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Sara Ahmadi, MD, ECNU
Brigham and Women’s Hospital
Boston, MA
November 19, 2021

Thyroid nodules and thyroid cancer are common clinical problems in adults. The yearly incidence of thyroid cancer in the United States has almost tripled from 4.9 per 100,000 in 1975 to 14.3 per 100,000 in 2009. It has been predicted that thyroid cancer will replace colorectal cancer as the fourth leading cancer diagnosis by 2030(1,2).

Surgery is the primary treatment for thyroid cancer. Most patients with differentiated thyroid cancer have an excellent outcome with a 98% long-term disease-specific survival.

Traditional therapy with total thyroidectomy and radioactive iodine(RAI) has not shown added benefit in patients with low-risk differentiated thyroid cancer and might result in more harm. Thyroid lobectomy, selective use of radioactive iodine, and active surveillance have gained attention in recent years. They have been recommended as potential management options for low-risk thyroid cancer and micropapillary thyroid cancer in the current American Thyroid Association guidelines(2). This has led to significant changes in clinical practice. A study of 35,291 patients using National Surgery Quality Improvement Program Data showed that there has been a 10-fold increase in the rate of thyroid lobectomy rather than total thyroidectomy after the publication of 2015 ATA guidelines(3).

However, many patients with differentiated thyroid cancer may overestimate the mortality implications, which may drive their willingness to undergo more aggressive treatment(4).

The Discrete Choice Survey Study of a cohort of 150 patients with newly diagnosed differentiated thyroid cancer or thyroid nodule requiring surgery showed that risk of thyroid cancer recurrence impacted patient’s preference around surgical treatment options the most, followed by risk of requiring completion thyroidectomy and recurrent laryngeal nerve injury. The risk of hypocalcemia and hypothyroidism had the least impact on patients’ preferences around treatment options. This study also showed that the average patient would prefer total thyroidectomy unless the risk of requiring completion thyroidectomy can be reduced to 30% or less(5).

Patients’ concern and worry can also limit their acceptability of less aggressive treatment options. A survey of 243 patients with papillary thyroid cancer enrolled in an active surveillance program showed cancer worry is common among these patients. However, the patient’s level of concern improves over time(6).

Patient-physician communication also plays an essential role in providing the patient with a good understanding of the risks and benefits of different treatment options and an informed decision-making process. Computerized patient decision aids in addition to usual care can be associated with a significant increase in patients’ medical knowledge around treatment options and a reduction in decisional conflict at the time of decision making(7). In a recent study, 1319 patients with thyroid cancer in whom selective use of radioactive iodine was recommended were surveyed to assess patient perspectives regarding RAI decision making. More than half of the patients perceived they did not have a choice regarding RAI. These patients were also more likely to receive RAI and to have lower decision satisfaction(8).

There has been a significant change in clinical practice since the publication of the 2015 ATA guidelines. It is of vital importance that we improve our understanding of patients’ preferences, ensure excellent patient-physician communication, and use educational decision aids in conjunction with physician counseling to facilitate shared-decision making.

References:
1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer research. 2014;74(11):2913-2921.
2. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid : official journal of the American Thyroid Association. 2016;26(1):1-133.
3. Ullmann TM, Gray KD, Stefanova D, et al. The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer. Surgery. 2019.
4. Dixon PR, Tomlinson G, Pasternak JD, et al. The Role of Disease Label in Patient Perceptions and Treatment Decisions in the Setting of Low-Risk Malignant Neoplasms. JAMA Oncol. 2019.
5. Ahmadi S, Gonzalez JM, Talbott M, et al. Patient Preferences Around Extent of Surgery in Low-Risk Thyroid Cancer: A Discrete Choice Experiment. Thyroid : official journal of the American Thyroid Association. 2020;30(7):1044-1052.
6. Davies L, Roman BR, Fukushima M, Ito Y, Miyauchi A. Patient Experience of Thyroid Cancer Active Surveillance in Japan. JAMA Otolaryngol Head Neck Surg. 2019;145(4):363-370.
7. Sawka AM, Straus S, Rodin G, et al. Thyroid cancer patient perceptions of radioactive iodine treatment choice: Follow-up from a decision-aid randomized trial. Cancer. 2015;121(20):3717-3726.
8. Wallner LP, Reyes-Gastelum D, Hamilton AS, Ward KC, Hawley ST, Haymart MR. Patient-Perceived Lack of Choice in Receipt of Radioactive Iodine for Treatment of Differentiated Thyroid Cancer. J Clin Oncol. 2019;37(24):2152-2161.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Ulla Feldt-Rasmussen, MD, DMSc
University of Copenhagen
Copenhagen, Denmark

October 18, 2021

Endocrine disruptors are chemical pollutants in the environment that can affect the action of endocrine glands, including the thyroid gland. Some are suspected to influence thyroid function negatively, while a direct causative relationship may not have been scientifically verified. This is especially the case with triclosan, a polychloro phenoxy phenol with hormonal disrupting properties and widespread use in toothpaste and cosmetic and household products.

To appreciate that an influence from triclosan can be detrimental to human health, it is important to understand the significance of intact thyroid function, and how triclosan may impair it. The thyroid gland produces primarily thyroxine (T4), which is paramount for metabolism in every single cell and organ by conversion to the metabolically active triiodothyronine (T3). T4 is thus essential for maintenance of optimal organ function, including the brain, heart, bones, and muscles, and it is vital to fetal neurological and cognitive development.

Triclosan is structurally similar to T4, and it is therefore possible that it can interfere with the function of T4 at one or more sites of the thyroid function pathways. Triclosan may potentially result in hypothyroidism in the person who has been directly exposed to it, but it can also potentially indirectly compromise neurodevelopment through placental transfer to the fetus.

So, why is triclosan problematic for human health? Triclosan is a broad spectrum antimicrobial used as an antiseptic, disinfectant or preservative in clinical settings and various consumer products including cosmetics, household cleaning products, plastic materials, toys, paints, etc. It was detected in the urine of 97% of young Danish men in 2013, with a decreasing tendency over 8 years, consistent with Denmark’s restriction of the use of triclosan before the official recommendations. Results from The National Health and Nutrition Examination Survey (NHANES) of a nationally annual representative sample of about 5,000 persons from different places within the USA also demonstrated declined concentrations of triclosan, but the NHANESIII 2019 study measured concentrations three to ten times higher in young Americans compared to young Danes.

Both the FDA and the EU introduced regulations with triclosan limits up to 0.3% due to suspicion of skin reactions, cancer development and hormonal disruption in both humans and animals, but it is unknown if these regulations suffice as thyroid protection. It is also unknown if people living in relative iodine deficient areas and people, mainly women, with a low thyroid reserve such as thyroid autoimmunity are more prone to the negative influence on thyroid function.

It is largely unknown if the rest of the world complies with the levels in FDA and EU regulations, but in China and Vietnam for example, triclosan is measured at very high levels in household dust. This is possibly due to slow leakage from its incorporation onto surfaces of medical devices, plastic materials, textiles, kitchen utensils, etc., intended for a long period of biocidal effect in these household products.

The global threat from triclosan as a thyroid disrupter is therefore not solved. As a traveler or online shopper importing potentially affected products, it is therefore important to bear this in mind. It remains necessary to explore the effects of triclosan in human thyroid health in more detail by both clinical and basic research.

References:
1. https://www.thyroid.org/patient-thyroid-information/ct-for-patients/march-2020/vol-13-issue-3-p-11-12/
2. https://ec.europa.eu/health/scientific_committees/opinions_layman/triclosan/en/l-3/2-uses-cosmetics-disinfectant.htm

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Liuska M. Pesce, MD
University of Iowa Stead Family Children’s Hospital
Iowa City, IA
April 16, 2021

I was reviewing the normal growth charts of a very smart 14-year-old patient with congenital hypothyroidism, whom I had followed since birth, when I heard the question:
-Doctor, what would have happened to me if I did not receive treatment?

How should I explain this to a 14- year-old? I decided to use pictures which showed severe short stature, coarse features, large tongue, coarse skin, swelling of the face and dull facies. These were historical pictures of a diagnostic term that is no longer widely used: cretinism, defined as intellectual disability and physical abnormalities caused by congenital thyroid hormone deficiency. I also reflected on how many of us have forgotten about cretinism, a frequent condition of the past, secondary to the delayed diagnosis and treatment of congenital hypothyroidism (1).

In 1950, in the book The Diagnosis and Treatment of Endocrine Disorders in Childhood and Adolescence, Dr. Lawson Wilkins wrote: “In the very young cretin, the diagnosis sometimes cannot be made with certainty because sufficient time has not elapsed for the deviation below the normal level of development to become obvious.” This meant that diagnosis and treatment was universally delayed until 2-3 months of age or longer (1,2).

Congenital hypothyroidism is defined as insufficient thyroid hormone production or action present at birth. It encompasses central or primary hypothyroidism as well as impaired thyroid hormone action. Greater understanding of congenital hypothyroidism has led to prevention, early diagnosis, timely treatment, and adequate counseling. However, we still need to optimize early diagnosis, treatment and follow up. This year, a 2020-2021 consensus guideline update was published as part of an ENDO-European Reference Network (ERN) initiative, which still emphasized the importance of newborn screening for congenital hypothyroidism for all children (3).

Newborn screening for congenital hypothyroidism (first published in 1973), obtained by heel stick, has almost eliminated the profound negative effects of thyroid hormone deficiency in growth and development (cretinism) in the countries where it is available. However, 70% of babies worldwide are born in areas without access to newborn screening. Even in the countries where newborn screening is available, it is not universally recognized that the screening methods have limitations. Some newborns may have false negative results (pre-term, low weight, and sick babies), and clinical judgement is still critical to suspect congenital hypothyroidism even if the newborn screening is normal (1,3,4,5).

Treatment should never be delayed, and close follow up by a specialist is recommended to prevent under-treatment and over-treatment, both of which have deleterious effects. Coordination between primary care providers and specialists is fundamental, and a well-planned transition to adult care is essential to prevent morbidity, poor educational and social outcomes and, in women, to improve fertility, pregnancy and newborn outcomes (3).

Most importantly, we need to continue to advocate for equity for all the children around the world, so we can completely eradicate preventable intellectual disability. Guidelines that offer best practices based on the most up-to-date scientific data can’t be followed if the necessary resources are not available.

As I end this reflection, I realize that I am lucky to search for historical pictures to explain untreated congenital hypothyroidism. However, I wonder how many children with congenital hypothyroidism around the world are asking:

– Doctor, why was I treated late?
Or … not asking any questions at all.

References:
1. Salisbury S. Cretinism: The past, present and future of diagnosis and cure. Paediatr Child Health 2003;8(2):105-6. DOI: 10.1093/pch/8.2.105.
2. Wilkins L. The diagnosis and treatment of endocrine disorders in childhood and adolescence. 1st ed. Springfield, Ill.,: Thomas, 1950.
3. van Trotsenburg P, Stoupa A, Leger J, et al. Congenital Hypothyroidism: A 2020-2021 Consensus Guidelines Update-An ENDO-European Reference Network Initiative Endorsed by the European Society for Pediatric Endocrinology and the European Society for Endocrinology. Thyroid 2021;31(3):387-419. DOI: 10.1089/thy.2020.0333.
4. American Academy of P, Rose SR, Section on E, et al. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics 2006;117(6):2290-303. DOI: 10.1542/peds.2006-0915.
5. Leger J, Olivieri A, Donaldson M, et al. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. Horm Res Paediatr 2014;81(2):80-103. DOI: 10.1159/000358198.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

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Matthew Ettleson, MD
University of Chicago Medicine
Chicago, IL
March 16, 2021

The illustrative example of proptosis may be one of the more memorable images in the medical school textbook, but often the more subtle signs and symptoms of thyroid eye disease (also known as Graves’ orbitopathy or ophthalmopathy) can be overlooked. While severe thyroid eye disease is uncommon, up to 40% of patients with Graves’ disease have some signs or symptoms of thyroid eye disease (1). Most patients with mild eye disease have stable symptoms, but those that develop moderate-to-severe disease may benefit from more aggressive therapies, including glucocorticoids and anti-insulin-like growth factor-1 receptor (IGF-1R) therapy.

The diagnosis of thyroid eye disease relies on a focused history and exam of the eyes. Patients may complain of dry eyes or grittiness, excessive tearing, pain with eye movements and blurry or double vision. Patients may present classically with proptosis and lid retraction, but also redness and swelling of the eye lids or conjunctiva may be present. If several of these findings are present, it suggests the patient has active eye disease and thus may be more responsive to medical therapy. Any concern for visual impairment should prompt urgent evaluation by an endocrinologist and ophthalmologist for a more detailed assessment.

What are first steps to take once the diagnosis of thyroid eye disease is made? The patient’s thyroid function should be assessed and, if abnormal, should be treated promptly. Both hyperthyroid and hypothyroid states can contribute to worsening eye disease. For a patient with newly diagnosed Graves’ disease, this usually begins with antithyroid medication followed by more definite therapy, as discussed in the prior blog post by Dr. Oltmann. It is important to note that radioactive iodine (RAI) therapy has been associated with worsening of thyroid eye disease. Thus, RAI therapy should not be given to those with moderate-to-severe eye disease (2). Cigarette smoking has also been associated with progression of eye disease. For some patients, recognizing that smoking leads to worsening eye symptoms may help convince them it’s finally time to quit!

For patients with mild eye disease, local symptom management is key. Treatment strategies include artificial tears, cool compresses, humidifiers, and sunglasses for protection on excessively sunny or windy days. In over 50% of patients with mild eye disease at the time of diagnosis of Graves’ disease, symptoms will resolve over the following 1-2 years (3).

For those with active, moderate-to-severe disease, a course of pulse doses of IV methylprednisolone is first-line therapy, and can be safely done in the clinic. Often, patients will show improvement within the first 4 weeks of treatment, and most will have a good response after 6 months of therapy. Rarely, long-term glucocorticoid therapy is necessary to prevent clinical worsening. The most promising new therapy for moderate-to-severe disease is teprotumumab, a monoclonal antibody against IGF-1R. Teprotumumab was tested in two clinical trials demonstrating significant improvement in those with severe, active eye disease and was recently approved by the FDA for severe thyroid eye disease (4). In patients who do not respond to glucocorticoids, orbital decompression surgery may be necessary. Finally, after thyroidectomy for definitive treatment of Graves’ disease, there can be thyroid eye disease regression in the year following surgery. Therefore, patients may be able to avoid orbital decompression surgery.

Thyroid eye disease is a common complication of Graves’ disease and can contribute significantly to the morbidity of the disease. However, when recognized, thyroid eye disease in most cases can be treated effectively. This is why it’s so important to keep an eye out for thyroid eye disease!

References:
1. Chin YH, Ng CH, Lee MH, Koh JWH, Kiew J, Yang SP, Sundar G, Khoo CM 2020 Prevalence of thyroid eye disease in Graves’ disease: A meta-analysis and systematic review. Clin Endocrinol (Oxf) 93:363-374.
2. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA 2016 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 26:1343-1421.
3. Tanda ML, Piantanida E, Liparulo L, Veronesi G, Lai A, Sassi L, Pariani N, Gallo D, Azzolini C, Ferrario M, Bartalena L 2013 Prevalence and natural history of Graves’ orbitopathy in a large series of patients with newly diagnosed graves’ hyperthyroidism seen at a single center. J Clin Endocrinol Metab 98:1443-1449.
4. Kahaly GJ 2020 Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab 105.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

The post Thyroid Health Blog: Keeping an Eye Out for Thyroid Eye Disease appeared first on American Thyroid Association.

Benjamin Gigliotti, MD
University of Rochester Medical Center, NY
January 15, 2021

A common clinical dilemma is the management of patients with treated hypothyroidism and/or Hashimoto’s thyroiditis who feel unwell despite normal thyroid function tests. Weight gain, fatigue, brain fog, depressed mood, cold intolerance, constipation, dry skin, joint/muscle aches, hair loss, and brittle nails may be reported. These symptoms are commonly referred to as “thyroid symptoms,” and an internet search will reveal innumerable sources that reinforce a link between these and inadequate treatment or thyroid autoimmunity itself. However, clinicians must be cautious not to reflexively infer causation from correlation since:

– Even the most classic symptoms of hypothyroidism are non-specific and are commonly found in other diseases and in the general population.
– Anti-thyroid antibodies are often ordered in patients with unexplained symptoms, so autoimmune thyroid disease is disproportionately diagnosed in this setting; it remains unclear if this causes symptoms in and of itself.
– Most online resources emphasize the voices of people with thyroid disease who feel unwell since those who feel well do not tend to seek out or contribute to these resources.

In my experience, vague symptoms in this setting often have a multifactorial explanation, and thyroid disorders are rarely the dominant or only cause. Although the severity or number of symptoms can be daunting to evaluate, it is critical to meet the patient’s frustration with compassion, longitudinal relationship-building and thoughtful inquiry. Asking the following questions may prove helpful in determining the source(s) of symptoms:

-Is the normal TSH truly reflective of the patient’s thyroid axis?

• Repeating the TSH over time can exclude spuriously or transiently normal results.
• The upper limit of the TSH reference range (4-5mIU/L for most assays) is debated and may be lower in young patients or higher in older or obese patients. Regardless, I have never seen resolution of severe symptoms from treatment of a TSH that is within (or even slightly above or below) the reference range; several studies support this observation.(1)
• Checking a free T4 level at least once can ensure concordance with the TSH and exclude assay interference (e.g. biotin or heterophile antibodies) or rare cases of central hypothyroidism).(2)
• Total T3, free T3, and reverse T3 assays perform poorly in hypothyroidism and are rarely helpful, especially if the TSH and free T4 are normal

-Could there be an alternative explanation for each symptom that warrants workup, treatment, or counseling?

• Weight gain and/or fatigue are particularly common, occurring in up to half of all adults. Inadequate or poor-quality sleep, excessive work, suboptimal diet, and inadequate exercise are common causes. Menopause can also contribute, especially if vasomotor symptoms disrupt sleep.
• Hashimoto’s is associated with a higher rate of other clinically significant autoimmune diseases (e.g. lupus, rheumatoid arthritis, celiac disease) and numerous functional disorders (e.g. depression, migraines, irritable bowel syndrome, fibromyalgia).
• Iron deficiency is common in menstruating women, a population enriched in autoimmune thyroid disease, and can cause a similar spectrum of symptoms, even without anemia or frankly low ferritin levels.

– Can thyroid hormone therapy be optimized?

• Some patients on levothyroxine report improved symptoms after targeting a “low normal” TSH, although it is increasingly unclear if this approach is effective, and caution should be used in patients at risk for harm from iatrogenic hyperthyroidism.(3)
• Many patients express interest in therapies other than standard-of-care levothyroxine (4); Dr. Shrestha recently wrote a thoughtful blog post on thyroid hormone formulations (https://www.thyroid.org/thyroid-prescription-levothyroxine/). It is prudent to consult with an experienced endocrinologist familiar with the literature and pros/cons of using T3 and T4+T3 combination therapy to determine their appropriateness on a case-by-case basis.

While there is rarely a panacea, engaging in supportive listening, initiating an appropriately comprehensive evaluation, setting realistic expectations, and seeking consultation with endocrinology (especially when questions about assay reliability or optimal thyroid hormone replacement arise) can prove beneficial.

References:
1. Biondi B 2013 The normal TSH reference range: what has changed in the last decade? J Clin Endocrinol Metab 98:3584-3587.
2. Burch HB 2019 Drug Effects on the Thyroid. N Engl J Med 381:749-761.
3. Samuels MH, Kolobova I, Niederhausen M, Janowsky JS, Schuff KG 2018 Effects of altering levothyroxine (L-T4) doses on quality of life, mood and cognition in L-T4 treated subjects. J Clin Endocrinol Metab. ePub 2018 Mar 2.
4. Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, et al. 2014 Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 24:1670-1751.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

The post Thyroid Health Blog: An Approach to the Patient with Thyroid Disease and High Symptom Burden appeared first on American Thyroid Association.

May 7, 2018—In the spring of 2017, 12,146 individuals with hypothyroidism responded to an online survey posted on a variety of websites and social media for two months by the Program Committee of the Satellite Symposium on Hypothyroidism, organized by the American Thyroid Association (ATA). The ATA Hypothyroidism Treatment Survey asked responders to answer questions about demographic data, their satisfaction with treatments and their physicians, their perceptions of the physicians’ knowledge about hypothyroidism treatments, the need for new treatments, and the impact of hypothyroidism on their lives, among others.

The committee members do not claim that the views of the 12,146 individuals who responded necessarily reflect the general views of patients with hypothyroidism in the US. In fact, in the editorial introduction to the Survey report, Dr. Alan Farwell (also a member of the Program Committee) points out that, “It is important to realize that this was a voluntary survey and respondents may not represent the majority of the >10 million individuals in the U.S. with hypothyroidism.”

The results of the survey, however, are significant in other ways:

First, the survey demonstrated a distinct subset of patients who are dissatisfied with their therapies and their physicians. On a scale from 1 to 10, overall degree of satisfaction with therapy was rated 5. How much hypothyroidism has affected their lives received a score of 10.

Second, patients taking natural preparations, rather than synthetic hormone replacement therapy or combination therapy, were more satisfied with their treatment. DTE (animal-derived natural thyroid preparations or desiccated thyroid extract) was the original form of treatment and received a satisfaction score of 7. DTE was widely replaced in the 1960s when L-T₄ (levothyroxine, a synthetic hormone replacement therapy) could be mass-produced inexpensively; its patients gave it a score of 5. The combination therapy of L-T₄ along with synthetic T₃ (liothyronine or cytomel) received a satisfaction score of 6. Patients taking DTE were less likely to report problems with weight management, fatigue/energy levels, mood, and memory compared to those taking either the L-T₄ monotherapy or the combination therapy. The survey authors recommend further investigation into the apparently high dissatisfaction rates.

And third, a great majority of those responding expressed “a strong desire for the development of additional hypothyroidism treatment options.” This question received an overall score of 10. Dr. Farwell comments that, “even the DTE group reported continued symptoms attributed to hypothyroidism. I am sure that this will be illuminating, and controversial, as hypothyroidism is considered by many physicians to be a medical disorder that is rather straightforward to treat. In any event, the ATA Hypothyroidism Survey does make clear that more research is needed in this area and that future studies on the optimal management of hypothyroidism are necessary.”

ATA guidelines do not recommend routine use of either combination therapy or DTE, relying instead on monotherapy with levothyroxine.

For full details of the survey and its results, refer to Clinical Thyroidology for the Public, vol. 11, issue 4, April 2018, pp. 3–5.

###

The American Thyroid Association^® (ATA^®) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis, and treatment of thyroid disorders and thyroid cancer. ATA is an international membership medical society with over 1,700 members from 43 countries around the world. Celebrating its 94^th anniversary, the ATA continues to deliver its mission of being devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health.  These efforts are carried out via several key endeavors:

•  The publication of the highly regarded professional journals Thyroid^®, Clinical Thyroidology^®, and VideoEndocrinology
• Annual scientific meetings
• Biennial clinical and research symposia
• Research grant programs for young investigators
• Support of online professional, public, and patient educational programs
• Development of guidelines for clinical management of thyroid disease and thyroid cancer

 The ATA promotes thyroid awareness and information online through Clinical Thyroidology^® for the Public and extensive, authoritative explanations of thyroid disease and thyroid cancer in both English and Spanish. The ATA website serves as the clinical resource for patients and the public who look for reliable information on the Internet. Every fifth year, the American Thyroid Association joins with the Latin American Thyroid Society, the European Thyroid Association, and the Asia and Oceania Thyroid Association to cosponsor the International Thyroid Congress.

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