
I think we've had plenty of reports from members who have seen women. With little evidence that they are significantly better.
Quite possibly, the simple fact that most endos were trained by male endos who themselves were trained by male endos, and so on, is a more powerful factor than whether the endo in front of you is male or female.
This is very much in keeping with the "second-opinion-endo" who told me that I was wasting tax payers' money. He also said that T3 has no function, a comment which confirmed that seeing him was definitely a waste of tax payers' money.
Other than that I feel like slapping my forehead and also go with "no comment" because my jaw just hit the floor.
Interesting. Glad they defined 'overdiagnosis'. I was diagnosed subclinical hypothyroid aged 58. Aged 61 my bone density had lowered (previously good), aged 63 I developed atrial fibrillation and had hypertension after a lifetime of low blood pressure. I was not advised of the risks. I'd probably been subclinical hypothyroid since an earlyish menopause at 46. Here I am.
Unbelievable, it takes so long to get diagnosed for anything, then in your 40s they assume everything is menopause. I think I had the thyroid issue developing first before meno, but have no test results to prove either way to myself that it was my thyroid. They just don’t take thyroid issues seriously.
"provide effective outcome-based treatment to our patients." The outcome being to their benefit, not ours. Nothing in that paper taking about patient symptom resolution. 😩
I know you shouldn't wish bad things on people, but I really hope that each and every one of these idiots (and those who came out with that BTA/ES statement the other day) develop the worst thyroid condition possible and then get hoist with their own petard!
Are these people opposed to assisted dying by any chance?
It's interesting isn't it. I met a private doctor once, who told me he used to trot out the standard nonsense to patients concerning hypothyroidism all the time. Saw the light when he developed hypothyroidism and didn't get better on any amount of levothyroxine and HE was the frustrated patient going to clueless Endos.
On the other hand considering the prevalence of hypothyroidism in the population, he couldn't be the only doctor in that position. So what are the other's doing? If they do well on levo they surely can't relate to the patient at all. If they don't... clearly many aren't advocating for change even if they themselves have suffered.
Yes. They certainly have haven't they? So these people knew all along that M.E. was real but treated patients with scorn. 'Yuppy Flu' it was derisively called. Now suddenly long covid is legit.
These are the ones, like the best endo I ever had here in Manitoba, who have suffered with thyroid issues, did the research, treated their patients according to that research and had to close practice before losing their license because they were hounded by the College of Physicians.
I find it so frustrating (and I'm using that word because the word I'd like to use would get me thrown off here) 😁 yes there must be some specialist's and gps with a thyroid condition , although in my experience (graves disease thyrotoxicosis) took gp a full year to Diagnose me kept saying it was my menupausal state and to stop bothering him😠.
After thyroidectomy I was given T4 to which the surgeon who took my thyroid out said.. "take these as instructed you'll never look back" 🙄 😂 it took another 5 months of sheer hell with my gp (as I'm lactose intolerant and have colitis) and the first lot contained LACTOSE!! spoke to endo who said he's never heard of anyone who can't take T4 so I should just persist with a lactose free T4.
I've spoken and seen plenty endocrinologists who do not believe thyroid medication doesn't work for certain people, it's all in your head.
Well in my case it was all in my blood results 😠
But let's look at the difference in diagnosis between let's say.. Us! we get the below standard treatment if we even get that! See these un educated endos who go through there check sheet and determine whether or not you need treatment.
On the other hand the gp/specialists who developed a thyroid condition can take his or her pick of specialists to see, probably an old chum they know or be forwarded to a top notch specialist (love to be a fly on the wall at those consultations 👍) you can bet your bottom dollar they are treated way better than us, no barriers by nhs rule's no let's wait 3 months to do another test without medication.. No a gp or specialist can't afford to do that... So they are given top treatment you can bet!!
I spoke to a nurse when I was having my boob scan, she was telling me she had thyroid cancer (full thyroidectomy) and was struggling to hold down this part time job she loved❤️ but the thyroid medication was not doing the job for here, and no endo was helping her with the recovery😔 she told me this.. "I work in a medical environment you'd think I'd get the best treatment and help from the expert's"
I told her in no uncertain terms "your not important enough to warrant that kind of treatment 🤷♀️ and went on to show her my scar and how I am being treated on my thyroid journey 😠 the poor woman just looked at me and said" well it doesn't look good for me, I'm thinking of packing it in as I just don't have the energy to come here everyday 😔
Love this post Birkie! I sure do wish Healthunlocked would allow for some expletives😄 I was politely told off by the Fibromyalgia UK mods for using c*ap in a post once lol. I'm so sorry you've been treated so badly. I have a thyroid, I can't imagine trying to survive on T4 only with no thyroid! Lol you'll never look back🤣 maybe he meant literally because of the joint pain of turning your neck and shoulders from no sufficient T3 hormone!
It is beyond frustrating and unjust. I'm not working and only in my mid 40's so the paternalism and dismissal is pretty much a given. It goes like:
"Well of couuuurrrsssee you're not well! Yeah sure your medication doesn't work. It doesn't work because in your mind it doesn't work. You're depressed obviously, and deluded and frankly the more you speak the more I think hysteria needs to be added to your notes. I'll add it covertly anyway in doctor code, along with your current employment status(!) You're not happy you say? Well how can I help you, Ms Alanna, when you insist on questioning the help and do not seem appreciative! Even if you think you know how the thyroid works, you don't have a degree in medicine and 20 years practice behind you, as I do, so you don't know what you think you know. I do. You're clearly spending too much time on Google, getting worked into a panic by online idlers with nothing to do all day except reinforce each other's biases, which leads me back to if you got out more, exercise instead of staying in bed and sitting in the house and spend time buying decent food and actually cooking it, (please don't to try tell me you aren't eating junk. Your cholesterol is high...no . it's nothing to do with your hormone levels your T4 is within the range. This is what I mean...) then you would feel remarkably better. What's that? You can't lift a bag of shopping without getting exhausted? It's because you're not doing it enough!! That is the point you keep missing. What do you want me to do if you even refuse the mood enhancers? Look my time is now gone and I have other miserable people who I can't help either but at least are grateful and magnanimous. Some of them buy me gifts. You never do. Now leave please. Yes, yes I suppose I can at least give you a blood count to make you feel I've done something there is no need to test your B12 levels your results 6 years ago were within range now please go"
The poor nurse. A nurse, not high enough up I agree. My uni lecturer had fibromyalgia he got best of the best treatment he knew doctor pals from his uni days and when he speaks it's clear he has authority. He acknowledged his status resulted in better care.
Loved your post back to me, gave me a good chuckle 😂😂😂 which I need right now, 👍 yes I seem to have been given the same response from my gp as yours😂.
REALLY!! do these gps think we want to be like this? I honestly never saw my gp until I became ill not well.
I was a big gym bunny, aerobics, gym ball, weights I was slim and fit I could jump into my size 10 levi jeans and go 😁 (ho the day's 😔) obviously I lost a lot of weight with graves going down to a size 6, 😬 then the thyroid was ripped from me and all hell as broken loose since.. Weight gain, can't loose it, eventho the medication is giving me cramps and very loose bowels 😖 fatigue, am not cold never🤷♀️ always hot, sweating for England, tremors, palpitations (not over medicated at all) but these symptoms are ruining my life😔 I don't go out now, don't see friends, it's a chore to get my groceries and I'm done for the day after getting them, and yes I can get them delivered (and I do on really bad days) but it the only time I get out!.. It breaks my heart seeing people going about there lives doing things I should be doing, but can't 😔.
And as you say the gps just either don't give a dam or care just gaslighting us, and yes bloods.... Don't get me started on that😠 I had a full blood work up in june... I look on the results.. No minerals or vitamins done😠 some flipping blood work up that was, my gp won't do my adrenals, says I don't need them so going to have to pay to get it done😠 everyday is a fight🥊 but to our GPS who are supposed to be there to help 🤷♀️ we are just a big nuisance 😠 tell you what... If I ever won big on the lottery I'd be right down to harley street get myself to a professional specialist 👍😂😂
Awwwww Birkie, I've just had a look at some of your other posts and you are really suffering, and I thought I had the monopoly on that!! I'm so sorry, I really hope you get help soon, the parathyroids will absolutely make you feel C**p so hopefully you may feel some alleviation of your symptoms once they are treated.
The Roma T3 doesn't suit everybody. But T3 isn't easy just like T4 isn't easy and you can be hot and sweating buckets and still not be optimal on your dose.
I can relate on so many levels with what you're saying about not being able to look at people zooming around doing things you can't and the size 10 jeans. Those days are loonnnggg gone for me too. For ages I wouldn't buy myself new clothes because I refused to accept I needed to buy larger sizes.
I also have dark circles the size of saucers and look perpetually worn and tired.
Forget talking to a GP about adrenals. Unless you're certified Addisons and arrive at the appointment in a coffin on a horse-drawn hearse, they don't care. They'll think you're really bonkers if you mention it. Adrenal fatigue doesn't exist. They might listen to an endo though for a Synacthen Test or if you fail the rubbish blood cortisol test they provide.
No vitamins or minerals! God it's awful! Honestly, even if they do them, its mostly for your own scrutiny that it matters. My vit D was below range, my ferritin was none existent and I was told no big deal, during covid nonetheless!
I would LOVE and ENJOY being their only Endo too. Well your tsh is in range, so nothing prescribed. No buts, shhhhh, you are fine. Oh I see your tsh is 500. Here is 25mcg of Levo. Come back to see me in 20 years. It's all in your head mr or mrs patient. I see your T3 is zero, but that is useless.
Looks like PYA to me..( protect your arse). .if they ca make a case for doing nothing , might it protect them from. Malpractice claims . I am a cynic and suspect that " the love of money is the root cause of all evil " Oh dear you don't want to be in my head .
Well, over a year ago my GP said that my thyroid wouldn't support me for the next twelve months! If the surgery do send me for a test soon, I hope that I'm not diagnosed with anything that requires treatment, but they probably won't think of it unless I bother them. I do have new symptoms, but whether they are thyroid-related, I don't know.
So I'm a bit scared now after reading this ,does it mean that levythyroxine isn't good for you ,I take 100mg a day and I'm 44 am I at increased risk of bone loss and other problems, x
I posted because I thought a lot of it was very poor. Not because I thought anyone should follow what they say.
It is true that excess thyroid hormone - which we most often see in people who are hyperthyroid through Graves - seems to cause bone loss and other issues.
But achieving an appropriate level of thyroid hormones is essential to maintain bone health.
I take about 125 micrograms a day. And I don't intend to stop.
We have a number of members who found their bone density improved significantly by proper thyroid hormone treatment.
Too many medics emphasise the theoretical issues of excess and fail to have any appreciation of the issues actually being caused by failing to treat, or under-treating.
My response to this would have me barred from the forum. So I'll just say Arti Bhan: go and play on the M25 to prevent us from reading any more of your smug, endocentric claptrap.
Doubtless, the brain-dead Dr Buffoon, my GP, will have read the ink off this and next time I go to 'consult' him will let me know with his usual sneer, 'You're too old to be on levo' The fact I haven't taken it for 8 years and haven't had it prescribed for 6 continues to pass him by.
Oh dear. What a pity. Never mind. Forge on, fam 😘 They shall not have us. And BTW, this simply reinforced my belief that misogyny is afoot, in the management of thyroid disease. Can you imagine medics questioning non-compliance with men taking Viagra? Thought not.
Approximately 1 in 8 women will be affected by a thyroid condition at some point in their lives. The risk for women is about 10 times higher than for men.
The thing is, EMBoy when men approach their GPs my gut tells me they are less likely to put up with, 'It's your age' 'It's the menopause' 'Have some ADs' 'Eat less and move about more' 'It's all in your head' 'You're in range.'
Furthermore, I doubt that GPs hand out this nonsense to men.
Well I don't know whether to duck, but I do see some of it as trying to note that nodules do not always mean something needs to be done, beyond scanning and possible biopsies.
At times patients can become overwhelmed & think something has to be done beyond monitoring.
I had to have a total thyroidectomy because two of my nodules became too large and that and their positioning impacted breathing, voice and swallowing.
But if it did not go that way, I would have been completely content with monitoring and fine needle aspiration, when needed. Here they have a very specific schedule on when that is necessary & when that isn't. It is written in a point system for each module in terms on consistency, irregularity and size. But I know patients get nervous and push at those recommendations.
Surgery, life after surgery & fine needle aspiration/biopsies are not without their risks.
And in talking to a couple of doctors a lot of patients become nervous and push for surgery, push for scans & biopsies on all of their nodules(mine were on two of six).
I was also told that at the minimum 60% will have thyroid nodules in their lifetime, and sometimes they do not impact quality of life.
There is always a flip side,.of course. Our new mayor here chose the same as me - monitoring - all her biopsies clear. It was her doctor from the start wanted surgery. She said no and carried on with monitoring and life.
And then for whatever reason chose surgery later, despite continual clear biopsies.
She had it.
Pathology - cancer.
(And her endocrinologist put her on Cytomel only for the first year, which I found interesting.)
So such a fine balance all around, with some aspects. Obviously it leans more to problems with our care - a given. But I don't think the paper was all cuckoo for cocoa pops.
Happy to note my new endocrinologist listens, debates with me but still listens and actually asks me How would you like to go forward? I hope he does not get in trouble. And 'I don't think it is apathy but boy am I thankful. Now I just have to figure out how to afford the sudden options.
There appears to be an assumption that the prescribing of levothyroxine is inappropriate based on numbers. But there are many grounds for questioning how well historical incidence can guide the present and future.
The downer on ultrasounds might appear to make some sense. But some benefits of ultrasounds seem to be missing.
That an ultrasound can give a reasonable confirmation both of Hashimoto's/autoimmune thyroid disease and around how far it has progressed.
That easy and ready access to ultrasounds might actually encourage many patients to be happier with waiting and watching. If they feel something has changed, they should be able to speedily get another. Not feel they must leave arbitrary and long gaps.
The downer on ultrasounds might appear to make some sense. But some benefits of ultrasounds seem to be missing.
I had one of these at my own cost for less than a ton in Canary Wharf ( granted, 12 years ago...) which showed a wizened blob. This confirmed my self diagnosed autoimmune thyroid disease. Dr Buffoon had refused me an ultrasound. I told him about the results and had a moment of glorious control when he asked for a copy and I declined. 😈
I'd just like to make these specialists aware of what undertreated thyroid has done to my mental and physical health . All because the focus is on TSH . Also the lack of knowledge amongst endocrinologist and GPs of what can affect thyroid assays.
Content on HealthUnlocked does not replace the relationship between you and doctors or other healthcare professionals nor the advice you receive from them.
Never delay seeking advice or dialling emergency services because of something that you have read on HealthUnlocked.
PhD in Thyroid Disorders 
is identification of thyroid disorders good enough?
Updated diagnosis of autoimmune thyroid disorder 
