Thyroid Disorders

Most straightforward hypothyroidism and hyperthyroidism can be managed by your primary care doctor. But for Graves' disease, Hashimoto's with fluctuating levels, thyroid nodules, or symptoms despite normal labs — see an endocrinologist. The American Thyroid Association (thyroid.org) has a specialist directory.

TSH is the most important thyroid test. High TSH = underactive thyroid. Low/suppressed TSH = overactive thyroid. Always ask for your actual number, not just normal or abnormal. Also ask for Free T4 at baseline. If you have Hashimoto's, test TPO antibodies once to confirm the diagnosis.

Levothyroxine must be taken on an empty stomach, 30–60 minutes before food, coffee, or other medications. Taking it with food, coffee, calcium, iron, or antacids reduces absorption by 30–50%. Keep dosing consistent. Tirosint gel capsule may help patients with documented absorption issues.

When starting or changing doses, recheck TSH in 6–8 weeks — not 6 months. Wait at least 6 weeks for a true reflection of your new dose. Once stable, annual TSH monitoring is appropriate. Pregnancy dramatically changes thyroid requirements — monitor TSH every 4 weeks in the first trimester.

Thyroid disease increases risk of cardiovascular disease, osteoporosis (from over-treatment or hyperthyroidism), atrial fibrillation, and vitamin D/B12/iron deficiency. Annual lipid panel, bone density if you have a history of hyperthyroidism, and B12/iron/vitamin D levels are recommended.

Hypothyroidism means too little thyroid hormone (TSH elevated, T4 low). Symptoms: fatigue, weight gain, cold intolerance, constipation, depression, brain fog, dry skin, hair loss. Most common cause: Hashimoto's thyroiditis. Treatment: levothyroxine. Hyperthyroidism means too much thyroid hormone (TSH suppressed). Symptoms: weight loss, heat intolerance, rapid heartbeat, anxiety, insomnia, hand tremors. Most common cause: Graves' disease. Treatment: methimazole, radioactive iodine, beta-blockers, or surgery.

Hashimoto's is an autoimmune disease where the immune system attacks the thyroid gland, slowly destroying thyroid cells. It is the most common cause of hypothyroidism in the US. Not everyone with Hashimoto's becomes hypothyroid immediately — thyroid function may be normal even with elevated TPO antibodies. Treatment of Hashimoto's is the same as hypothyroidism: levothyroxine when TSH is elevated.

The standard reference range is approximately 0.5–4.5 mIU/L, though this varies by laboratory. Many patients feel best with TSH between 1.0–2.5 mIU/L. Sub-clinical hypothyroidism (TSH mildly elevated with normal T4) is treated in pregnant women and symptomatic patients. Ask your doctor what TSH target is appropriate for your specific situation.

If TSH is normal but you still have fatigue, brain fog, and weight struggles: (1) Optimize TSH to 1.0–2.0 mIU/L; (2) Ask about Free T3 — some patients don't convert T4 to active T3 efficiently, and adding liothyronine or switching to Armour Thyroid can help; (3) Check iron, vitamin D, B12 — all commonly deficient in thyroid patients and causing similar symptoms; (4) Request a full panel: TSH, Free T4, Free T3, and Reverse T3.

TED (Graves' orbitopathy) is an autoimmune condition causing inflammation around the eye, leading to eye bulging (proptosis), double vision, eye pain, and in severe cases vision loss. Most commonly associated with Graves' hyperthyroidism. For moderate-to-severe active TED, Tepezza (teprotumumab) — IV infusions every 3 weeks for 24 weeks — achieves proptosis reduction in 80%+ of patients. A TED specialist ophthalmologist is essential.