June 2024 query

Our member asks

Do thyroid antibodies ever go away? 

Our medical advisor replies

For Graves’ disease, if you've had successful treatment with antithyroid drugs your TSH receptor antibodies will disappear towards the end of treatment, and that will be an indicator for your doctor to stop your antithyroid drug treatment.

For thyroid peroxidase antibodies they don’t really correlate very well with the disease activity. They’re just a marker that you have the disease and there’s no value to repeating the measurements.

May 2024 query

Our member asks

I am 70 and have recently been told I have subclinical (borderline) hyperthyroidism. Will it need treating?

Our medical advisor replies

People aged over 65 are particularly at risk from the adverse effects of excess thyroid hormones, especially the development of an irregular heart rhythm and osteoporosis. European and US guidelines recommend treatment for subclinical hyperthyroidism in older people over 65 years of age, or in those under 65 years old with symptoms, osteoporosis, or heart disease when the serum TSH is consistently undetectable (<0.1mU/l). Therapy may be considered when the serum TSH is persistently in the low but detectable (0.1-0.4mU/l) range, but it should be avoided in patients without symptoms under 65 years in the absence of osteoporosis or heart disease.

April 2024 query

Our member asks

How can scans be used to distinguish between Graves’ disease and postpartum thyroiditis?

Our medical advisor replies

We don’t commonly use thyroid ultrasound to determine the cause of hyperthyroidism nowadays. This is because, first of all, an ultrasound scan is not very sensitive in diagnosing these conditions. Secondly, blood thyroid autoantibodies and thyroid uptake scans are more sensitive and specific diagnostic tests.

We only do ultrasound scans, for example, if a patient with hyperthyroidism is found to have a thyroid nodule. Even then we would defer the ultrasound until after the thyrotoxicosis is treated. This is because if you have an overactive thyroid gland, there is a high chance that an ultrasound scan will show some indeterminate features.

This could lead to unnecessary investigations, such as a biopsy. So, we tend to wait until thyroid function is normal and then we do the scan, unless the thyroid nodule has increased in size or the patient has  obstructive symptoms from a large nodule.

The best test to distinguish between Graves’ disease and postpartum thyroiditis is a blood test. If you have very high TRAb levels then this is Graves’ disease and not postpartum thyroiditis. If the TRAb level is negative, then we would do a thyroid uptake scan.

We can also predict the likelihood of Graves’ disease or thyroiditis by judging the thyroid hormone levels. We know that thyroid follicles produce/store more T4, so when we look at the ratio between T4 and T3 we will have an idea of whether it is more likely to be Graves’ disease as opposed to thyroiditis.

February 2024 query

Our member asks

Can people with thyroid disease start perimenopause/menopause earlier?

Our medical advisor replies

Treated hypothyroidism is not explicitly associated with early menopause. However, Premature Ovarian Insufficiency (POI) is associated with autoimmune thyroid disease. Thyroid problems can occur in 14–27% of women with POI, so these women should be tested for thyroid peroxidase antibodies and screened for thyroid-stimulating hormone levels at presentation.

Hyperthyroidism does not specifically cause an earlier menopause. Uncontrolled hyperthyroidism can cause stress across your hormone system. For this reason, it can affect, and even stop, menstrual periods in fertile women and increase perimenopausal symptoms in women who are already nearing, or in, the menopause transition. Once the overactive thyroid is treated, these effects may subside. They may also continue if your body was already heading towards perimenopause before the thyroid problem began.

January 2024 query

Our members asks

I have Graves' disease and the endocrinologist has confirmed I do not have any signs of thyroid eye disease. I would like to have laser eye surgery for my short-sightedness however I am not sure whether I would be a suitable candidate?

Our medical advisor replies

Laser eye surgery is not recommended due to possible dry eye and exposure issues. It is not an absolute contraindication; however, you would need to accept the risks if you decided to proceed.  

December 2023 query

Our member asks

What is the link between thyroid blood tests and symptoms? For example, do higher thyroid antibodies levels determine how symptomatic patients are?

Our medical advisor replies

Not always. Higher free thyroid hormones indicate more severe disease but do not always correlate with how severe symptoms are. For example, you can have young people with mild disease who are very symptomatic but older patients who have minimal symptoms despite being much higher thyroid levels, in terms of their blood results. So, the level of thyroid hormones does not always correspond with the severity of the symptoms.

Apart from age, there could be a difference in symptoms between men and women. For example, we see men present with less severe symptoms than women in some cases.

The TSH Receptor Antibody (TRAb) doesn’t directly determine the severity of symptoms. A high TRAb is diagnostic for Graves’ disease and the higher the TRAb level, the greater the immune attack going on in the thyroid. In these patients, we may see more severe thyrotoxicosis*. It may also mean you are more likely to take longer to respond to anti-thyroid medication or require a much higher dose of anti-thyroid medication to achieve remission.

Also, the higher the TRAb level, the greater the likelihood of developing Thyroid Eye Disease (TED). So, it’s fair to say that the TRAb level can indicate whether you are more likely to develop TED but it does not determine the severity of thyrotoxic symptoms.

*Too much thyroid hormone in the body

November 2023 query

Our member asks

I have a multinodular goitre; does it mean you have to remove the whole thyroid or just some 
of it?

Our medical advisor replies

With a small multinodular goitre you may need to do nothing at all. If it is causing discomfort, 
you may be offered Radioactive Iodine (RAI) therapy. Where surgery is needed for a multinodular 
goitre affecting just one of the thyroid lobes, then you may be offered a partial thyroidectomy
(hemithyroidectomy). If is on both sides of the neck, then it is best to remove the entire thyroid
(thyroidectomy). This is because if some tissue is left behind it may regrow. Repeating surgery on the 
same spot increases the risk of damaging the thyroid.

October 2023 query

Our member asks

How often will I have check-ups after RAI? I am worried I will go hypothyroid and it won't be picked up.

Our medical advisor replies

Any RAI centre should provide you with a treatment plan.This will offer you follow-up tests at set intervals or sooner if there are symptoms or new symptoms. This will typically be at six weeks, three months, six months and one year after RAI. These appointments are often held virtually. You will be given a series of blood test forms and we monitor them. We may need to see you face-to-face in our clinics though. 

August 2023 query

Our member asks

Why does TSH sometimes stay persistently low? For example, in someone who has Graves’ disease whose T4 levels are now in range but their TSH remains suppressed?

Our medical advisor replies

This is an unusual phenomenon. The truth is we do not exactly know why the TSH stays chronically suppressed.

I can give you two possibilities:
1. When we measure the thyroid hormones in the blood, it is a snapshot in time. It is not the T3 level throughout the 24 hour period. So, it is possible that in that Graves’ disease patient the snapshot measurement of T3 is ok but over a 24 hour period the thyroid gland is producing just a little too much T3. And this is what accounts for the persistently suppressed TSH.

2. Another explanation, for which there is also good evidence, is that the receptor to which TSH receptor antibodies bind is, strangely enough, also expressed on the TSH producing cells of the pituitary. So, there is a suggestion that the Graves’ antibody cells – the Thyroid Stimulating Hormone Receptor Antibodies (TSHR Ab, also known as TRAb) – is what binds to the pituitary and shuts off the TSH for a long time. I think Prof Moran and I would agree that when we see this in clinical practice we observe this as a
phenomenon that when we treat a patient with Graves’ disease, the TSH can remain suppressed for months. As things get better, it then flips.

July 2023 query

Our member asks

Can the surgical use of iodine cause goitres?

Our medical advisor replies

There is no evidence that iodine uptake scans nor surgical iodine cause nodules or goitres. If anything it is iodine deficiency that causes goitres or nodule, not excess iodine as such. In someone who has Graves’ disease and borderline overactivity, if they took a lot of iodine (i.e. seaweed) this could make their thyroid more overactive in the short term.

Other than that, surgical iodine does not get absorbed into the skin in any meaningful amount. In iodine contrast medium used in x-rays, the amount of iodine is trivial; much, much less than is in a normal diet.

June 2023 query

Our member asks

I have Graves’ disease but no sign of Thyroid Eye Disease (TED). Will having thyroid surgery
reduce the risk of TED developing?

Our medical advisor replies

The Thyroid Stimulating Hormone Receptor Antibodies (TRAb) antibodies which can trigger TED do decline over time when removing the thyroid. We also know that if someone has TED, giving them RAI can make it worse. I am not aware of any concerns about giving RAI for someone with Graves’ disease who hasn’t yet developed TED. Yes, thyroid surgery can be helpful where people already have TED but I wouldn’t be offering surgery to someone just because of worries about developing TED at a later date.

May 2023 query

Our member asks

I am struggling to get pregnant after several miscarriages. I have a family history of thyroid problems and have tested positive for thyroid antibodies. Would taking levothyroxine improve my chances of having a successful pregnancy?

Our medical advisor replies

There is no evidence that treating women who have positive TPO antibodies but normal thyroid function tests will result in improved pregnancy outcomes even in those with previous pregnancy losses.

If your TSH is above the pregnancy-specific reference range (or greater than 4.0 mU/L where there are no pregnancy ranges available) then treatment with levothyroxine is recommended.

The evidence for treating those with a TSH between 2.5 mU/L and the upper limit of the pregnancy reference range (or 4.0 mIU/L) who are TPO positive and have recurrent miscarriages is less clear and the TABLET trial showed no benefit. A number of fertility clinics and the current American Thyroid Association (ATA) guidelines however would treat someone with a TSH greater than 2.5 mU/L in this situation.

April 2023 query

Our member asks

I believe my son has hypothyroidism as we have a strong family history of thyroid disease. His thyroid function is only showing elevated TSH and a borderline T4. The paediatric endocrinologist has indicated he may develop hypothyroidism in the future but does not currently require treatment. Yet, he is experiencing extreme tiredness, heavy legs, low mood and he has been found to have a low vitamin D. I wish to avoid the problems we had getting his sister’s diagnosis. Is there anything else I should be asking my son’s doctor?

Our medical advisor replies

Firstly, I think it would be good to highlight your concerns with the paediatric endocrinologist.

He or she may make the point that other issues may need to be addressed as well before the picture becomes clear. For example, low vitamin D concentrations can also cause tiredness and heavy legs etc. I imagine your son is on vitamin D now, which may improve his symptoms.

Many studies have shown that subtle TSH increase in isolation (for example, a TSH less than 10mU/l) does not seem to be associated with the kind of profound symptoms that you describe in your son and it would be good to know how high the TSH actually is. If it is persistently elevated in the presence of symptoms, many endocrinologists would consider a trial of thyroxine, particularly if the free T4 is borderline as you suggest. I do think it is important that the team try and understand why the TSH is increased though. Has your son got positive autoantibodies for example? Is he on a diet that does not contain much iodine?

I would just bear in mind that in some individuals mild TSH elevation or mild thyroid dysfunction can actually be the consequence of illness and not the underlying cause. We see this very commonly. If this is the case then the thyroid dysfunction can correct itself spontaneously. Nature and time are sometimes better than a prescription.

Again, this underlines the importance of discussing the specifics with your paediatric endocrinologist who I am sure will be very receptive to your thoughts about the possible way forwards.  

Ultimately, if the TSH continues to rise and the Free T4 continues to fall he will need thyroxine.

March 2023 query

Our member asks:

I was diagnosed with Graves’ disease a few years ago. After taking carbimazole for over a year I became euthyroid and was able to stop treatment. I am now trying to become pregnant and was wondering if I am now completely clear of hyperthyroidism or could the illness come back? 

Our medical advisor replies:

You should have thyroid function tests and thyroid stimulating hormone receptor antibodies (TRAb) checked in the first trimester. Even if you are euthyroid, if the TRAb is positive, you should be referred to a local antenatal clinic during pregnancy. This is precautionary but because thyroid receptor antibodies cross the placenta, monitoring during pregnancy is recommended.

There is a risk of Graves' disease relapse pre-pregnancy or in early pregnancy, or in the postpartum period.Thyroid function tests should be checked if you develop symptoms of hyperthyroidism at any stage, or in early pregnancy. 

Do you have a medical query?  As a BTF member, you receive priority access to our medical query service. 

Submit your medical query 

Please see link for terms and conditions.