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Its very sensitivity, however, may create a dilemma, since some patients are found to have elevated serum TSH levels, suggesting hypothyroidism, but have normal levels of thyroid hormone, whether measured as free thyroxine (T level—is referred to as subclinical hypothyroidism.
The term “subclinical” may not be strictly correct, since some of these patients may have clinical symptoms, but no better term has been proposed.
Treatment is commonly initiated with 25 to 50 μg daily and raised by increments of 25 to 50 μg, according to TSH measurements at six- to eight-week intervals.
In patients who are elderly or debilitated, or who have heart disease, lower starting dosages and slower increases are advisable.
In some cases, the TSH level will be normal if measured again several months later; we would then attribute the initial elevation to laboratory error or, perhaps, to an episode of silent thyroiditis with a transient hypothyroid phase.
The presence of symptoms that might be related to mild hypothyroidism also increases the potential benefit of treatment.
In the absence of definitive guidelines, some clinicians may elect to perform routine screening with serum TSH measurement or to measure TSH in patients with persistent non-specific complaints, especially women, the elderly and persons with risk factors for thyroid failure Measurement of serum TSH is generally considered the best screening test for thyroid disease; increased values usually indicate hypothyroidism, and decreased values usually indicate hyperthyroidism.
This test has proved to be both sensitive and specific.
Some studies,1213 but not others,10 have shown a decrease in LDL cholesterol and total cholesterol levels after treatment with levothyroxine (Levoxyl, Levothroid, Synthroid).
In several studies, a sensitive measure of myocardial contractility, the ratio of pre-ejection period to left ventricular ejection time (PEP: LVET) was shown to improve significantly in patients with subclinical hypothyroidism who were treated with levothyroxine, compared with patients who were treated with placebo.10Indications for treatment in subclinical hypothyroidism are not established, but general guidelines can be offered.
Currently, no organizations recommend routine universal screening. More recently, some authors3 have recommended testing in women more than 40 years of age and in patients in geriatric facilities.