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Think It's Your Thyroid? Midlife Fatigue, Weight Gain, and the Myths Behind "Normal" Labs · Clearly Hormonal

• 0:01
  Dr. Komal Patil-Sisodia: Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies.
• 0:09
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:10
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam.
• 0:21
  Dr. Komal Patil-Sisodia: I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it.
• 0:37
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:40
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:48
  Dr. Komal Patil-Sisodia: A quick disclaimer: I'm a physician, but this is education, not personalized medical advice.
• 0:53
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 0:56
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:04
  Dr. Komal Patil-Sisodia: How many of you have ever wondered whether you have a thyroid condition?
• 1:07
  Dr. Komal Patil-Sisodia: I know I've been guilty of this, and what I see very commonly in my practice is women come in wondering if they have a thyroid condition when truly it is something else entirely.
• 1:21
  Dr. Komal Patil-Sisodia: And today's episode is going to focus on why your thyroid is not the only explanation for your symptoms.
• 1:28
  Dr. Komal Patil-Sisodia: I very frequently see women who are in their mid-40s, sometimes even late 30s, and they're feeling exhausted and cold when everyone else is warm, and they can't lose weight despite doing everything right.
• 1:40
  Dr. Komal Patil-Sisodia: I've been in that situation, and I've asked my doctor to check my thyroid, but then the thyroid test comes back totally normal, and we're often told to sleep more and stress less, and then we leave the office with not really having much of a plan.
• 1:57
  Dr. Komal Patil-Sisodia: And a lot of us will spend time wondering,"Gosh, is it in my head?
• 2:01
  Dr. Komal Patil-Sisodia: Like, what is actually going on?" So today, I want to talk about the most tested, most Googled, most misunderstood gland in the female body, the thyroid gland.
• 2:12
  Dr. Komal Patil-Sisodia: And I want to start by telling you something that could be uncomfortable.
• 2:16
  Dr. Komal Patil-Sisodia: Most of the time, when a woman comes to me convinced that it's their thyroid, it isn't.
• 2:22
  Dr. Komal Patil-Sisodia: But that doesn't mean nothing's wrong.
• 2:24
  Dr. Komal Patil-Sisodia: It means we've been asking the wrong questions.
• 2:27
  Dr. Komal Patil-Sisodia: So let's talk about the first myth that I want to dispel, which is fatigue and weight gain mean you automatically have thyroid disease.
• 2:34
  Dr. Komal Patil-Sisodia: And I see this myth everywhere.
• 2:37
  Dr. Komal Patil-Sisodia: Hypothyroidism's Textbook symptoms, the ones that we learn about in medical school, are things like fatigue, weight gain, cold intolerance, brain fog, hair loss.
• 2:48
  Dr. Komal Patil-Sisodia: And if you Google, like, that's the first thing that will pop up, thyroid, thyroid, thyroid.
• 2:52
  Dr. Komal Patil-Sisodia: And thyroid is the most tested endocrine organ in primary care because when it's the right diagnosis, it's something that's easily fixable and can actually alleviate a lot of these symptoms.
• 3:05
  Dr. Komal Patil-Sisodia: And it's interesting because the labs are now starting to do these direct-to-consumer lab tests, so people are testing their own thyroid.
• 3:13
  Dr. Komal Patil-Sisodia: I've had a few patients show up, and I don't see that they've done my labs in the system, but they're like,"Oh, no, no, no, I just ordered my own thyroid labs through this other lab, and I got them done." What I actually want to talk about is whether you need this testing or not, right?
• 3:31
  Dr. Komal Patil-Sisodia: It's not that you shouldn't get tested.
• 3:33
  Dr. Komal Patil-Sisodia: In fact, one in four women will have some degree of thyroid dysfunction postmenopausally, and that's, like, 25% of us, right?
• 3:41
  Dr. Komal Patil-Sisodia: So it's not unreasonable to check it, but when the tests come back normal, it's reasonable to do a little bit more and ask more questions Fatigue and weight gain are generally the most common presenting symptoms of thyroid disease.
• 3:57
  Dr. Komal Patil-Sisodia: And most people with these symptoms should get tested.
• 3:59
  Dr. Komal Patil-Sisodia: This is appropriate and reasonable.
• 4:02
  Dr. Komal Patil-Sisodia: And the myth isn't that the testing is wrong.
• 4:04
  Dr. Komal Patil-Sisodia: The myth is the assumption that these symptoms automatically equal thyroid disease.
• 4:09
  Dr. Komal Patil-Sisodia: And the related myth is that a normal thyroid result means the search is over.
• 4:13
  Dr. Komal Patil-Sisodia: Fatigue and weight gain are two of the most common and non-specific symptoms we have in medicine, and the majority of patients who present with those symptoms don't actually have hypothyroidism.
• 4:24
  Dr. Komal Patil-Sisodia: In fact, when I test people, more often than not, the levels come back normal.
• 4:31
  Dr. Komal Patil-Sisodia: So definitely go get tested.
• 4:32
  Dr. Komal Patil-Sisodia: That part is right.
• 4:33
  Dr. Komal Patil-Sisodia: And the US Preventative Services Task Force guidance basically says we shouldn't screen everybody if they're asymptomatic, but if you're having symptoms, you should get screened.
• 4:46
  Dr. Komal Patil-Sisodia: But if the labs come back normal, it's not the end of the workup.
• 4:51
  Dr. Komal Patil-Sisodia: There is still something causing your fatigue and weight gain, and we need to find out what that is.
• 4:55
  Dr. Komal Patil-Sisodia: So in midlife women, what I commonly see is that the normal thyroid labs plus fatigue and weight gain are commonly due to things like perimenopause, insulin resistance, or sleep disruption from perimenopause, menopause symptoms.
• 5:11
  Dr. Komal Patil-Sisodia: So getting tested is the right move.
• 5:13
  Dr. Komal Patil-Sisodia: Stopping when the labs are normal is the mistake.
• 5:15
  Dr. Komal Patil-Sisodia: A normal thyroid panel doesn't mean nothing is wrong.
• 5:18
  Dr. Komal Patil-Sisodia: It just means that nothing is wrong with the thyroid, and we gotta keep looking.
• 5:22
  Dr. Komal Patil-Sisodia: So now let's talk about myth number two, which is everyone needs a full thyroid panel, and this one drives me bananas because this myth goes in, like, the opposite direction of myth one, this is a common thing that I hear in wellness and functional medicine spaces, where getting a full panel has become default advice.
• 5:42
  Dr. Komal Patil-Sisodia: And I think that's wrong because it creates more questions than it does answers.
• 5:47
  Dr. Komal Patil-Sisodia: And I want to talk a little bit about what the guidelines say, the ones that are based in science and evidence and research.
• 5:54
  Dr. Komal Patil-Sisodia: For the vast majority of, people who are in that outpatient setting who are being evaluated for primary thyroid disease, TSH alone is the initial recommended test.
• 6:05
  Dr. Komal Patil-Sisodia: And let's talk about why that is., TSH stands for thyroid-stimulating hormone, which is a hormone that is released from the pituitary gland.
• 6:12
  Dr. Komal Patil-Sisodia: The pituitary gland is the center in your brain that controls the hormonal action of the adrenals, the thyroid, the testes, and the ovaries.
• 6:24
  Dr. Komal Patil-Sisodia: It can also produce other hormones that regulate salt and water balance, like desmopressin or prolactin, which is crucial for breastfeeding.
• 6:32
  Dr. Komal Patil-Sisodia: The pituitary does a lot.
• 6:33
  Dr. Komal Patil-Sisodia: I call it almost like the remote control of the endocrine organs in our body.
• 6:37
  Dr. Komal Patil-Sisodia: For the thyroid specifically, the pituitary gland will release TSH, which stands for thyroid-stimulating hormone.
• 6:46
  Dr. Komal Patil-Sisodia: And if we look at the general majority of people, most people will have dysfunction or disease that originates in their thyroid gland, not in their pituitary.
• 6:59
  Dr. Komal Patil-Sisodia: And finding a pituitary tumor that's disrupting TSH is much less common than finding something going wrong with your thyroid gland.
• 7:08
  Dr. Komal Patil-Sisodia: So, the first and best test tends to be the TSH.
• 7:13
  Dr. Komal Patil-Sisodia: And if the TSH is off, either too high or too low, then we do additional testing to figure out whether there's something else that could be going on, either in the thyroid or very rarely in the pituitary gland.
• 7:28
  Dr. Komal Patil-Sisodia: When we're evaluating whether a lab test is a good starting test, we always look at two things, sensitivity, which rules a disease out, and then specificity, which rules a disease in.
• 7:38
  Dr. Komal Patil-Sisodia: Meaning, is the test sensitive and specific enough in order to do that?
• 7:43
  Dr. Komal Patil-Sisodia: And for a TSH, it's important to note that the sensitivity is ninety-eight percent and the specificity is ninety-two percent for detecting thyroid function.
• 7:56
  Dr. Komal Patil-Sisodia: Those are pretty good odds.
• 7:57
  Dr. Komal Patil-Sisodia: So a two percent chance that you didn't rule it out versus an eight percent chance that you didn't rule it in, like, those are pretty good odds when we look at overall lab testing.
• 8:09
  Dr. Komal Patil-Sisodia: Guidelines from the American Association of Clinical Endocrinologists and the American Thyroid Association are very clear when they state if TSH is within the normal reference range and you don't suspect that something is going on in the pituitary gland, measuring free thyroid hormones like free T4, free T3, they don't actually add any further relevant information.
• 8:32
  Dr. Komal Patil-Sisodia: And the reason why is that free T4 and free T3 are in constant flux.
• 8:37
  Dr. Komal Patil-Sisodia: Those are the thyroid hormones that your thyroid gland, is producing.
• 8:40
  Dr. Komal Patil-Sisodia: Your thyroid gland produces ninety percent T4, which I always call that, like, the savings account of your thyroid, right?
• 8:49
  Dr. Komal Patil-Sisodia: That's the cash that you put aside for a rainy day, and it gets activated to T3 when your body and the different tissues need to use it.
• 8:58
  Dr. Komal Patil-Sisodia: Now, your thyroid gland makes about ten percent T3'cause you gotta have some that you can pull on in a pinch, and I call that the checking account.
• 9:05
  Dr. Komal Patil-Sisodia: But every tissue in your body has these enzymes called deiodinases, and they're called that because thyroid hormone's made out of iodine molecules.
• 9:15
  Dr. Komal Patil-Sisodia: And T4 has four iodine molecules, and T3 has three iodine molecules.
• 9:21
  Dr. Komal Patil-Sisodia: And because each tissue is metabolically active at a different rate, how much T3 you need in each different tissue is going to vary.
• 9:29
  Dr. Komal Patil-Sisodia: That's why our body is so smart.
• 9:31
  Dr. Komal Patil-Sisodia: That's why we have these deiodinase enzymes that are present within different tissues so that it can work on that conversion process of turning T4 into T3 so that that particular organ system can use it.
• 9:45
  Dr. Komal Patil-Sisodia: And when I say organ systems are metabolically active at different rates, I'm going to give, a very basic example.
• 9:52
  Dr. Komal Patil-Sisodia: We think about our heart and our cardiovascular system.
• 9:56
  Dr. Komal Patil-Sisodia: Our heart is very active.
• 9:57
  Dr. Komal Patil-Sisodia: It's continuously pumping blood through our body.
• 9:59
  Dr. Komal Patil-Sisodia: All of the arteries and veins have to take it to the end tissues and back.
• 10:05
  Dr. Komal Patil-Sisodia: And so it is a very active system.
• 10:07
  Dr. Komal Patil-Sisodia: Versus think of your skin as an organ.
• 10:10
  Dr. Komal Patil-Sisodia: Our skin is not as visually metabolically active as our heart is.
• 10:16
  Dr. Komal Patil-Sisodia: So it may need less T3 than the heart system to continue functioning.
• 10:22
  Dr. Komal Patil-Sisodia: And so because each tissue in our body is so fine-tuned, the T4 and T3 that we measure in our bloodstream is not actually indicative of what might be going on at a tissue level, like what's actually happening in the tissues of the heart or what's happening in the skin for T4 and T3.
• 10:38
  Dr. Komal Patil-Sisodia: So they're not really the most reliable markers, and I think continually testing those because they are fluctuating up and down depending on what's going on in your body, it can create a really confusing picture, and people can get diagnoses that are not necessarily true.
• 10:54
  Dr. Komal Patil-Sisodia: So doing a full panel, right, to include all the free hormone levels, it doesn't always necessarily help.
• 11:01
  Dr. Komal Patil-Sisodia: And honestly, as an endocrinologist, when I'm looking at it, if those levels are in the normal range for the most part, or even if they aren't and the TSH is normal, I will have a discussion kind of based around that that's a little bit more nuanced There are a few scenarios in which we want to know these things.
• 11:23
  Dr. Komal Patil-Sisodia: So if the TSH is elevated, we want to know the free T4 level because the free T4 level, if it is normal or low, indicates to us whether there is what we call overt hypothyroidism, meaning this is obvious hypothyroidism because the T4 is low and we don't have enough circulating in the system, or what we call subclinical hypothyroidism, meaning you can have a normal free T4, but the TSH is above the reference range.
• 11:53
  Dr. Komal Patil-Sisodia: And if the TSH is low, for example, then we look at free T4 and free T3 to look at whether somebody has hyperthyroidism.
• 12:03
  Dr. Komal Patil-Sisodia: Because TSH is the signal going from your brain to the thyroid gland to make it produce thyroid hormone.
• 12:11
  Dr. Komal Patil-Sisodia: The two main scenarios in which it might be too high or too low, are hypothyroidism and hyperthyroidism.
• 12:16
  Dr. Komal Patil-Sisodia: Think about your brain like a mom who is waiting for a call from their kid, right?
• 12:27
  Dr. Komal Patil-Sisodia: And if the kid is not calling, so think of that as like the thyroid not making enough thyroid hormone, the mom is getting increasingly worried, like the pituitary gland is getting increasingly worried that there's not enough thyroid hormone in circulation.
• 12:42
  Dr. Komal Patil-Sisodia: And so it starts sending out a signal rapidly to try and get in touch with the thyroid, and that's why the TSH goes up.
• 12:50
  Dr. Komal Patil-Sisodia: It's the same way like a mom would keep calling their kid if they're not hearing from them within a certain timeframe, right?
• 12:57
  Dr. Komal Patil-Sisodia: Now, on the flip side, think about it like the thyroid gland is super overactive, so it's overproducing thyroid hormone.
• 13:05
  Dr. Komal Patil-Sisodia: And I always think about this like when a kiddo wants something from their parents, right?
• 13:10
  Dr. Komal Patil-Sisodia: Like they want a new toy or they want something that has caught their attention and they keep asking again and again and again and again.
• 13:17
  Dr. Komal Patil-Sisodia: And the mom, in this case the pituitary gland, is like,"Oh my gosh, there's too much going on," and they kind of shut down their communication a little bit.
• 13:27
  Dr. Komal Patil-Sisodia: So this is the mom hiding in the pantry just trying to get a moment of peace while their toddler is asking why a million times or I want this a million times, right?
• 13:37
  Dr. Komal Patil-Sisodia: And again, I'm being facetious with these descriptions, but sometimes it helps to visualize how that system works so that you can understand why we do the testing that we do.
• 13:47
  Dr. Komal Patil-Sisodia: Now, when the pituitary gland doesn't work, then the tests are not as predictable as what I just described.
• 13:56
  Dr. Komal Patil-Sisodia: The scenarios that I just described to you are as if your pituitary gland is working perfectly.
• 14:01
  Dr. Komal Patil-Sisodia: However, there are things that can affect the pituitary gland, just like there are things that can affect the thyroid gland.
• 14:07
  Dr. Komal Patil-Sisodia: The most common thing we see is if there is a growth in the pituitary gland that is affecting how the cells function in that area.
• 14:15
  Dr. Komal Patil-Sisodia: You can have issues with your thyroid.
• 14:17
  Dr. Komal Patil-Sisodia: You can have issues with your adrenals.
• 14:18
  Dr. Komal Patil-Sisodia: You can have issues with the estrogen and testosterone coming from the ovaries and the testes.
• 14:22
  Dr. Komal Patil-Sisodia: So if we suspect what we call central or secondary hypothyroidism because something's wrong with the pituitary, then we need to do additional testing.
• 14:32
  Dr. Komal Patil-Sisodia: And free T4 will really help us because if the TSH is low, meaning the pituitary isn't producing enough, and the free T4 is low, then we worry that there's something going on in the pituitary gland.
• 14:43
  Dr. Komal Patil-Sisodia: And in patients that I see that in, I will scan their head with an MRI to make sure that there's not a tumor there Now, other scenarios where these tests cannot fall into those regular patterns will be pregnancy.
• 14:56
  Dr. Komal Patil-Sisodia: In pregnancy, the reference ranges for what is a normal TSH and what is a normal T4 are very different than what they are in non-pregnant individuals.
• 15:06
  Dr. Komal Patil-Sisodia: And then in acute illness, so say you're sick enough to be hospitalized or put in the ICU, because thyroid hormone is an active hormone and it's constantly putting you in this state of being able to metabolize, your body actually wants you to heal and slow down.
• 15:24
  Dr. Komal Patil-Sisodia: And so the thyroid tests actually become very unpredictable.
• 15:27
  Dr. Komal Patil-Sisodia: And there's this condition called non-thyroidal illness that can either transiently increase or decrease the amount of thyroid hormone, that can either transiently decrease or increase the amount of TSH.
• 15:42
  Dr. Komal Patil-Sisodia: And the free T4 and free T3 levels can also be affected depending on what the body needs in that stage.
• 15:48
  Dr. Komal Patil-Sisodia: And we call that, non-thyroidal illness or euthyroid sick was the old term.
• 15:53
  Dr. Komal Patil-Sisodia: And a lot of times what we'll do is if we think it is all due to illness, we let the illness resolve before we put people on treatment.
• 16:01
  Dr. Komal Patil-Sisodia: I've seen people get started on thyroid medication or anti-thyroid medication when they're in the hospital, and it really causes some issues for them when they get out because their thyroid function was actually fine.
• 16:12
  Dr. Komal Patil-Sisodia: It just looked a little funny because they were sick.
• 16:14
  Dr. Komal Patil-Sisodia: So if you're sick, you don't want to get your thyroid levels tested during that time.
• 16:18
  Dr. Komal Patil-Sisodia: You want to wait two to four weeks after the illness has resolved, usually four.
• 16:23
  Dr. Komal Patil-Sisodia: That tends to be my preference.
• 16:25
  Dr. Komal Patil-Sisodia: So we can actually see if there is something going on with your thyroid.
• 16:30
  Dr. Komal Patil-Sisodia: And then early in treatment changes, right, when we change your medication and we're looking to see how that's working, sometimes the tests don't catch up to what we're giving you.
• 16:43
  Dr. Komal Patil-Sisodia: So that will be why your doctor tells you you can't have your thyroid test checked every week or every two weeks because the And that's why your doctor will tell you it's not reasonable to check thyroid tests every week or every two weeks.
• 16:59
  Dr. Komal Patil-Sisodia: We'll usually wait every four to six weeks to give all of the tests time to settle and the new dose to build up in your system.
• 17:07
  Dr. Komal Patil-Sisodia: Usually, it takes three to four weeks for a dose change to show itself, so I like to wait four to six weeks before repeating labs.
• 17:14
  Dr. Komal Patil-Sisodia: Really, ideally, it would be three months because that really gives your body some time to settle into that dose.
• 17:20
  Dr. Komal Patil-Sisodia: But that tends to be the recommendation from the endocrine societies.
• 17:26
  Dr. Komal Patil-Sisodia: Now, a lot of people will ask me,"Why aren't you checking my free T3?" And when the studies were done and they looked at whether T3 was helpful in the diagnosis of hypothyroidism, the answer is it's not.
• 17:39
  Dr. Komal Patil-Sisodia: It does not add anything to the diagnosis.
• 17:42
  Dr. Komal Patil-Sisodia: We will still treat you.
• 17:43
  Dr. Komal Patil-Sisodia: And like we talked about before, just because your T3 is a little low in that moment doesn't mean that you need T3 supplementation because you could check it, like, two days later and it could be in the normal range.
• 17:55
  Dr. Komal Patil-Sisodia: So we don't base things off of just T3 because that doesn't necessarily make sense in how we treat people.
• 18:02
  Dr. Komal Patil-Sisodia: Free T3, however, is useful when we're trying to diagnose hyperthyroidism, right?
• 18:07
  Dr. Komal Patil-Sisodia: So if the TSH is low and we check a free T4 and a free T3, if those are elevated, that tells us that your thyroid gland is overproducing thyroid hormone, and it's very helpful in making the diagnosis of hyperthyroidism.
• 18:20
  Dr. Komal Patil-Sisodia: And sometimes, it can be helpful in differentiating which type of hyperthyroidism you have.
• 18:26
  Dr. Komal Patil-Sisodia: Now, in terms of thyroid antibodies, there's not any specific guidance around thyroid antibodies like anti-TPO, which stands for thyroid peroxidase antibodies.
• 18:38
  Dr. Komal Patil-Sisodia: This is not considered to be a screening test and is not indicated in people who have a normal TSH in general.
• 18:47
  Dr. Komal Patil-Sisodia: However, if people have subclinical hypothyroidism where their TSH is a little elevated and their free T4 is normal, in people who have an enlarged thyroid gland, in people who have a personal history of autoimmune disease or a strong family history of autoimmune thyroid disease or other types of autoimmune disease, if they're pregnant or they're going through fertility planning or if they develop hyperthyroidism after they deliver, it all makes sense to check these antibodies.
• 19:16
  Dr. Komal Patil-Sisodia: But in general, they're not recommended as a screening test.
• 19:20
  Dr. Komal Patil-Sisodia: Knowing that one in four women will develop hypothyroidism and eighty percent of all autoimmune disease happens in women, I tend to check it more frequently than not, but the guidelines say that it's not necessarily indicated.
• 19:37
  Dr. Komal Patil-Sisodia: So you really want to tailor it to your specific situation, and this is where that discussion with your doctor becomes really important.
• 19:45
  Dr. Komal Patil-Sisodia: Now let's talk about myth number four, which is that subclinical hypothyroidism always needs treatment, meaning when your TSH is elevated but your T4 and T3 are normal, that you should be started on thyroid medication.
• 19:59
  Dr. Komal Patil-Sisodia: This is hard because the reference ranges are all over the place.
• 20:04
  Dr. Komal Patil-Sisodia: Like, if you look at LabCorp or Quest or your local hospital lab, they'll all be slightly different.
• 20:09
  Dr. Komal Patil-Sisodia: So what is truly the range in which we would consider treating?
• 20:15
  Dr. Komal Patil-Sisodia: TSH that is above the upper limit of the reference range of the lab with a normal free T4 is technically means that you have enough circulating thyroid hormone to keep your tissues working properly and you can see this in up to 10% of the adult population.
• 20:31
  Dr. Komal Patil-Sisodia: Thyroid disease is more common in female patients than in male patients.
• 20:36
  Dr. Komal Patil-Sisodia: Age also matters.
• 20:37
  Dr. Komal Patil-Sisodia: TSH will naturally rise as we get older.
• 20:40
  Dr. Komal Patil-Sisodia: So sometimes when we have patients who are 70 or older and their TSH is kind of in that borderline range, we may not need to treat them because they may feel fine, and in putting them on thyroid medication, we can actually make them a little hyperthyroid, which has implications for their heart and their bones.
• 20:59
  Dr. Komal Patil-Sisodia: So you have to be really careful about that.
• 21:00
  Dr. Komal Patil-Sisodia: Now, if they have positive antibodies and they're having symptoms of hypothyroidism, it may be a reasonable consideration.
• 21:07
  Dr. Komal Patil-Sisodia: But again, this is a nuanced conversation with your doctor to make sure that you're getting the right advice.
• 21:12
  Dr. Komal Patil-Sisodia: There was a recent study from the UK that looked at about 22,000 patients and found that the cardiovascular benefit from levothyroxine was actually limited to people whose TSH level was over age-specific ranges.
• 21:31
  Dr. Komal Patil-Sisodia: Now, these age-specific reference ranges are not used frequently, nor are they published by the labs frequently, but the study was interesting because it basically told us that a single fixed cutoff for all people is not the right answer.
• 21:45
  Dr. Komal Patil-Sisodia: These things are going to vary a bit with age, so a higher TSH might be better for somebody over the age of seventy compared to somebody who is in their twenties.
• 21:54
  Dr. Komal Patil-Sisodia: So again, a very nuanced discussion is needed with your doctor.
• 21:59
  Dr. Komal Patil-Sisodia: So let's talk a little bit about the evidence in older adults.
• 22:02
  Dr. Komal Patil-Sisodia: So in patients who are sixty-five and older, there's actually not any existing evidence that levothyroxine is beneficial for subclinical hypothyroidism.
• 22:13
  Dr. Komal Patil-Sisodia: So there was a trust trial that was done in twenty seventeen and published in the New England Journal of Medicine that looked at seven hundred thirty-seven adults sixty-five plus on levothyroxine versus placebo, and they actually found no difference in hypothyroid symptoms, meaning like fatigue, quality of life, their cognition, their blood pressure, their weight, or their vascular markers one year out for being on that therapy.
• 22:39
  Dr. Komal Patil-Sisodia: And a second analysis that looked at this also found that the people who had the most symptoms also did not feel any benefit.
• 22:47
  Dr. Komal Patil-Sisodia: So they really did try and narrow in on who was feeling symptoms concerning for hypothyroidism the most, and treating them when they had subclinical hypothyroidism didn't actually produce any benefit to their symptoms.
• 22:59
  Dr. Komal Patil-Sisodia: And then there was another combined analysis of adults eighty and older from two separate trials that basically found the same thing.
• 23:07
  Dr. Komal Patil-Sisodia: Treatment with levothyroxine, can increase the risk of heart arrhythmias like atrial fibrillation, can increase the risk of osteoporosis, and can increase mortality.
• 23:20
  Dr. Komal Patil-Sisodia: But It's the over-treatment that actually does those things.
• 23:24
  Dr. Komal Patil-Sisodia: So if you are treating somebody who doesn't need it, the odds that you put them into hyperthyroidism and put them at the risk of all of these other things is going to be there.
• 23:36
  Dr. Komal Patil-Sisodia: So what we call iatrogenic thyrotoxicosis, which means becoming hyperthyroid from taking too much levothyroxine or another thyroid hormone formulation, and making that person's TSH become too low, so under point four, that will increase the risk of atrial fibrillation and osteoporosis and fracture risk.
• 23:58
  Dr. Komal Patil-Sisodia: And this has been well established in the data, and it's common.
• 24:01
  Dr. Komal Patil-Sisodia: It's noted that fifteen to thirty-eight percent of people on levothyroxine have a TSH that's below range, meaning they're over-treated.
• 24:10
  Dr. Komal Patil-Sisodia: And a recent Journal of the American Medical Association study found that sixty-four percent of older adults who are now on low-dose levothyroxine, meaning less than fifty micrograms a day, could probably successfully stop their medication entirely and not have to go back on it, which means that they were probably treated unnecessarily in the first place.
• 24:32
  Dr. Komal Patil-Sisodia: So let's circle back to levothyroxine that has been appropriately dosed.
• 24:37
  Dr. Komal Patil-Sisodia: And I can't tell you the number of people who come into my office and they're like,"Oh, I just read on the insert for my levothyroxine that it causes osteoporosis, and I have osteoporosis." And we look back, and their thyroid levels have been normal the whole time.
• 24:50
  Dr. Komal Patil-Sisodia: That levothyroxine has not caused their osteoporosis.
• 24:53
  Dr. Komal Patil-Sisodia: It's truly only if you over-treat somebody and you make them hyperthyroid.
• 24:58
  Dr. Komal Patil-Sisodia: And this has been shown in a meta-analysis of five observational studies and two randomized control trials that showed that if you have a normal TSH, and you're on thyroid hormone, your all-cause mortality or cardiovascular mortality was actually appropriate or lower because you weren't being overdosed.
• 25:20
  Dr. Komal Patil-Sisodia: So the risk isn't with the medication, it's all with the dose and whether the medication was indicated to begin with.
• 25:27
  Dr. Komal Patil-Sisodia: For the general population, we say that treatment is appropriate when the TSH is consistently greater than ten, and that's endorsed by the American Thyroid Association, the European Thyroid Association, and other societies.
• 25:41
  Dr. Komal Patil-Sisodia: Younger symptomatic patients with other risk factors will benefit from treatment.
• 25:46
  Dr. Komal Patil-Sisodia: And then in pregnancy or preconception, we want to make sure that the TSH level is below 2.5 prior to conceiving a pregnancy and even throughout the pregnancy to make sure enough thyroid hormone is going from mom to the baby.
• 26:00
  Dr. Komal Patil-Sisodia: Because for the first 20 to 24 weeks in utero, the baby doesn't have a formed or functional thyroid gland, so it's dependent on mom And another claim that I hear made over and over again is that thyroid medication is important for reducing your cardiovascular disease risk.
• 26:19
  Dr. Komal Patil-Sisodia: I think that that benefit A lot of the data around this statement is observational, and a lot of the benefit is actually in younger patients versus older patients.
• 26:30
  Dr. Komal Patil-Sisodia: So we need to be really careful about who we're treating when and how and with what dose.
• 26:35
  Dr. Komal Patil-Sisodia: So again, this is not about whether thyroid medication is safe.
• 26:42
  Dr. Komal Patil-Sisodia: It is safe when it's dosed appropriately and to the right patients.
• 26:46
  Dr. Komal Patil-Sisodia: So this isn't about whether thyroid medication is safe.
• 26:49
  Dr. Komal Patil-Sisodia: It's about, number one, did you need it in the first place?
• 26:52
  Dr. Komal Patil-Sisodia: And number two, did you get the right dose?
• 26:55
  Dr. Komal Patil-Sisodia: So those are I want to switch gears a little bit now and talk about the menopause thyroid connection that no one explains.
• 27:02
  Dr. Komal Patil-Sisodia: So this is kind of where my two specialties collide, the endocrinology and the women's health, and I think we do a really crappy job of explaining it to people.
• 27:09
  Dr. Komal Patil-Sisodia: Perimenopause and menopause change how we interpret thyroid tests and how we manage thyroid medications.
• 27:16
  Dr. Komal Patil-Sisodia: I always tell my patients that thyroid symptoms and menopause symptoms are kinda like a Venn diagram where the circles are almost entirely overlapping, and what gets left out is really the vaginal symptoms and the pelvic floor symptoms that we see with menopause that you don't necessarily see with thyroid conditions.
• 27:38
  Dr. Komal Patil-Sisodia: Most of the symptoms can actually occur in either condition, so hot flashes, palpitations, sweating, mood changes, weight fluctuations, sleep disturbances.
• 27:47
  Dr. Komal Patil-Sisodia: These are core menopause symptoms, and they're core thyroid symptoms, so that overlap is really not subtle at all.
• 27:53
  Dr. Komal Patil-Sisodia: And even in women whose thyroid function is completely normal, the severity of the menopause symptoms can correlate with the thyroid hormone levels It's kind of like the two systems are talking to each other, and because of this overlap, several professional societies recommend a lower threshold for checking TSH in perimenopausal women.
• 28:13
  Dr. Komal Patil-Sisodia: That's why I test the way that I do.
• 28:15
  Dr. Komal Patil-Sisodia: You don't need a higher threshold, you need a lower threshold because there are so many things that are going on and changing all at once.
• 28:21
  Dr. Komal Patil-Sisodia: And so menopausal symptoms should prompt testing, but not make you think that,"Oh, I don't need to test this person for thyroid disease." Because the TSH starts rising as we get older, your TSH reference range is probably not going to be the same as when you were 28 when you're in your 40s and 50s, because that's really when that upper limit starts rising, and that's earlier than when it happens to men.
• 28:44
  Dr. Komal Patil-Sisodia: For men, that doesn't really start to happen until they hit 60 plus.
• 28:48
  Dr. Komal Patil-Sisodia: There have been, several studies looking at this.
• 28:51
  Dr. Komal Patil-Sisodia: There was a large 2025 Annals of Internal Medicine analysis of NHANES data that found that applying age, sex, and race-specific TSH reference ranges actually reclassified almost 50%, so 48 and a half percent of people who were previously diagnosed with subclinical hypothyroidism as totally normal, especially in women and older adults.
• 29:13
  Dr. Komal Patil-Sisodia: A 2026 population study in Hong Kong found that same pattern, that age and sex-specific ranges cut the proportion of people who were classified with thyroid dysfunction from 30.8% down to 18.6%.
• 29:27
  Dr. Komal Patil-Sisodia: So the point is that we're over-diagnosing thyroid conditions when people don't actually have them.
• 29:32
  Dr. Komal Patil-Sisodia: And that overall, a TSH of five to six in a 55-year-old post-menopausal woman might be normal for her and not subclinical hypothyroidism that requires treatment.
• 29:44
  Dr. Komal Patil-Sisodia: I have several patients in my practice who feel terrible when we lower their TSH below five, and I have let them be at higher TSH levels if we're keeping their free T4 normal and their symptoms are under control and they're not having any weird metabolic things like high cholesterol or other changes like weight gain that are happening to them Now interestingly, thyroid disease does increase as we age, so it's important to know that even with those higher cutoffs, more people will develop thyroid dysfunction as they age There's a Korean study of over fifty-three thousand women that showed both overt, meaning clear diagnosis of hypothyroidism, and subclinical hypothyroidism were more common in late perimenopause and postmenopause, even when we adjusted for age.
• 30:37
  Dr. Komal Patil-Sisodia: And in women over sixty, subclinical hypothyroidism was present in up to about twenty percent of the population.
• 30:42
  Dr. Komal Patil-Sisodia: And there are other studies that show that that number can be as high as twenty-three or twenty-four percent.
• 30:48
  Dr. Komal Patil-Sisodia: And here's the part that almost no one tells patients.
• 30:51
  Dr. Komal Patil-Sisodia: Estrogen therapy is going to change your thyroid numbers a little bit.
• 30:54
  Dr. Komal Patil-Sisodia: I will always reassess thyroid levels after I start somebody on hormone therapy if they're already on levothyroxine.
• 31:01
  Dr. Komal Patil-Sisodia: Oral estrogen increases a protein called thyroxine-binding globulin, and this is the protein that thyroid hormone binds to, which can raise your total T4, and it can increase your levothyroxine requirement because what's floating around in your blood gets bound up by this protein and your free T4 levels can drop, and you can feel more hypothyroid.
• 31:23
  Dr. Komal Patil-Sisodia: So in a trial that looked at this, it was estimated that about three out of ten hypothyroid women, so about thirty percent, on oral estradiol needed a dose increase.
• 31:35
  Dr. Komal Patil-Sisodia: Now interestingly, the transdermal estradiol, the patch, because it's not going through the liver, has a minimal effect on the thyroxine-binding globulin, and we may not have to adjust the dose as much.
• 31:48
  Dr. Komal Patil-Sisodia: Additionally, if thyroid function is normal, oral estrogen will cause a temporary rise in TSH because that binding protein increases, but then it levels out because your thyroid gland compensates.
• 32:01
  Dr. Komal Patil-Sisodia: And that happens in about eighteen percent of women.
• 32:04
  Dr. Komal Patil-Sisodia: But if you're hypothyroid and you can't compensate, and your free T4 falls, that's when we're going to adjust your medication.
• 32:10
  Dr. Komal Patil-Sisodia: So the bottom line is, if you're starting menopause hormone therapy, and you're hypothyroid, we're going to need to repeat your thyroid function test six to eight weeks after starting oral estrogen and adjust your levothyroxine dose.
• 32:23
  Dr. Komal Patil-Sisodia: And if that is something that's happening, you can talk to your doctor about whether transdermal might make more sense for you.
• 32:31
  Dr. Komal Patil-Sisodia: I personally will check with transdermal estradiol starts as well sometimes if people are starting to develop worsening symptoms And one more thing I want to call out is that avoiding overtreatment really matters.
• 32:44
  Dr. Komal Patil-Sisodia: We don't want to overtreat with levothyroxine because as estrogen levels fall, that has an effect on your cardiovascular disease risk as well as your risk of developing osteoporosis.
• 32:57
  Dr. Komal Patil-Sisodia: And if we're overtreating women and giving them thyroid hormone when they don't necessarily need it, we're also enhancing those risks.
• 33:04
  Dr. Komal Patil-Sisodia: So you have to talk to your doctor.
• 33:06
  Dr. Komal Patil-Sisodia: You have to make sure that they're aware of your history, of your family history, of what your symptoms are so that you can make the best decision based on your lab tests.
• 33:17
  Dr. Komal Patil-Sisodia: Because each age range deserves some nuance.
• 33:19
  Dr. Komal Patil-Sisodia: So if you're perimenopausal and your symptoms overlap with thyroid symptoms, that's a reason to test.
• 33:25
  Dr. Komal Patil-Sisodia: It's not a reason to assume it's just menopause.
• 33:28
  Dr. Komal Patil-Sisodia: And if you start estrogen while you're on thyroid medication, that's a reason to retest your thyroid levels, not just a reason to guess, like, you know, what's going to happen to those levels.
• 33:38
  Dr. Komal Patil-Sisodia: So if you're symptomatic and you're told that your thyroid is fine because you had some screening lab tests, here's what to ask.
• 33:47
  Dr. Komal Patil-Sisodia: And notice that nothing on the list that I say is going to be to demand a full panel.
• 33:51
  Dr. Komal Patil-Sisodia: So the first question I want you to ask your doctor is,"Does my clinical picture fit one, one of the specific scenarios where testing beyond TSH actually adds information?" So,"Do you think I have a pituitary disorder?
• 34:04
  Dr. Komal Patil-Sisodia: Were there any recent medication changes that could affect my thyroid levels?
• 34:08
  Dr. Komal Patil-Sisodia: Could I be pregnant?" That's more common in midlife than you would think.
• 34:12
  Dr. Komal Patil-Sisodia: Or,"Was I really sick when I had those levels drawn?" Next question would be,"If my TSH is normal, what else could explain these symptoms?
• 34:21
  Dr. Komal Patil-Sisodia: Has anyone evaluated me for perimenopause?
• 34:24
  Dr. Komal Patil-Sisodia: Has my estradiol been checked?" Has anyone evaluated me for perimenopause?
• 34:30
  Dr. Komal Patil-Sisodia: The other thing you can ask, is my TSH being interpreted against an age and sex appropriate reference range or is it just a standard lab cutoff?
• 34:42
  Dr. Komal Patil-Sisodia: The next question is, could my insulin resistance be contributing?
• 34:45
  Dr. Komal Patil-Sisodia: What about my iron levels?
• 34:47
  Dr. Komal Patil-Sisodia: What if my TSH is mildly elevated?
• 34:50
  Dr. Komal Patil-Sisodia: Is there any evidence for me to be on treatment at my age?
• 34:54
  Dr. Komal Patil-Sisodia: And then if I'm starting estrogen and I'm on levothyroxine, when should we recheck my TSH and should I be on transdermal instead of oral?
• 35:02
  Dr. Komal Patil-Sisodia: And if you're already on levothyroxine and still don't feel well, that's also a real clinical conversation that's worth having, and I can do a whole separate episode on that about the different thyroid hormone formulations that are out there and what combinations you can try, but we'll get to that another day.
• 35:21
  Dr. Komal Patil-Sisodia: The next episode in this thyroid series is going to look at all of the different myths that we hear online and in the wellness space, and I'm excited to break that down for you all.
• 35:31
  Dr. Komal Patil-Sisodia: So make sure you tune in to talk about the diet and treatment myths, cruciferous vegetables, soy, gluten, desiccated thyroid, iodine supplements and more.
• 35:41
  Dr. Komal Patil-Sisodia: That's it for today, but the conversation doesn't have to stop here.
• 35:45
  Dr. Komal Patil-Sisodia: Come find me on Instagram or TikTok at drpatilsisodia.
• 35:49
  Dr. Komal Patil-Sisodia: And if something from today's episode resonated, I'd genuinely love to hear about it.
• 35:53
  Dr. Komal Patil-Sisodia: Leave a review, which makes the podcast searchable, share the episode, or just send me a message.
• 35:59
  Dr. Komal Patil-Sisodia: The more women who have access to this information, the better.
• 36:02
  Dr. Komal Patil-Sisodia: I'll see you next week on the next episode