Hypothyroidism in Primary Care: When to Hold Them, When to Refer Them

Detangling Conflicting Guidelines

Linda Brookes, MSc; Kenneth D. Burman, MD


March 04, 2015

In This Article

Hypothyroidism in Primary Care

Hypothyroidism is a clinical disorder frequently encountered by primary care providers (PCPs).[1] The latest estimates suggest that hypothyroidism occurs in 4.6% of the US population aged 12 years or older,[2] and most of these cases can be effectively and safely managed in primary care.

US guidelines for the management of hypothyroidism by PCPs, such as those provided by the American College of Physicians (ACP)[3] and the American Academy of Family Physicians (AAFP),[4] are generally based on the specialist guidelines drawn up by such organizations as the American Thyroid Association (ATA) and the American Association of Clinical Endocrinologists (AACE). Recently, however, as reported by Medscape,[5,6,7,8] these guidelines have differed in their interpretations of the clinical evidence to date.

To try to clarify guidance for PCPs in the diagnosis and treatment of hypothyroidism, Medscape spoke with Kenneth D. Burman, MD, director of the Endocrine Section at MedStar Washington Hospital Center in Washington, DC. Dr Burman is also professor of medicine and director of the Georgetown University Hospital/Washington Hospital Center Endocrinology Fellowship Program. He is a past president of the ATA (2008-2009) and was a coauthor of the ATA's most recent guideline on the treatment of hypothyroidism.[9]

Universal Screening for Hypothyroidism?

Opinions differ on screening for thyroid dysfunction. Hypothyroid patients can present with a variety of symptoms that are also seen in patients with normal thyroid function. In a recent study, almost 6% of overtly hypothyroid patients were free of symptoms,[10] implying that screening only symptomatic patients would miss a significant proportion of hypothyroid patients.

In 2000, the ATA recommended assessing thyroid-stimulating hormone (TSH) levels every 5 years in all adults starting at 35 years of age,[11] a position that appears to remain unchanged.[12] The AACE, which recommended routine TSH measurement in older patients (age unspecified), especially women,[13] later reported "compelling evidence" to screen in certain groups at increased risk,[14] a position supported by the ACP.[3] The AAFP has concluded that evidence is insufficient to recommend for or against routine screening for thyroid disease in adults,[4] a conclusion also recently reached by US Preventive Services Task Force (USPSTF).[15] Dr Burman agrees that this area is controversial and should be examined thoroughly using a more recent analysis.


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