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Screening and Treatment of Subclinical Hypothyroidism or Hyperthyroidism [Internet]

Screening and Treatment of Subclinical Hypothyroidism or Hyperthyroidism [Internet]

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US)

Version: October 2011


Our search identified 86 unique reviews whose abstracts were reviewed for inclusion (Figure 2). After review, 18 were pulled for full-text review. Of those 18 reviews, four were not systematic reviews; six did not address the key questions of this review;,,, two fell outside the timeframe for included reviews;, and three were excluded for reasons discussed below. The studies included in the three remaining reviews are compared in Table 6.,,


A mildly elevated thyroid stimulating hormone (TSH – also called thyrotropin) concentration is the most common thyroid function test abnormality encountered in everyday practice. Most patients who have a mildly elevated TSH have a normal free thyroxine (T4) level. The treatment of such patients is controversial, particularly when they have few or no symptoms and no other clinical evidence of thyroid disease. Less frequently, clinicians encounter patients who have a low or undetectable serum TSH and normal triiodothyronine (T3) and free T4 levels. The management of these patients is also unclear.


Tables 21 and summarize our findings by key question.

Executive Summary

Mildly elevated or decreased serum thyroid stimulating hormone (TSH, also called thyrotropin) levels are the most common abnormalities related to thyroid function. Subclinical thyroid dysfunction, defined as an abnormal TSH with normal levels of serum thyroid hormones (T3 and T4), affects 5 percent of women and 3 percent of men. Subclinical hypothyroidism is defined as a high TSH and normal T3/T4, and subclinical hyperthyroidism as having a low or undetectable TSH and normal T3/T4. Subclinical thyroid dysfunction has been shown to be a risk factor for the later development of overt thyroid disease. In addition, a high TSH level may be a risk factor for coronary events, elevated cholesterol levels, and increased rates of congestive heart failure, while a low TSH level is a risk factor for atrial fibrillation and osteoporosis. Therefore, it has been proposed that screening for and treating subclinical thyroid dysfunction might lead to a decrease in the morbidity associated with overt thyroid disease, heart disease, and possibly osteoporosis. To date, evidence-based reviews have recommended against routine screening and treatment of subclinical thyroid dysfunction, primarily based on the lack of evidence that treating subclinical thyroid dysfunction improves patient-centered outcomes. However, some experts, while acknowledging that evidence to support treatment is lacking, suggest that screening could decrease morbidity and mortality, and perceive the potential for harm as both minor and preventable. They argue it would be best to screen for and treat subclinical thyroid dysfunction until there are sufficient data to address this question definitively.

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