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Medically Verified By: Dr Mriganka Sekhar Sharma
As a consequence of the widespread adoption of preventive health checks and accessible laboratory tests, thyroid function levels have become a common part of a physician-patient interaction. However, it is not just thyroid levels that raise alarm; rather, it is a handful of results that are comparable to "borderline thyroid levels" for their ability to unsettle patients. Instead of a diagnosis that a physician has arrived at conclusively, patients are left bewildered about whether they are sick or not and concerned about being locked into a lifetime of drugs.
Speaking to Dr Mriganka Sekhar Sharma, MBBS, MS, Fellow American College of Surgeons, Director - General and Minimally Invasive Surgery (Unit-1) and Dr Amit D Goswami, MBBS, MS, FNB (MAS), FIAGES, FCLS, Associate Director - General & Minimally Invasive Surgery (Unit-1), the doctor said, "Thyroid function tests, especially Thyroid-Stimulating Hormone (TSH), are the most sensitive biochemical markers used in the field of medicine. Even a minute change can lead to a corresponding change in the level of TSH. However, it is crucial to note that the reference range used in the laboratory is a statistical calculation performed on a population basis. It aims to provide 95 per cent data on a "normal" population. Therefore, a slightly different level may not be indicative of a thyroid condition."
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One of the most common reasons for borderline results is normal biological variation. TSH follows a circadian rhythm, and levels vary at different times of the day. Stress, sleep deprivation, recent infections, fasting, and hard physical exertion will all influence test results. Steroids, dopamine, and anti-epileptic medications are among some of the more common drugs prescribed, which can alter thyroid parameters. Testing performed during or shortly after illness may therefore reflect temporary changes rather than a chronic problem.
Another commonly seen scenario is subclinical thyroid dysfunction, where TSH is mildly elevated or suppressed, and thyroid hormones remain within normal limits. Large epidemiology studies have reported that the majority of individuals with subclinical hypothyroidism or hyperthyroidism do not progress over many years. Indeed, approximately 50% return to being euthyroid on repeat testing. Progression to overt disease is more likely in selected groups, which include patients with autoimmune thyroiditis who can be identified by testing for thyroid antibodies.
However, the results that appear to be borderline are now more likely to trigger early and often unnecessary treatment. Of particular concern is that when this treatment is started, it is usually continued for the rest of the patient's life. While this is unnecessary for those who do not require the medication, it puts them at risk for conditions that can be prevented by having supplemental thyroid hormones. Complications of excess supplemental hormone that are of particular importance in older patients and those who have pre-existing cardiac conditions include palpitations, nervous agitation, sleep disturbances, bone loss, and arrhythmias.
Another aspect, which plays an equal role, is the trend to associate the occurrence of nonspecific complaints with borderline findings related to the thyroid. Fatigue, weight increase, hair loss, constipation, and depressed mood are among the most common complaints in the clinical setting. These symptoms, although occurring in cases related to the thyroid, are more commonly associated with anemia, vitamin D deficiency, B12 deficiency, stress, depression, poor sleep hygiene, and a sedentary lifestyle. Thus, borderline thyroid findings, treated without regard for the above, very often lead to persistence of symptoms and dissatisfaction with the patient.
Clinical context, accordingly, is very important. In providing a responsible way of managing borderline values for the thyroid function test, one must coordinate the results of the test with the symptoms and physical examination of the patient, along with age, pregnancy state, risk for cardiovascular disease, family history, and medical profile. There will justifiably be instances where the follow-up action will only be to re-evaluate the condition in exactly six to eight weeks. Based on the results requested in certain instances, testing for the presence of thyroid antibodies may need to be undertaken.
Special cases require special concern. In pregnancy, in cases of infertility, or in proven cases of heart disease, more people may be referred to treatment. Yet even then, patient management must not be governed by numbers alone.
Borderline Thyroid Cases: Reflections on a Larger Dilemma in Medicine Today by being pushed to the point of over-sensitivity, the problem of borderline results, as exemplified by borderline cases of thyroid dysfunction, points to a dilemma on the part of today's medical profession: the conflict between early detection as a positive medical objective, on the one hand, and the risk of intervening unnecessarily on the other.
Reassuringly, however, for the patient, one important message may be taken. It is that a thyroid borderline result need not necessarily translate to a lifetime commitment to drugs or a chronic illness. Very often, it only means extra diligence in follow-up visits. In fact, for health providers themselves, it is important to remember that good medicine is just as much a product of sound judgment as it is of good data. In thyroid conditions specifically, data is important, but it is not determinative.
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