Hypothyroidism and Somatization: Results from E-Mode Patient Self-Assessment of Thyroid Therapy, a Cross-Sectional, International Online Patient Survey

Psychological factors and obesity, not thyroid biomarkers, predict thyroid-dependent quality of life in treated hypothyroidism: a cross-sectional study

BACKGROUND

A significant number of patients with primary hypothyroidism report persistent symptoms and decreased quality of life (QoL) despite biochemically adequate levothyroxine replacement. Individual variations in thyroxine conversion, autoimmune inflammation, and psychological factors have all been implicated as a potential cause.

METHODS

In this cross-sectional study we have examined the association of numerous demographic, disease-specific, and laboratory parameters as well as three patient reported outcome measures with thyroid-dependent QoL as measured by the Underactive Thyroid-Dependent Quality of Life Questionnaire. Patients were stringently selected to minimize the confounding effect of comorbidities or inadequate hormone replacement. We used validated questionnaires to assess somatosensory amplification, depression, and symptom number. Determinants of QoL were evaluated using uni- and multivariable linear modeling, and mediation analysis.

RESULTS

Our final sample consisted of 157 patients. 70.7% had Hashimoto's, whereas 29.3% had iatrogenic hypothyroidism. Mean age was 49.5 ± 14.5 years, disease duration: 11.2 ± 8.2 years, thyroxine dose: 1.2 ug/kg bodyweight, TSH: 1.8 ± 0.9 mIU/L. Thyroid-specific biomarkers including TSH, FT3, FT4, rT3, SPINA-GD, anti-TPO, and SHBG had no association with thyroid-dependent QoL. Somatosensory amplification was a strong predictor of the presence and perceived bother of the most common hypothyroidism-associated symptoms. In our final multivariable model (r2 = 0.31) the factors associated with thyroid-dependent QoL were somatosensory amplification (p = 0.002), BMI (p = 0.021), and depression (p < 0.001).

CONCLUSION

These results suggest that psychological factors, particularly somatosensory amplification, might play a major role in influencing QoL in hypothyroid individuals on adequate levothyroxine replacement. Our findings do not corroborate a significant role for autoimmune inflammation or tissue-level hypothyroidism.

The effects of levothyroxine monotherapy versus combination therapy on quality of life and patient satisfaction

INTRODUCTION

Hypothyroidism is a relatively common condition, which generally cannot be reversed. Hypothyroid individuals are dependent on provision of exogenous thyroid hormone as a lifetime therapy. Levothyroxine therapy provides satisfactory treatment for most. However, a subset of patients are not restored to their baseline quality of life.

AREAS COVERED

As discussed here, a number of solutions have been tried, including addressing accompanying conditions, rigorous titration of therapy, and combination therapy with levothyroxine and liothyronine. The latter has limited success with improving quality of life, but does appear to be associated with patient preference. The discrepancy between quality of life and patient preference may be important to understanding the nuances of successful hypothyroidism treatment.

EXPERT OPINION

Future efforts to improve hypothyroidism therapy could tease out which are the specific subset of patients who benefit from combination therapy, such as those who have unresolved symptoms attributable to hypothyroidism at baseline and those with genetic polymorphisms that might impair thyroid hormone delivery to tissues. Better understanding of the drivers of patient preference for combination therapy should also be revealing. A future goal is to prevent autoimmune hypothyroidism from developing and to treat hypothyroidism completely by generating fully functioning thyroid follicles from stem cells.

Thyroid hormone use in clinical practice by Israeli endocrinologists: a THESIS* questionnaire survey : *Treatment of hypothyroidism in Europe by specialists: an international survey

OBJECTIVE

Several thyroid hormone formulations are available for treatment of hypothyroidism. This study aimed at evaluating the use of these treatment options by Israeli endocrinologists in various clinical scenarios.

METHODS

Israeli Endocrine Society members were invited to participate in a web-based questionnaire, Treatment of Hypothyroidism in Europe by Specialists: An International Survey.

RESULTS

99.2% of respondents used LT4 tablets as first line therapy for hypothyroidism. Thyroid hormone replacement options considered by respondents included LT4 tablets (100%), soft-gel capsules (4.0%), liquid solution (15.4%), combined LT4 + LT3 (2.4%) and LT3 tablets (17.8%). In cases of impaired absorption or persistent symptoms, most would continue LT4 tablets (86.1% and 95.1%, respectively), of whom 39.0% noted that only tablets are available in Israel. In patients with normal serum TSH and persistent symptoms, 95.1% would continue LT4 tablets, 57.5% would consider the addition of LT3 whereas 24.4% stated that LT4/LT3 combination should never be used. In euthyroid patients, LT4 therapy was considered in infertile women with high levels of thyroid antibodies (33.6%) and for simple goiter growing over time (11.4%).

CONCLUSIONS

In Israel, LT4 tablets are the treatment of choice for hypothyroidism in most clinical scenarios, including in patients with impaired absorption or with persistent symptoms, for whom a combination therapy with LT4 + LT3 is considered by half of respondents. Other LT4 formulations are not widely available in Israel, thus are infrequently considered compared to other European countries. These data suggest that international guidelines regarding the use of various thyroid hormone formulations in specific clinical scenarios are warranted.

Hypothyroidism and Type D Personality: Results From E-MPATHY, a Cross-sectional International Online Patient Survey

CONTEXT

Between 10% and 15% of people with hypothyroidism experience persistent symptoms, despite achieving biochemical euthyroidism. The underlying causes are unclear. Type D personality (a vulnerability factor for general psychological distress) is associated with poor health status and symptom burden but has not been studied in people with hypothyroidism.

OBJECTIVE

To investigate type D personality in hypothyroidism and explore associations with other characteristics and patient-reported outcomes.

DESIGN

Multinational, cross-sectional survey.

SETTING

Online.

PARTICIPANTS

Individuals with self-reported, treated hypothyroidism.

INTERVENTION

Questionnaire.

MAIN OUTCOME MEASURES

Type D personality and associations with baseline characteristics, control of the symptoms of hypothyroidism by medication, satisfaction with care and treatment of hypothyroidism, impact of hypothyroidism on everyday living.

RESULTS

A total of 3915 responses were received, 3523 of which were valid. The prevalence of type D personality was 54.2%. Statistically significant associations were found between type D personality and several respondent characteristics (age, marital status, ethnicity, household income, comorbidities, type of treatment for hypothyroidism, most recent TSH level), anxiety, depression, somatization, poor control of the symptoms of hypothyroidism by medication, dissatisfaction with care and treatment of hypothyroidism, and a negative impact of hypothyroidism on everyday living).

DISCUSSION

Our study found a high prevalence of type D personality among people with hypothyroidism who responded to the survey. Type D personality may be an important determinant of dissatisfaction with treatment and care among people with hypothyroidism. Our findings require independent confirmation. Close collaboration between the disciplines of thyroidology and psychology is likely to be key in progressing our understanding in this area.

Measurement Properties of the Patient Health Questionnaire-15 and Somatic Symptom Scale-8: A Systematic Review and Meta-Analysis

Importance

The subjective experience of somatic symptoms is a key concern throughout the health care system. Valid and clinically useful instruments are needed.

Objective

To evaluate the measurement properties of 2 widespread patient-reported outcomes: the Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Scale-8 (SSS-8).

Data Sources

Medline, PsycINFO, and Web of Science were last searched February 1, 2024.

Study Selection

English-language studies reporting estimates pertaining to factor analysis, taxometric analysis, internal consistency, construct validity, mean scores in relevant groups, cutoffs, areas under the receiver operating characteristic curves (AUROCs), minimal clinically important difference, test-retest reliability, or sensitivity to change.

Data Extraction and Synthesis

Search hits were reviewed by independent raters. Cronbach α, Pearson r, means, and between-group effect sizes indicative of sensitivity to change were pooled in random-effects meta-analysis. Study quality was assessed using 3 instruments. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 reporting guideline.

Main Outcomes and Measures

Comprehensive overview of evidence pertaining to the measurement properties of the PHQ-15 and SSS-8.

Results

A total of 305 studies with 361 243 participants were included. Most concerned routine care (178 studies) and the general population (27 studies). In factor analyses, both scales reflected a combination of domain-specific factors (cardiopulmonary, fatigue, gastrointestinal, pain) and a general symptom burden factor. The pooled PHQ-15 α was 0.81 (95% CI, 0.80-0.82), but with low item-total correlations for items concerning menstrual problems, fainting spells, and sexual problems (item-total correlations <0.40), and the SSS-8 α was 0.80 (0.77-0.83). Pooled correlations with other measures of somatic symptom burden were 0.71 (95% CI, 0.64-0.78) for the PHQ-15 and 0.82 (95% CI, 0.72-0.92) for the SSS-8. Reported AUROCs for identification of somatoform disorders ranged from 0.63 (95% CI, 0.50-0.76) to 0.79 (95% CI, 0.73-0.85) for the PHQ-15 and from 0.71 (95% CI, 0.66-0.77) to 0.73 (95% CI, 0.69-0.76) for the SSS-8. The minimal clinically important difference on both scales was 3 points. Test-retest reliability could not be pooled and was inconsistent for the PHQ-15 (PHQ-15: r = 0.65-0.93; ICC, 0.87; SSS-8: r = 0.996, ICC = 0.89). The PHQ-15 showed tentative sensitivity to change (g = 0.32; 95% CI, 0.08-0.56), but data for the SSS-8 were lacking.

Conclusions and Relevance

In this systematic review and meta-analysis, findings supported use of the PHQ-15 and SSS-8 for the assessment of symptom burden, but users should be aware of the complex, multifactorial structures of these scales. More evidence is needed concerning longitudinal measurement properties.

Medically not yet explained symptoms in hypothyroidism

Persistent symptoms are common in the general population and even more so in people with hypothyroidism. When symptoms are unexplained and brought to medical attention, they can be referred to as medically not yet explained symptoms (MNYES), a term preferred to other descriptors by patients, care-givers and experts. MNYES might be neglected by endocrinologists or misattributed to hypothyroidism. Awareness of MNYES could open up more effective and less harmful interventions for patients who present to endocrinologists with unexplained symptoms than costly over-investigations and over-treatment with thyroid hormones (such as levothyroxine and liothyronine). The role of the endocrinologist is to recognize and acknowledge that MNYES could be underlying a patient's presentation, to communicate effectively with the patient and others involved in the patient's care, to apply a 'two-track approach' in management by paying equal attention to physical and psychosocial contributors, and to collaborate with other relevant health professionals. Categorization of patients into levels of risk for symptom deterioration helps in selecting suitable therapies. Effective management of MNYES demands time, training, expertise and resources.

A Real-Life Study in Patients Newly Diagnosed with Autoimmune Hashimoto's Thyroiditis: Analysis of Asthenia as Admission Complaint

Background: Amid the large panel of autoimmune thyroid diseases, Hashimoto's thyroiditis (HT) represents a major point across multidisciplinary daily practice. When it comes to the clinical picture, particularly in regard to asthenia (also described as "fatigue" or "decreased energy"), the differential diagnosis is challenging, and a meticulous anamnesis should be backed up by focused lab investigations. Our objective was to analyze the thyroid panel in newly diagnosed patients with HT in relationship with the presence of asthenia as an admission complaint. Methods: This was a retrospective, multi-centric, real-life study conducted in secondary endocrine units (university hospitals) from July 2022 to July 2023. The exclusion criteria were COVID-19 infection; an active malignancy, etc. Results: The cohort (N = 120) included an asthenia group (AS, 49.2%) and a non-AS group of a similar age (49.3 ± 14.7 vs. 47.1 ± 14.8 y, p = 0.426). Headache was more frequent in the AS group (35.6% vs. 18%, p = 0.03). Thyroid function and HT-related antibodies assays were similar between the groups and show no correlation with serum total cholesterol and triglycerides, respectively. TSH levels did not vary among the age sub-groups (p = 0.701). One third of the studied population was affected by hypothyroidism (TSH > 4.5 μIU/mL), being seen at a higher rate in the AS (39%) vs. non-AS group (23%). Total cholesterol positively correlated with the patients' age (r = 0.180, p = 0.049) and triglycerides (N = 120; r = 0.324, p < 0.001), as found only in the non-AS group (r = 0.246, p = 0.006, respectively, r = 0.319, p < 0.001). Conclusions: The analysis of the AS vs. non-AS group pinpointed the fact that, in regard to daily practice, asthenia as an admission complaint seems less of an indicator of an underlying thyroid dysfunction or a higher level of serum antibodies against thyroid in patients without a full clinical picture of thyrotoxicosis or myxoedema.

Use of thyroid hormones in hypothyroid and euthyroid patients: A survey of members of the Endocrine Society of Australia

OBJECTIVE

Hypothyroidism is a common endocrine condition usually managed with levothyroxine (LT4). However, controversy remains around the use of liothyronine (LT3). We aimed to investigate the practices of Australian endocrinologists when managing patients with hypothyroidism, their use of LT3 + LT4 combination therapy and use of thyroid hormones in euthyroid patients.

DESIGN AND PARTICIPANTS

Members of the Endocrine Society of Australia (ESA) were invited to participate in an online questionnaire.

MEASUREMENTS

We analysed questionnaires that had complete demographic data.

RESULTS

Eighty-seven questionnaires fulfilled the criteria. LT4 was used as first line treatment for hypothyroidism by all respondents. Only 45% reported that their patients were dispensed the brand of LT4 that they recommend. LT3 (alone or in combination) was prescribed by 44% in their clinical practice. Although 49% of respondents would consider LT3 + LT4 in patients with normal TSH who had ongoing symptoms of hypothyroidism, the inability of LT4 to restore normal physiology was ranked the least likely explanation for persistent symptoms and only 32% would consider it for themselves if they were diagnosed with hypothyroidism. The majority (55%), in accordance with evidence, would not prescribe thyroid hormone to euthyroid individuals but 39% would consider use in euthyroid female infertility with high levels of thyroid antibodies and 11% in euthyroid patients with a simple goitre growing over time. LT4 use in pregnancy was variable among members.

CONCLUSIONS

Australian endocrinologists mostly follow international guidelines when prescribing thyroid hormone therapy and many prescribe combination LT3 and LT4 therapy, particularly for patients who remain symptomatic on LT4 monotherapy. Prescribing practices are largely similar to other countries who have completed similar questionnaires.

Patients' Persistent Symptoms, Clinician Demographics, and Geo-Economic Factors Are Associated with Choice of Therapy for Hypothyroidism by European Thyroid Specialists: The "THESIS" Collaboration

Background: Hypothyroidism is common, however, aspects of its treatment remain controversial. Our survey aimed at documenting treatment choices of European thyroid specialists and exploring how patients' persistent symptoms, clinician demographics, and geo-economic factors relate to treatment choices. Methods: Seventeen thousand two hundred forty-seven thyroid specialists from 28 countries were invited to participate in an online questionnaire survey. The survey included respondent demographic data and treatment choices for hypothyroid patients with persistent symptoms. Geo-economic data for each country were included in the analyses. Results: The response rate was 32.9% (6058 respondents out of 17,247 invitees). Levothyroxine (LT4) was the initial treatment preferred by the majority (98.3%). Persistent symptoms despite normal serum thyrotropin (TSH) while receiving LT4 treatment were reported to affect up to 10.0% of patients by 75.4% of respondents, while 28.4% reported an increasing such trend in the past 5 years. The principal explanations offered for patients' persistent symptoms were psychosocial factors (77.1%), comorbidities (69.2%), and unrealistic patient expectations (61.0%). Combination treatment with LT4+liothyronine (LT3) was chosen by 40.0% of respondents for patients who complained of persistent symptoms despite a normal TSH. This option was selected more frequently by female thyroid specialists, with high-volume practice, working in countries with high gross national income per capita. Conclusions: The perception of patients' dissatisfaction reported by physicians seems lower than that described by hypothyroid patients in previous surveys. LT4+LT3 treatment is used frequently by thyroid specialists in Europe for persistent hypothyroid-like symptoms even if they generally attribute such symptoms to nonendocrine causes and despite the evidence of nonsuperiority of the combined over the LT4 therapy. Pressure by dissatisfied patients on their physicians for LT3-containing treatments is a likely explanation. The association of the therapeutic choices with the clinician demographic characteristics and geo-economic factors in Europe is a novel information and requires further investigation.

The dangerous trend of levothyroxine medicalization

Thyroid hormone replacement is paramount in overt hypothyroidism; recently, however, thyroid hormone substitution is increasingly prescribed to patients with normal thyroid hormone levels. This forum article discusses the complex causes and the possible negative effects of overusing thyroid hormone replacement drugs.

Treating subclinical hypothyroidism in individuals with or without mental health problems -A Delphi based expert consensus study in two countries

Background

Subclinical hypothyroidism (SCH) is a common endocrine problem with prevalence estimates between 4% and 20%. Symptoms are often non-specific but can substantially affect well-being leading to repeated medical consultations. The effect of thyroid hormone replacement therapy (THRT) in patients with SCH remains uncertain. Current guidelines, limited by the lack of high-quality evidence, have been controversial with limited adherence in clinical practice.

Methods

Three-round modified Delphi method to establish consensus regarding diagnosis and treatment of individuals with SCH with and without affective disorder or anxiety, conducted with clinicians from three specialties, general practice, endocrinology and psychiatry, and two countries, Sweden and the United Kingdom.

Results

Sixty clinicians, 20 per specialty, were recruited. Fifty-three (88%) participants completed all three rounds. The participants reached consensus on five of the 26 practice statements that (a) repeated testing was required for the diagnosis of subclinical hypothyroidism, (b) antibody screening should usually occur, and (c and d) antibody screening would strengthen the indication for thyroid hormone replacement therapy in both individuals with or without affective disorder or anxiety. The participants disagreed with (e) a requirement of a TSH threshold ≥ 20 mIU/L for thyroid hormone replacement therapy start. Psychiatrists and GPs but not endocrinologists, agreed that there was a frequent discrepancy between laboratory results and clinical symptoms, and disagreed that testing for thyroid dysfunction was overused in patients presenting with depression or anxiety, or fatigue.

Conclusions

In many aspects, attitudes toward diagnosing and treating SCH remain diverse. The inability of our Delphi panel to achieve consensus on most items and the disagreement with a TSH ≥ 20 mIU/L threshold for treatment suggest that the concept of SCH may need rethinking with a better understanding of the hypothalamic-pituitary-thyroid physiology. Given that the scientific evidence is currently not conclusive, guidelines in this area should not be taken as definitive.