Thyroid disorders

The thyroid sets the pace of the body's metabolism, so a thyroid problem can show itself almost anywhere: energy, weight, mood, heart rate, bowels, periods. Most thyroid conditions are diagnosed and treated well by GPs. A specialist opinion helps when the results and the symptoms don't match, when treatment isn't working as you expected, or when a decision has lasting consequences, such as how to treat an overactive thyroid or how to prepare for pregnancy. It is also worth having if you would like time to go through your results properly and understand the options.

Reasons people are referred

• Underactive thyroid (hypothyroidism), including people who still feel unwell on treatment
• Borderline or "subclinical" results, where the question is whether treatment would help
• Symptoms that sound like a thyroid problem when the blood tests are normal
• Overactive thyroid (hyperthyroidism), including Graves' disease and overactive nodules
• Thyroid eye symptoms, with an eye specialist involved where needed
• Thyroid nodules and an enlarged thyroid (goitre)
• Planning a pregnancy with a thyroid condition. During a pregnancy, thyroid care is shared with your maternity team.
• Results that don't fit the picture, including results affected by recent illness, medicines or supplements

The first appointment

Dr Spiliotis goes through your symptoms, medicines and supplements, family history and previous treatment, and examines you. Past results are read as a series, because a run of TSH values over several years often says more than one new result. If you have earlier blood tests, please bring them.

Reading the results

Thyroid blood tests are accurate, but interpreting them can be harder than it looks, and part of a specialist assessment is checking that a result reflects the thyroid at all. TSH tends to rise with age, so a slightly raised value in an older person can be normal for them. Recent illness, pregnancy, some medicines and high-dose biotin supplements all change results, and occasionally an antibody in the blood interferes with the test itself. Less often, a normal TSH hides a problem in the pituitary gland, which controls the thyroid; this is looked for when the history points that way.

Tests

Tests are chosen for the question being asked. Depending on the problem, they may include:

• TSH and free T4, with free T3 when an overactive thyroid is suspected
• Thyroid antibodies, which show whether the immune system is involved
• TSH receptor antibodies, the main blood test for Graves' disease
• A repeat sample, sometimes measured by a different method, when a result looks implausible
• Ultrasound of a lump or an enlarged thyroid
• Ultrasound-guided fine-needle aspiration (FNA) or core biopsy of a nodule, if the ultrasound appearance calls for one. At One Hatfield these are carried out by a head and neck radiologist.
• Molecular testing of the needle sample, such as ThyroSeq, when the result is indeterminate and the answer would change the decision about surgery

Some tests, such as isotope (uptake) scans, are not available at One Hatfield. If you need one, Dr Spiliotis will explain where it can be done and arrange the referral. Each test is charged by the hospital or laboratory that performs it.

How decisions are made

Decisions follow the published evidence and UK guidance, chiefly the NICE thyroid guideline, applied to your circumstances. Some questions have a settled answer. Others, including some borderline results, do not, and then the options and their trade-offs are set out so that the decision can be made with you.

Two examples. For a mildly raised TSH with a normal free T4, trials have found that, on average, people treated with levothyroxine feel no better than people given a placebo. NICE still allows a time-limited trial in some younger adults with symptoms, because an average can hide the individual, and whether a trial makes sense for you depends on your own circumstances. For Graves' disease, tablets, radioactive iodine and surgery all work. The choice depends on the chance of the condition settling, the eyes, plans for pregnancy and what you prefer. Radioactive iodine and surgery are carried out at specialist centres.

If you still feel unwell on levothyroxine

Some people stay tired or unwell even when their blood results on treatment are normal. This is common, and it deserves a careful look before any change of dose. The assessment usually covers whether the original diagnosis was secure; whether the tablets are being absorbed, since food, coffee, some medicines, coeliac disease and stomach conditions can all interfere; whether a change of tablet brand coincided with the symptoms; and whether another condition explains them. Once the TSH is in range, small dose adjustments have not been shown to improve wellbeing, and European guidance advises against them.

Many people ask about adding T3, the body's other thyroid hormone. Its place in treatment has not been fully established: taken together, trials have not shown combination treatment to be better than levothyroxine alone for most people, and NICE advises against offering it routinely. UK specialist societies accept that a carefully monitored trial may be reasonable for selected people once other explanations have been looked at. Whether that applies to you is discussed at your consultation, and if a trial is appropriate it can be prescribed and monitored through the practice. Thyroid extracts made from animal glands are not recommended.

Thyroid lumps

Thyroid nodules are common and most are not cancer. Ultrasound shows which need a closer look. If an ultrasound or a needle sample raises the possibility of cancer, you will be referred promptly to a specialist thyroid cancer team, through the NHS or privately as you prefer, with your results and letters sent with the referral.

When a nodule needs sampling, Dr Spiliotis can request an ultrasound-guided fine-needle aspiration or core biopsy at One Hatfield. Some samples give an indeterminate result, neither clearly benign nor clearly cancerous. In that case molecular tests such as ThyroSeq, which look for genetic changes in the cells, can help decide between surgery and monitoring. They are sent to a specialist laboratory and charged separately.

A new or quickly growing neck lump, a hoarse voice that doesn't settle, or difficulty swallowing should be checked without waiting for a private appointment: your GP can refer you urgently through the NHS suspected cancer pathway. Difficulty breathing needs urgent medical help.