Rethinking Thyroxine Treatment: The High Rates of Spontaneous Normalization in Subclinical Hypothyroidism

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In a world where medical interventions are often the first line of defense, a recent study sheds light on the power of the body to heal itself, particularly when it comes to subclinical hypothyroidism in older adults. But what if we could go beyond watchful waiting and actively support the thyroid's natural healing process?

Subclinical hypothyroidism, a condition characterized by elevated thyroid-stimulating hormone (TSH) levels with normal free thyroxine (fT4) levels, is a common finding among older adults.1 While the knee-jerk reaction may be to prescribe synthetic hormone replacement therapy, a growing body of evidence suggests that a more conservative approach may be warranted.2

The Study: A Closer Look

A recent study by van der Spoel et al., published in the Journal of Clinical Endocrinology and Metabolism, delved into the natural history of subclinical hypothyroidism in older adults.3 The researchers pooled data from two randomized controlled trials, the TRUST and IEMO 80-plus thyroid trials, to investigate the incidence and determinants of spontaneous normalization of TSH levels in this population.

The study included a pretrial population of 2,335 adults aged 65 and older with at least one elevated TSH measurement and an in-trial placebo group of 361 participants with persistent subclinical hypothyroidism, defined as having at least two elevated TSH measurements more than three months apart.

The Findings: Time Heals

The results were striking. In the pretrial population, a whopping 60.8% of participants saw their TSH levels normalize without any intervention after a median follow-up of one year. Even in the in-trial placebo group, where participants had confirmed persistent subclinical hypothyroidism, 39.9% experienced spontaneous normalization after a year.

The study also identified several factors that increased the likelihood of TSH normalization, including younger age, female sex, lower initial TSH levels, higher normal initial fT4 levels, absence of thyroid peroxidase antibodies, and having a follow-up measurement during the summer months.

The Implications: Less May Be More

These findings have significant implications for the management of subclinical hypothyroidism in older adults. While current guidelines recommend confirming elevated TSH levels with a repeat measurement after 2-3 months, the high rate of spontaneous normalization observed in this study suggests that a third measurement may be prudent before considering treatment.4

The study's authors propose that the TSH reference range should be reevaluated for older adults, with age-related cutoffs that take into account factors like sex and season. By adopting a more nuanced approach, healthcare providers may be able to avoid unnecessary treatment and its associated risks, costs, and burdens.

Beyond Watchful Waiting: Supporting Thyroid Health Naturally

While watchful waiting may be appropriate for many older adults with subclinical hypothyroidism, there are several evidence-based natural approaches that can support thyroid function and potentially enhance the body's innate healing capacity. According to the GreenMedInfo.com database, here are 10 ways to naturally support thyroid health:

1. Ashwagandha: This adaptogenic herb has been shown to improve thyroid function and reduce complications in animal models of hypothyroidism.5

2. Vitamin C: Administration of vitamin C has been found to prevent hippocampal neuronal damage caused by neonatal and juvenile hypothyroidism in rats.6

3. Zinc: Zinc supplementation has been shown to protect against exercise-induced decreases in thyroid hormones and testosterone in both sedentary and athletic individuals.7

4. Vitamin D: Vitamin D supplementation has been found to alleviate hypothyroidism-associated liver dysfunction in animal models.8

5. Nigella sativa (Black Seed): Extracts of Nigella sativa have been shown to prevent hippocampal neural damage after inducing hypothyroidism in animal models.9

6. Magnesium: Magnesium supplementation has been found to prevent exercise-induced reductions in thyroid hormone activity in both sedentary and athletic individuals.10

7. Selenium: Selenium supplementation has been shown to restore euthyroidism in one-third of patients with subclinical hypothyroidism and autoimmune thyroiditis.11

8. Curcumin: Curcumin has been found to protect against hypothyroid-induced altered rectal temperature, serum transaminase activity, and hepatic histoarchitecture in animal models.12

9. Royal Jelly: Royal jelly has been shown to have a therapeutic effect on the degenerative changes associated with hypothyroidism in animal models.13

10. Yoga: Yoga has been found to have a positive effect on female patients suffering from hypothyroidism, potentially reducing the requirement for thyroxine replacement.14

Conclusion: Embracing the Body's Wisdom and Nature's Support

The van der Spoel study serves as a powerful reminder of the body's inherent wisdom and resilience. By shedding light on the natural history of subclinical hypothyroidism in older adults, it challenges us to reconsider our approach to this common condition and embrace a more conservative, patient-centered approach.

As healthcare providers, it's our responsibility to weigh the risks and benefits of intervention carefully and to trust in the body's ability to heal itself when given the chance. By incorporating evidence-based natural approaches to support thyroid function, we may further enhance the body's innate healing capacity and empower our patients to achieve optimal thyroid health.


References

1: Biondi, B., Cappola, A. R., & Cooper, D. S. (2019). Subclinical Hypothyroidism: A Review. JAMA, 322(2), 153-160. https://doi.org/10.1001/jama.2019.9052

2: Biondi, B., & Cappola, A. R. (2022). Subclinical hypothyroidism in older individuals. The Lancet Diabetes & Endocrinology, 10(2), 129-141. https://doi.org/10.1016/S2213-8587(21)00325-X

3: Spoel, E., Vliet, N. A., Poortvliet, R., Puy, R. S., Elzen, W., Quinn, T. J., Stott, D. J., Sattar, N., Kearney, P. M., Blum, M. R., Alwan, H., Rodondi, N., Collet, T.-H., Westendorp, R., Ballieux, B. E., Jukema, J. W., Dekkers, O. M., Gussekloo, J., Mooijaart, S. P., & Heemst, D. (2023). Incidence and Determinants of Spontaneous Normalization of Subclinical Hypothyroidism in Older Adults. The Journal of Clinical Endocrinology & Metabolism, 109(3), e1167-e1174. https://doi.org/10.1210/clinem/dgad623

4: Pearce, S. H., Brabant, G., Duntas, L. H., Monzani, F., Peeters, R. P., Razvi, S., & Wemeau, J. L. (2013). 2013 ETA Guideline: Management of Subclinical Hypothyroidism. European Thyroid Journal, 2(4), 215-228. https://doi.org/10.1159/000356507

5: Panda, S., & Kar, A. (1998). Changes in thyroid hormone concentrations after administration of ashwagandha root extract to adult male mice. Journal of Pharmacy and Pharmacology, 50(9), 1065-1068. https://doi.org/10.1111/j.2042-7158.1998.tb06923.x

6: Beheshti, F., Hosseini, M., Shafei, M. N., Soukhtanloo, M., Ghasemi, S., Vafaee, F., & Zarepoor, L. (2017). The effects of Nigella sativa extract on hypothyroidism-associated learning and memory impairment during neonatal and juvenile growth in rats. Nutritional Neuroscience, 20(1), 49-59. https://doi.org/10.1179/1476830514Y.0000000144

7: Kilic, M., Baltaci, A. K., Gunay, M., Gökbel, H., Okudan, N., & Cicioglu, I. (2006). The effect of exhaustion exercise on thyroid hormones and testosterone levels of elite athletes receiving oral zinc. Neuro Endocrinology Letters, 27(1-2), 247-252. https://pubmed.ncbi.nlm.nih.gov/16648789/

8: Rastegar-Moghaddam, S. H., Akbarian, M., Rajabian, A., Alipour, F., Ebrahimzadeh Bideskan, A., & Hosseini, M. (2023). Vitamin D alleviates hypothyroidism associated liver dysfunction. Heliyon, 9(8), e18860. https://doi.org/10.1016/j.heliyon.2023.e18860

9: Asiaei, F., Fazel, A., Rajabzadeh, A. A., Hosseini, M., Beheshti, F., & Seghatoleslam, M. (2017). Neuroprotective effects of Nigella sativa extract upon the hippocampus in PTU-induced hypothyroidism juvenile rats: A stereological study. Metabolic Brain Disease, 32(5), 1755-1765. https://doi.org/10.1007/s11011-017-0025-1

10: Cinar, V. (2007). The effects of magnesium supplementation on thyroid hormones of sedentars and Tae-Kwon-Do sportsperson at resting and exhaustion. Neuro Endocrinology Letters, 28(5), 708-712. https://pubmed.ncbi.nlm.nih.gov/17984925/

11: Pirola, I., Gandossi, E., Agosti, B., Delbarba, A., & Cappelli, C. (2016). Selenium supplementation could restore euthyroidism in subclinical hypothyroid patients with autoimmune thyroiditis. Endokrynologia Polska, 67(6), 567-571. https://doi.org/10.5603/EP.2016.0064

12: Subudhi, U., Das, K., Paital, B., Bhanja, S., & Chainy, G. B. N. (2009). Alleviation of enhanced oxidative stress and oxygen consumption of l-thyroxine induced hyperthyroid rat liver mitochondria by vitamin E and curcumin. Chemico-Biological Interactions, 183(1), 85-91. https://doi.org/10.1016/j.cbi.2009.09.005

13: Seymen, C. M., Çakır Gündoğdu, A., Bulut, D. I., Yılmaz Demirtaş, Ç., & Elmas, Ç. (2019). The healing effect of royal jelly on alterated hippocampus morphology against hypothyroidism. Biotechnic & Histochemistry, 94(8), 597-605. https://doi.org/10.1080/10520295.2019.1646997

14: Nilakanthan, S., Metri, K., Raghuram, N., & Hongasandra, N. (2016). Effect of 6 months intense Yoga practice on lipid profile, thyroxine medication and serum TSH level in women suffering from hypothyroidism: A pilot study. Journal of Complementary and Integrative Medicine, 13(2), 189-193. https://doi.org/10.1515/jcim-2014-0079

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