Thyroid Disease: One Size Does Not Fit All

one size doesn't fit all
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Thyroid disease is a term used to describe a broad range of thyroid-related disorders, each with their own characteristics, causes, treatments, and outcomes. As with many other types of disease, there is no "one-size-fits-all" solution for a disorder largely characterized by uncertainty. 

Hyperthyroidism, also known as an overactive thyroid, can sometimes manifest with few symptoms or be so severe as to trigger life-threatening thyroid storm. By contrast, hypothyroidism, an underactive thyroid, may be a mild annoyance for some and a debilitating, life-changing disease for others.

Similarly, a small encapsulated, papillary thyroid cancer may be relatively easy to treat, while an anaplastic thyroid cancer has a median life expectancy of as little as four months.

While none of these facts are surprising to anyone living with a chronic disease, thyroid disease is unique in that there is an extreme variability in how it is diagnosed and treated. 

Improving Diagnosis of Thyroid Disease

One of the first areas where one size definitely does not fit all is with the diagnosis of thyroid disease. Current guidelines are simply far too reliant on utilizing thyroid stimulating hormone (TSH) levels as a means to diagnose an overactive or underactive thyroid. 

Conventional wisdom dictates that a TSH above 5.0 is considered subclinical hypothyroidism not warranting treatment, while a TSH above 10.0 constitutes overt hypothyroidism warranting treatment. Given that some persons can experience symptoms of thyroid disease at TSH levels below 0.5, it brings into question whether the decision to treat should be driven by numbers of symptoms.

It is why many other disease guidelines, including those for chronic obstructive pulmonary disorder (COPD), have begun to direct treatment based on both the patient's symptoms and a self-assessment of how "bad" or "good" the person believes the symptoms to be.

By contrast, in the field of endocrinology, the diagnosis of thyroid disease has been the subject of debate for more than a decade with an extreme variability among treaters in how the disease is diagnosed.

In order to offer a more informed diagnostic, many endocrinologists have taken a more integrative approach when evaluating a person believe affected by thyroid disease. For example:

  • Some physicians rely on a broader TSH reference range to make a diagnosis.
  • Thyroid ultrasounds are routinely used in some practices to look for goiters, nodules, and other anomalies that a TSH cannot detect.
  • Others doctors have become more proactive in investigating the underlying causes of thyroid disease, running antibodies tests to exclude or confirm Hashimoto's disease and Graves' disease (both of which can cause symptoms before effecting changes in thyroid hormones).
  • Others still have taken the position of treating things like euthyroid Hashimoto's disease (during which the thyroid gland is still functioning) with the aim of avoiding the development of overt hypothyroidism.

Improving Thyroid Treatment Approaches

As with diagnosis of thyroid disease, the treatment of a disorder should never to cookie-cutter but, sadly, often is. 

For example, persons diagnosed with Graves' disease and hyperthyroidism, endocrinologists will often rush to radioactive iodine (RAI) ablation in first-line treatment to "hit it hard and fast" when a more conservative approach could be just as effective and far less harmful.

Informed practitioners, by contrast, will consider the severity of the disease, the symptoms, and the patient's history to individualize the treatment plan. In many cases, antithyroid drugs like Tapazole (methimazole) can offer temporary or even permanent remission from Grave's disease without RAI, surgery, or the risk of hypothyroidism. 

The same applies to thyroid cancer. A typical course might include the complete surgical thyroidectomy, followed by RAI and high-dose thyroid hormone replacement therapy. But is this always necessary? Today, some practitioners are taking a more wait-and-see approach to treatment depending on the nature and extent of the malignancy.

Nowhere is the one-size-fits-all approach more evident than in treatment of hypothyroidism. Today, the standard guideline dictates the use of levothyroxine (synthetic T4 hormone) to restore a patient to the "normal" reference range.

While the drug on its own could very well be tolerable and effective in certain individuals, the cookie-cutter approach overlooks an ever-widening range of treatment options, including:

  • Tirosint, a newer hypoallergenic form of levothyroxine which is better absorbed than tablets
  • Cytomel (synthetic T3 hormone)
  • Natural desiccated thyroid drugs
  • Levothyroxine in combination with Cytomel
  • Levothyroxine in combination with a natural desiccated thyroid 
  • A custom compounded formulation incorporating any of the above-listed drugs

These don't include the complementary treatments and dietary changes that can help alleviate symptoms and improve the overall physiological state of the affected individual.

A Word From Verywell

As scientists gain greater insights into the mechanisms of thyroid disease in all of its form, greater emphasis is being placed on taking an individualized approach to diagnosis and treatment. It requires doctors to take the person into account as well as the pathology. 

To this end, if you have (or believe yourself to have) thyroid disease, take the time to educate yourself and become an advocate for your own care. When selecting a doctor, take the time to ask as many questions as you can to understand the options available to you. If the doctor is unable to address your concerns, meet with others physicians or seek a second opinion.

By doing so, you can make informed choices and be better ensured of optimal treatment.