Wartofsky, L., Van Nostrand, D., & Burman, K. D. (2006). Overt and 'subclinical' hypothyroidism in women. Obstetrical & Gynecological Survey, 61(8), 535-542. https://doi.org/10.1097/01.ogx.0000228778.95752.66
Wartofsky L, Van Nostrand D, Burman KD. Overt and 'subclinical' hypothyroidism in women. Obstet Gynecol Surv. 2006;61(8):535-542. doi:10.1097/01.ogx.0000228778.95752.66
Wartofsky, Leonard, et al. "Overt and 'subclinical' hypothyroidism in women." Obstetrical & Gynecological Survey, vol. 61, no. 8, 2006, pp. 535-542.
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A 2006 review by three physicians gives its position: the authors believe confirmed mild thyroid failure in women warrants treatment. It was written for gynecologists and family doctors. Experts still disagree on whether early treatment helps.
Key Findings
Primary thyroid disease accounts for virtually 95% of hypothyroidism in adult women. Its most common cause is autoimmune Hashimoto thyroiditis.
Hashimoto disease is some 5 to 8 times more common in women than men.
Mild hypothyroidism shows up as a slightly raised thyrotropin (TSH) blood level, with thyroxine (T4) and triiodothyronine (T3) still in their reference ranges.
The authors say a single mildly raised TSH calls for a repeat test before treatment starts, since modest elevations can be transient.
One cited study found higher odds of aortic atherosclerosis (odds ratio 1.7) and myocardial infarction (odds ratio 2.3) in women meeting criteria for mild thyroid failure.
Interpretation
The article is a narrative continuing education review. It gives the authors' reasoned position and pools no data. All three authors disclosed ties to drug companies. Claims about pregnancy, heart risk and treatment benefit rest on studies the authors cite, mostly reporting associations. An expert panel found little convincing evidence that early treatment helps, and reviewers from all three sponsoring societies disagreed with the panel. The authors say large, carefully done studies are still needed. The review covers primary hypothyroidism only.
RRM Context
Restorative reproductive medicine looks for the cause of cycle problems and infertility. The review lists irregular periods, heavy periods and infertility among the possible early signs of low thyroid function. Thyroid disease is one named cause.
Our editorial summary of this paper, not the article's abstract.
Abstract
Thyroid disease in general, and hypothyroidism in particular, are very common in women. In the USA, the most common cause of primary thyroid deficiency is on an autoimmune basis due to lymphocytic (Hashimoto) thyroiditis. Because there are thyroid hormone receptors in virtually every tissue of the body, the manifestations of hypothyroidism are varied, but problems with abnormal menses, conception, fertility, and pregnancy can be especially troubling in young women. The single most important diagnostic test is measurement of serum thyrotropin (TSH). The overwhelming majority of patients with hypothyroidism are treated with a single daily dose of synthetic levothyroxine with the goal of therapy being restoration of a normal metabolic state with return of the TSH level down to the range of 0.5 to 1.5 mlU/L. "Subclinical" hypothyroidism refers to those patients with early or mild thyroid hypofunction manifested as slight elevations of thyrotropin (approximately 4-10 mlU/L) although serum thyroxine (T4) and triiodothyronine (T3) levels are within their reference ranges. The entity is somewhat controversial in regard to its consequences if left untreated, and whether or not we should be screening patients, at least susceptible populations, for the condition. Reports indicate an association between subclinical hypothyroidism and poor outcomes of pregnancy, as well as dyslipidemias, atherogenesis, and increased mortality in the long term. We believe these consequences are sufficiently compelling to warrant screening and treatment with levothyroxine when found to halt progression to overt hypothyroidism, and improve symptoms, pregnancy outcomes, lipid abnormalities, and cardiovascular function.
Intended Users
Obstetricians & Gynecologists, Family Physicians.
Learning Objectives
After completion of this article, the reader should be able to recall that hypothyroidism is a common disease in women, has many protean manifestations, and can be successfully diagnosed and treated; explain that the condition of subclinical hypothyroidism can be diagnosed and if treated can prevent many untoward complications; and state that there should be heightened awareness of the disease so that proper screening tests can be performed.
