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Thyroid Diagnosis
This patient's clinical story raises the following questions and concerns for me:What was the patient's thyroid diagnosis and what were the results of her thyroid function studies? Did she really have an autoimmune disease of her thyroid, and why then could she stop her thyroid medication without any ill effect? Is she the infrequent patient who has transient thyroiditis and is now better -- for the time being at least?
It is unusual and often dangerous for a patient with an underactive thyroid from autoimmune destruction (or surgical removal for that matter) to stop their thyroid medication for more than a few days to weeks. Once the diagnosis of low thyroid is correctly made, lifelong thyroid replacement is usually necessary and life-saving. It can however be very difficult to find the correct thyroid replacement medication and dose. But what is not questioned is the continued lifelong need for treatment.
This leads me to question whether the patient really has thyroid disease. She may have had blood tests and symptoms that were borderline or conflicting, and one doctor agreed to try empiric treatment to see how she would respond. I have done this myself for a number of conditions and patient complaints in practice. Doctors and laboratory tests are not perfect. Sometime the patient knows best and is the one to decide if treatment is helping. Her lack of response to treatment, however, strongly suggests she does not have a thyroid problem.
Even if our patient was impatient and didn't give the medication enough time, she could not safely and comfortably forego the medication altogether if her thyroid was underactive and not making enough thyroid.
What about the history of high blood pressure and exercise-induced symptoms? Does the patient still have high blood pressure (hypertension) and exercise-induced palpitations? What is her resting heart rate and blood pressure?
A history of high blood pressure and exercise-induced symptoms worries me about possible underlying heart disease -- which I presume our patient has already been tested for. One of the earliest signs of overactive thyroid can be a rise in the pulse rate at rest, and it can often be felt as palpitations or a rapid heartbeat with exercise. In that case, a specific type of heart and blood pressure medication is usually prescribed to slow the heartbeat in cases of overactive thyroid while the thyroid medication is taking effect.
These medications are called beta blockers, with generic drug names such as tenormin or propanolol. These often life-saving medications commonly have side effects such as mental cloudiness, lethargy, feeling slowed down and even depressed. If that happens, I often tell my patient to try taking them at night to avoid some of these side effects. I also tell patients they may tolerate them better if they increase the dose slowly.
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