Treat based on symptoms or test results?

DEAR DR. ROACH » I am 57 and just starting menopause. I was on birth-control pills for 40 years. I currently take no medications. My TSH level is slightly elevated (5.50) under the new standards. T3 and T4 are both normal. My doctor wants to put me on thyroid medication. He asked me about all the symptoms, and I have none except for the high readings. Nothing I look at discusses having high levels with no symptoms. These articles only discuss having symptoms with normal levels. I feel great and don’t want to go on medication for the rest of my life when I have zero symptoms. Am I wrong? — V.E.

DEAR READER » This is quite a common issue, especially when physicians order thyroid tests in people with no symptoms. TSH is a hormone made in the pituitary gland, which “tells” the thyroid gland to make more thyroid hormone (T4), which is then converted into active hormone (T3). In your case, the TSH is high, but the thyroid is making normal amounts of hormone. There are two schools of thought about whether to treat a case like yours.

The first is yours: Since you have no symptoms, there is no good reason to treat you. Taking thyroid medication every day isn’t terribly expensive, but there are costs for the medicine and for monitoring thyroid levels. It’s possible (but not likely) to give more thyroid hormone than necessary, increasing the risk of heart problems (especially abnormal heart rhythms).

The second view is that you may have symptoms that are subtle, which you would notice only if they went away with thyroid hormone replacement: Some people report improved energy levels or mood. In your case, the presence of thyroid antibodies suggests that you have a mild form of Hashimoto’s thyroiditis, which means your risk of developing overt hypothyroidism is increased (one study estimated that about 4 percent of women per year will develop low T3 and T4 levels (the actual thyroid hormones) and symptoms.

Most experts and societies recommend against treating people in your situation, which is my clinical practice as well. Instead, I recommend that my patients repeat a TSH level in six months and then every year, and I treat if they develop symptoms or if their TSH level goes above 10 (at which point, symptoms become very likely). Of course, your desires are important, too: Since you don’t want to go on treatment, I would respect that and continue to monitor you.