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Diagnosis Challenge:

The Patient With Aches and Changes

After months of fatigue, depression, achy muscles and an intolerance to cold temperatures, Michelle* made an appointment to see Cleveland Clinic endocrinologist Christian Nasr, M.D. For the entire story, go to the Spring/2006 issue of Cleveland Clinic Magazine, page 8.

After a careful history and physical examination, Dr. Nasr determined that Michelle's stress levels were real but not an explanation for other symptoms like achy muscles, dry skin and sensitivity to cold.

Christian Nasr, M.D.
Michelle was definitely experiencing the onset of menopause and body changes as a result of normal aging, such as slower metabolism (resulting in weight gain) and irregular menstrual periods. Depression was likely a psychological response to Michelle's condition. Still, this did not explain many of her other physical symptoms.

Dr. Nasr was concerned about Michelle's just-above-normal thyroid stimulating hormone (TSH) level, which was 5.9 milliunits per liter of blood. At Cleveland Clinic labs, 0.4 to 5.5 is considered normal. In the absence of symptoms, and if other thyroid tests are normal, TSH levels between 5.6 and 10 are considered subclinical, a level that indicates possible early-stage disease. A TSH level above 10 indicates a thyroid disorder. TSH is the barometer of thyroid function; it rises when the glands are failing.

Individuals with a TSH of 10 would not require additional screening, but Dr. Nasr could not diagnose Michelle with hypothyroidism without conducting another critical lab test: the free T4 (thyroxine). TSH levels are prone to change based on proteins in the blood or estrogen levels, among other causes.

Dr. Nasr knew he would get a more accurate reading by measuring the two active thyroid hormones, T3 (triiodothyronine) and T4. When these hormone levels are low, TSH levels are high, indicating potential hypothyroidism.

The thyroid gland weighs less than an ounce, but affects all of the body's systems
The Diagnosis: Subclinical Hypothyroidism
When Dr. Nasr measured Michelle's free T4 level, it was 0.9 nanogram/deciliter. Because the normal level is between 0.8 and 1.8, Michelle's results were borderline. However, her combined free T4 and 5.9 TSH levels indicated subclinical hypothyroidism. Michelle's physical symptoms supported Dr. Nasr's diagnosis: weight gain, achy muscles, low tolerance to cold temperatures and dry skin. Further, Michelle's fatigue and psychological symptoms - depression - also are signs of hypothyroidism.

The thyroid gland weighs less than an ounce, but it affects all of the body's systems, from heart rate to how quickly you burn calories. When the thyroid does not release the proper amount thyroid hormones, it upsets the balance of chemical reactions in your body. Significant hypothyroidism can boost blood pressure and cholesterol levels, which in turn increases a patient's risk of cardiovascular disease.

Hypothyroidism is linked with increased estrogen levels, which could explain why women, particularly those older than 40, are more likely to have hypothyroidism than men. Age also is a factor. As a person ages, his or her likelihood of being diagnosed with a thyroid disorder increases. Female patients experience menstrual dysfunction, even losing their period for months at a time. Because many hypothyroid patients are aging and their bodies changing, it is easy to overlook these symptoms as signs of a possible thyroid problem.

In fact, depending on a person's threshold for pain and fatigue, a hypothyroidism candidate may overlook symptoms entirely. Some people can tolerate achy muscles, dry skin and fatigue; others can't imagine being tired or sore for too long. This is why the biochemical tests that Dr. Nasr conducted are critical to properly diagnosing hypothyroidism.

Treatment
Because of the low severity of Michelle's hypothyroidism, Dr. Nasr presented her with a couple of options. She could choose to take a thyroid hormone replacement therapy to normalize her TSH to 1.5 or 2.0, which might lower her cholesterol and blood pressure and also alleviate her achiness, fatigue and depression. Or Michelle could choose not to take medication and see whether her TSH level naturally dropped. Because she was borderline "normal" and TSH can fluctuate, it is possible that her body chemistry would change over time.

Michelle chose the prescription. Dr. Nasr started her on a low dose and ordered a reassessment in four months so he could retest her TSH and free T4 levels. Some patients who do not suffer from severe symptoms and are subclinically hypothyroid choose not to take medication. Michelle, on the other hand, wanted to try hormone replacement therapy because her symptoms were affecting her quality of life. Even if Michelle would not have chosen hormone replacement therapy, she still would have needed to have her TSH measured every six to 12 months or if her symptoms worsened.

* The patient and history presented in "Diagnosis Challenge" are fictional.


thyroid disorders
To learn more about thyroid disorders, check out the following book from Cleveland Clinic Press:
Thyroid Disorders
(A Cleveland Clinic Guide)
by Mario Skugor, M.D.
http://www.clevelandclinicpress.org/

 

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