AUCTORES
Globalize your Research
Case report | DOI: https://doi.org/10.31579/2640-1045/177
Family Physician & Public Health Consultant, Bengaluru.
*Corresponding Author: Suresh Kishanrao, MD, DIH, DF, FIAP, FIPHA, FISCD, Family Physician & Public Health Consultant, Bengaluru.
Citation: Suresh Kishanrao, (2024), Subclinical Hypothyroidism in Adults- to Treat or Not? J. Endocrinology and Disorders, 8(2): DOI:10.31579/2640-1045/177
Copyright: © 2024, Suresh Kishanrao. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 18 March 2024 | Accepted: 28 March 2024 | Published: 08 April 2024
Keywords: euthyroid; subclinical hypothyroidism (scht); overt hypothyroidism; iodine intake; normative ranges; prevalence; autoimmunity; levothyroxine; population screening tests
Background: Subclinical hypothyroidism (ScHt) is a condition in which the Laboratory reports show normal T3 or FT3, normal T4 or FT4, and increased TSH concentrations, associated with few or no signs & symptoms of hypothyroidism. ScHt prevalence is estimated to be ranging from 4% to 20% of adults, with a higher prevalence in women, older people, and those with thyroid autoimmunity. It is higher in iodine-sufficient areas and genetics also plays a role.
ScHt can progress to overt hypothyroidism, especially if antithyroid antibodies are present. It has been associated with adverse metabolic parameters like dyslipidaemia, reproductive, maternal-foetal, cardiovascular, neuromuscular, and cognitive abnormalities. ScHt among pregnant women is significant as the prevalence of overt & ScHt among them is reported to be 2.5 % and almost fourfold (9.54%) respectively. The good news is that half of the cases resolve spontaneously in within 2 years.
Methods & Materials: This article is an outcome of literature review following the author and his son’s annual blood test results showing indications of ScHt in late February 2024.
Results: The results of annual blood tests in a recognised laboratory showed TSH levels of 6.233 and 7.529 respectively for the author and his son respectively. The authors Hb1Ac were 6.4 despite being just on oral anti-diabetics (with diet control and exercise routine) since 1991, indicative of a good management. It was surprising to note that both have ScHt. However, after an intensive literature search and discussions decided for “a wait and watch strategy” instead for jumping for treatment.
Conclusion: In India 4% to 20% of adults have subclinical hypothyroidism, with a higher prevalence in women, older people, and those with thyroid autoimmunity. Though ScHt can progress to overt hypothyroidism, especially if antithyroid antibodies are present, half of the cases are expected resolve spontaneously in within 2 years. As most endocrinologists, Cardiologists and Public health professionals in India do not recommend treatment for 1-2 year unless either i) when TSH >10 mIU/L, or signs become explicit, or ii) Cardiovascular risk individuals, we have decided to monitor the progress for entire 2024 with quarterly assessments of the parameters.
SAMA= Serum antimicrosomal antibodies, S. anti-TPO= anti-thyroid peroxidase autoantibody, GOI= Government of India, TSH= Thyroid Stimulating Hormone, T3=Triiodothyronine, T4= Thyroxine, CABG= Coronary artery bypass grafting, NFHS=National Family Health Survey,
The prevalence of self-reported goitre or thyroid disorder in National Family Health Survey was 2.7 % for women and 0.5 % for men in NFHS-V report (2019-2021) in 15-49 years age group in India as compared to 2.2% in NFHS IV report (2015-2016)] was among women and 0.5 % among men in the age group of 15-49 years. The data indicates an increase in women by about 22.7% and stationary at 0.5% among men over 5 years [1]. The community based serological data is lacking in the country. However, various clinical and epidemiological studies conducted across India have shown a prevalence rate varying between 6% and 15%.
Subclinical Hypothyroidism (ScHt)’s is based on biochemical profile as of now! Subclinical hypothyroidism is defined as normal T3 or FT3, normal T4 or FT4, and increased TSH concentrations, associated with few or no signs & symptoms of hypothyroidism. Its incidence increases with advanced age, female gender, and greater dietary iodine intake and in individuals with metabolic syndrome, thyroid impairment is frequent. National guidelines use goitre as the key sign for self or community-based reporting, most of the ScHt patients do not have goitre (stage 0- 60%) or stage 1 goitre (21%), rest of 19% having Gr I to Gr iii goitre, whereas, among biochemically euthyroid subjects 9% stage I or II goitre [2,6].
ScHt is estimated to affects 3–15% of the adult population in India [3,4]. Mean S.TSH in our population is 2.22 μlu/mL (euthyroid outliers: 0.3–4.6 μlu/mL); therefore, S.TSH levels above 4.6 μlu/mL is considered abnormal [4,13,14]. The prevalence of thyroid autoimmunity increases after age of 35 years. ScHt presents mainly in agoitrous form and with positive antibodies, due to autoimmunity [5]. Serum thyroid autoantibody titres {antimicrosomal antibodies [S.AMA]}, and anti-thyroid peroxidase autoantibody [S. anti-TPO]) are used to diagnose the subclinical cases. ScHt can progress to overt hypothyroidism, especially if antithyroid antibodies are present, and has been associated with adverse metabolic parameters like dyslipidaemia (7,8) reproductive, maternal-foetal [6,7], cardiovascular [9], neuromuscular, and cognitive abnormalities [8]. ScHt among pregnant women is significant as the prevalence of overt & ScHt among them is reported to be 2.5 % and almost fourfold (9.54%) respectively [6].
As ScHt is recognized only in laboratory tests, no one seeks care, and often goes away on its own with time. Most endocrinologist, Cardiologists and Public health professionals in India do not recommend treatment for 1 year unless either i) when TSH >10 mIU/L, or signs become explicit, or ii) Cardiovascular risk individuals. Current thinking is to treat it with levothyroxine if it persists after repeated laboratory examination. In older adults with subclinical hypothyroidism, the mildly raised TSH levels may become normal in at least half of the cases within 1-2 years, according to a study published recently [10]. In milder ScHt cases, a wait-and-watch strategy is advocated [12,13,14].
Therefore, it is time debate and decide when to treat ScHt.
This article as an outcome literature review after the authors and his son’s February 2024 annual blood test indicated S.TSH levels above 4.6 μlu/mL and Free T3 & T4 being normal.
Case Reports: In routine annual check of my entire family went through and comprehensive annual checkup on 24 February I was surprised to see some parameters abnormal and most striking among them was an indication of Subclinical Hypothyroidism in myself and my sons Parameters. Both of us have familial Minor Thalassemia.
Self: I am diabetic since 1991 relatively well managed keeping Hb1Ac around 6.5 since last 2 years after it had reached over 7.5 in 2021. While this time in February 2024 my Hb1Ac is 6.6 and FBS 147. Having undergone CABG operation in June 2005 and a Post CABG Angio in February 2023, I had opted for strict diet management including intermittent fasting and increasing fruit consumption to the extent that My breakfast has been 0.5 kg of papaya fruit daily. All other parameters were in acceptable range except TSH which was 6.233 as against a range of 0.55-4.78 and T3 was 10.7, T4 6.5 and TSH 6.2333 uIU/ml. Surprised I checked my 2023 report 17 February 2023 which showed Triglycerides as 3.8 uIU/ml and T3 T 4 also in normal range. In my case 162% increase in TSH level over a year is concerning
On the other hand, my son aged 36-years has no clinical symptoms or signs of any metabolic disorder also showed a raised TSH 7.529 uIU/ml, with normal T3 -1.48 ng/mL, T4- 7.529uIU/ml. All other parameters were normal. His previous report of 26 May 2022 also had shown T4= 1.76 ng/mL, T4= 10.98 µg/dl and TSH= 6.433 uIU/ml. In May I had missed his reporting to ScHt, which continued to increase to a TSH of 7.529, fortunately still not signalling the need for the treatment. His TSH went up by 117% over 1 year and 9 months.
My wife’s report has dyslipidaemia indication, but her Thyroid functions are normal.
However, this suspicion of ScHt in two of the three led me to do the literature review about when to start treating the condition and the subject of this article for alerting everyone!
Table 1: Comparative Statements of Key Lab Findings with immediate previous Reports
The thyroid gland is one of the largest and ductless glands of the endocrine glands, situated in the front portion of the neck and resembles the shape of a butterfly. This gland is responsible for the production of two main thyroid hormones called T3 (Triiodothyronine) and T4 (Thyroxine). The thyroid hormones are mainly involved in the regulation of many functions and aspects of the human body, such as regulation of i) Bone density ii) Body weight iii) Energy levels iv) Body temperature v) Growth of hair and nails. Hyperthyroidism, is a hormonal disorder caused by the excessive production of T3 and T4 hormones from the thyroid gland, caused by an auto-immune disorder and females are at higher risks compared to males. Complications related to excessive production of thyroid hormones are excessive hair fall, less or frequent periods, infertility, osteoporosis, brittle bones, weakness, etc. On the other hand, the enlargement of the thyroid gland irrespective of its pathology is called goitre. This is more common in females than males, especially after the age of 40 years, i.e., after menopause. Our thyroid needs iodine to produce thyroid hormone. If we don't get enough iodine in our diet, our thyroid makes grows and to try to make more thyroid hormone, a most common cause of goitre, The goitre is the most frequent clinical manifestation of the nutritional deficiency of iodine. If present in more than 5% of the general population or more than 10% of the children in school of a defined geographic area, goitre is defined endemic. Over time, the thyroid gland may stop making enough thyroid hormone and resulting in hypothyroidism.
Subclinical Hypothyroidism (ScHt)’s is based on biochemical profile. ScHt is defined as normal T3 or FT3, normal T4 or FT4, and increased TSH concentrations, associated with few or no signs & symptoms of hypothyroidism [2,3,4].
The natural course of ScHt Subclinical” suggests that the disease is in its early stage, with changes in TSH apparent but decreases in thyroid hormone levels not explicit. Subclinical hypothyroidism can progress to overt hypothyroidism, although it has been reported to resolve spontaneously in half of cases within 2 years in patients with TSH values of 4 to 6 mIU/L. The rate of progression to overt hypothyroidism is estimated to be 33% to 55% over 10 to 20 years of follow-up. The risk of progression to clinical disease is higher in patients with thyroid peroxidase antibody, reported as 4.3% per year compared with 2.6% per year in those without this antibody. In one study, the risk of developing overt hypothyroidism in those with subclinical hypothyroidism increased from 1% to 4% with doubling of the TSH. Other risk factors for progression to hypothyroidism include female sex, older age, goitre, neck irradiation or radioactive iodine exposure, and high iodine intake [14].
Prevalence of thyroid disorders at the community level among adult people in India, was studied using Random cluster sampling strategy in Cochin Kerala in 2013 on 971 adult subjects’ The results showed a prevalence of hypothyroidism was 3.9%.[3]. The prevalence of subclinical hypothyroidism was also high in this study, the value being 9.4%. In women, the prevalence was 11.4%, when compared with 6.2% in men. The prevalence of subclinical hypothyroidism increased with age. About 53% of subjects with subclinical hypothyroidism were positive for anti-TPO antibodies. In this study, Urinary Iodine Status was studied in 954 subjects from the same population sampled, and the median value was 211 μg/l; this suggested that this population was iodine sufficient [3].
The study also analysed the symptoms of Thyroid disorders as shown in the graph by the side. As of now I occasionally feel my voice becoming hoarse if I talk loudly and excessive sweating. My son has absolutely none of these symptoms. On the contrary we both excessive hair growth over head and all parts of the body
The term "metabolic syndrome" refers to a group of disorders that include weight gain, hypertension, an abnormal lipid profile with high triglyceride (TG) levels and low levels of high-density lipoproteins (HDLs), and higher fasting blood sugar (FBS) levels [7]. The incidence increased globally from 1.1% in 1980 to 3.85% in 2015 over the past three decades, contributing to high body mass index (BMI) related mortality rates (cause specific) increase by 28.3
From 4% to 20% of adults have subclinical hypothyroidism, with a higher prevalence in women, older people, and those with thyroid autoimmunity.
It is higher in iodine-sufficient areas, and it increases in iodine-deficient areas with iodine supplementation.
Genetics also plays a role, as subclinical hypothyroidism.
A difficulty in estimating the prevalence is the disagreement about the cutoff for TSH, which may differ from that in the general population in certain subgroups such as adolescents, the elderly, and pregnant women.
Subclinical hypothyroidism can progress to overt hypothyroidism, especially if antithyroid antibodies are present, and has been associated with adverse metabolic, cardiovascular, reproductive, maternal-foetal, neuromuscular, and cognitive abnormalities.
Further trials are needed to clearly demonstrate the clinical impact of subclinical hypothyroidism and the effect of levothyroxine therapy.
Due to apparently asymptomatic nature of the illness, the “American Thyroid Association” (ATA) has recommended routine population screening of both sexes at age 35 years and then every 5 years thereafter for early detection and treatment of ScHt.
National and State Health Departments must collate the Laboratory data (Private and Public sector) Lipid and Thyroid parameters across the country and assess current situation.
For future the author recommends, that GOI and States to take up population-based studies at least in known Goitre endemic districts of the country to start with.
Making the screening facility available in all public Sector facilities across in India urgently.
Until such time individuals over 35 years must get routine screening done and treat if needed
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
