For laboratory testing procedures, see Appendix 1: BC Laboratory Algorithm for Thyroid Tests. Email: hlth.guidelines@gov.bc.ca Subclinical thyroid disease is a biochemical diagnosis and typically has either no symptoms or non-specific symptoms, is more common in women, and prevalence increases with advanced age18, 21. • Even when there are no symptoms, treatment may be advised to reduce the risk of long-term complications. See Figure 1 for a Clinical Algorithm of Thyroid Function Tests for Diagnosis and Monitoring in Symptomatic Non-Pregnant Patients and Table 2 for Potential Causes of Abnormal Hormone Levels. Targeted testing for overt hypothyroidism is recommended in pregnancy. Testing may be indicated when non-specific symptoms or signs are present in patients who have specific risk factors for thyroid disease. Risk factors for thyroid disease include1: For risk factors during pregnancy, see Table 3 in the Thyroid Disease in Pregnancy section below. Subclinical thyroid disease (abnormal TSH but normal free T4) does not require treatment. This is reserved for situations where thyroid disease is suspected clinically and TSH is abnormal, but fT4 is inappropriately normal. Interpretation of Thyroid Function Tests During Pregnancy T he thyroid gland is normally regulated by thyroid-stimulating hormone (TSH), also called thyrotropin, which is secreted by the pituitary. Information on other tests, including thyroglobulin/antithyroglobulin (Tg/anti Tg) and antibodies to the thyroid stimulating hormone receptor (TRAb), are covered in the associated BC Guideline Hormone Testing – Indications and Appropriate Use. Interpretation of thyroid function … There is a significant risk for recurrent postpartum thyroiditis in subsequent pregnancies14. A preconception TSH between the lower reference limit and 2.5 mU/L is recommended in women being actively treated for hypothyroidism14. The disorder may present as hyperthyroidism followed by hypothyroidism and subsequent recovery of normal thyroid function. Although there have been a number of studies linking abnormal thyroid function to increased risk of pregnancy complications, universal screening for thyroid disease during pregnancy is still debated. In the absence of universal screening recommendations, laboratories should outline carefully defined screening parameters to guide clinicians in determining when it is appropriate to screen for thyroid dysfunction in pregnancy. Care should be taken not to overtreat with levothyroxine, as it can result in atrial fibrillation (more commonly in the elderly) and bone loss in postmenopausal women13. This information is endorsed by the British Thyroid Association. Measurement of fT3 is rarely indicated in suspected thyroid disease6, 13. See the associated BC Guideline Ultrasound Prioritization. The British Thyroid Foundation is a registered charity: England and Wales No 1006391, Scotland SC046037. • People may feel well even when their thyroid function tests are outside the reference range. In the elderly, there is a higher cardiovascular risk and an increased risk of fracture. Because of changes in the modulation of the immune system, there is an increased risk of thyroiditis and new presentation or relapse of Graves’ disease in the postpartum period14. First trimester reference intervals, in particular, are less than the normal population reference interval. Fatigue often comes hand in hand with a thyroid disorder. There is clear evidence that treating a pregnant woman known to be hypothyroid has important benefits14. Laboratories in BC should report trimester specific reference intervals as an appended comment on all women of child bearing age. Treatment should be initiated for women whose TSH is above the trimester specific upper limit of normal as reported by the laboratory (see Treatment of Women with Subclinical Hypothyroidism in the Controversies in Care Section below). Consensus-based recommendation Patients with subclinical hyperthyroidism due to multi-nodular goitre or toxic adenoma are unlikely to normalize and are therefore more likely to benefit from treatment. We have created a pocket-sized Thyroid and Pregnancy Alert Card which sets out the key messages in respect of pregnancy and thyroid disorders. The increasing metabolic demands of pregnancy alter the thyroid physiology in early pregnancy… 2019 Mar;29(3):412-420. Patients newly diagnosed with hypothyroidism whilst pregnant should have T4 treatment commenced immediately with a starting dose of 100 microgram daily. If a patient is persistently hyperthyroid postpartum, referral to an appropriate specialist in endocrinology or maternal-fetal medicine (e.g., obstetric internal medicine) is recommended. Pregnancy places unique demands on the thyroid gland and thyroid function, and has been called a stress test for this master regulator of metabolism. If you are pregnant and have a history of thyroid disease (even if you are not on treatment now) for example. The normal results for thyroid function tests change a little as a pregnancy progresses. See Monitoring: Hypothyroidism or Thyroid Disease in Pregnancy, TSH high (usually less than 10 mU/L)A, Subject: Pregnancy/reproduction. Similar to the non-pregnant situation, TSH, FT4, and to a lesser extent Thyroid Peroxidase Antibodies (TPO-ab's) and (F)T3 are the most commonly requested thyroid function tests that form the hallmark of the diagnosis of thyroid disease. Malnutrition, renal and cardiac failure, hepatic diseases, uncontrolled diabetes, cerebrovascular diseases, and malignancy can also produce abnormalities in thyroid function tests15. This study aimed to establish a thyroid function reference range more suited to the Chinese population by evaluating the current thyroid function reference range in pregnant Chinese women and comparing it to the ATA guidelines. A decision to treat is often made if the TSH is >10 mU/L even if the fT4 is within the reference range. After starting thyroid hormone replacement or a dose change during pregnancy, TSH should be remeasured every 4–6 weeks20, 33. Subclinical hyperthyroidism is less common, with a prevalence of 0.7%21. TPO antibody positivity increases the risk of developing hypothyroidism in patients with subclinical hypothyroidism, autoimmune diseases (e.g., type 1 diabetes), chromosomal disorders (e.g., Turner syndrome and Down syndrome) or patients who are on certain drug therapies (e.g., lithium, amiodarone) or are pregnant or postpartum (see Thyroid Disease in Pregnancy section below)13, 14. thyroid function because of the potential adverse risks of sub-optimally treated hypothyroidism in pregnancy. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. The results are used to adjust the dose of thyroxine if necessary. Although there is no strong evidence to support routinely measuring TPO antibodies in pregnant women, the American Thyroid Association recommends that treatment may be initiated at lower TSH levels in women known to be TPO antibody positive14. This guideline is based on scientific evidence current as of the Effective Date. We defined continuation of thyroid hormone therapy … For further information or advice please speak to your GP or specialist doctor. Immunoassays for thyroid function tests are subject to analytical interference due to heterophile antibodies, evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases; or, history of pregnancy loss, preterm delivery, or infertility, type 1 diabetes or other autoimmune disorders, history of hypothyroidism/hyperthyroidism or current symptoms or signs of thyroid dysfunction, family history of autoimmune thyroid disease or thyroid dysfunction (1st degree relative, history of head or neck radiation or prior thyroid surgery, known TPO antibody positivity or presence of a goitre, currently receiving levothyroxine replacement, use of amiodarone or lithium, or recent administration of iodinated radiologic contrast, residing (or recently resided) in an area of known moderate to severe iodine insufficiency. At one time, studies suggested that failure to detect even subclinical hypothyroidism might have similar consequences34, 39. This table reflects common manifestations of thyroid disease in adults. fT3 - Free triiodothyronine It does not … As patients recover from their illness, TSH may normalize or become elevated19. Where thyroid testing in an asymptomatic patient has occurred and the patient has been diagnosed with subclinical thyroid disease, see the Subclinical Thyroid Disease section. If initial testing is normal, repeat testing is unnecessary unless there is a change in clinical condition. (fT3 not indicated), See Subclinical Hypothyroidism or Thyroid Disease in Pregnancy, Testing not usually indicated Hyperthyroid patients should have appropriate specialist consultation (endocrinologist or maternal-fetal medicine (e.g., obstetric internal medicine)) when contemplating pregnancy or during pregnancy. The guidance below was written by the British Thyroid Foundation (BTF) for patients with primary thyroid disease who are female and of reproductive age. speak to your GP and arrange thyroid blood tests as soon as you have a positive pregnancy test. Methods: A total of 52,027 pregnant women were enrolled from January 2013 to December 2016. Treatment reduces adverse pregnancy outcomes including preterm delivery or miscarriage38 and neuropsychological impairment of the offspring is associated with hypothyroidism34. In patients over age 60 with TSH 0.1 mU/L but with a normal fT4, the relative risk for atrial fibrillation increases threefold28. Vancouver Coastal Health Region/Providence Health Care: Northern RACE: 1-877-605-7223 (toll free). The following information is designed to help patients understand more about their thyroid disorder and how it may affect, or be affected by, pregnancy. This guideline outlines testing for thyroid dysfunction in patients (pediatric and adult), including pregnant women or women planning pregnancy, and the monitoring of patients treated for primary thyroid function disorders. Areas of agreement are the following: gestational normative reference ranges for thyroid function tests are required for proper interpretation of any abnormalities. fT4 - Free thyroxine *Don't provide personal information .   Comments will be sent to 'servicebc@gov.bc.ca'. Interested in contributing to BC Guidelines? We would love to hear from you. Testing is indicated for patients with a clinical presentation consistent with thyroid disease as delineated in Table 1: Symptoms and Signs of Thyroid Disease below. Measurements of fT4 and fT3 have replaced those of total T4 and total T3 levels. These include measurements of the T4 level and the thyroid stimulating hormone (TSH). A. Hypothyroidism rarely causes weight gain in pediatric populations9. Some women may present with hypothyroidism without a hyperthyroid interval and may remain hypothyroid14. If fT4 is being ordered to investigate or follow central hypothyroidism, “suspicion of pituitary insufficiency” should be included as a clinical indication and a request for fT4 (with or without TSH) should be written in the space provided on the standard out-patient laboratory requisition. Thyroid disorders in pregnancy are important causes of adverse pregnancy outcome. Subsequent better designed studies have not confirmed these concerns41. Consultation with a lab physician or an endocrinologist is recommended when the test result is in conflict with the clinical presentation so that investigation for analytical interferences or rare conditions can be undertaken. TSH may be repeated after at least 6 weeks following a change in thyroid hormone replacement dose or in a patient’s clinical status13. Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder Effective Date: October 24, 2018 Scope This guideline outlines testing for thyroid dysfunction in patients (pediatric and adult), including pregnant women or women planning pregnancy, and the monitoring of patients treated for primary thyroid function disorders. If a woman has risk factors, TSH testing is specifically recommended in early pregnancy (see the section on Thyroid Disease in Pregnancy).14 In a woman without symptoms and without risk factors, testing is discretionary. Consensus-based recommendation Recommendation 3 Grade There is insufficient evidence to support universal TSH screening and treatment of subclinical hypothyroidism in pregnancy. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Website: www.BCGuidelines.ca. Dr Andrew Day and Dr Paul Thomas, Clinical Biochemistry. Normal Upper Limit for Thyroid Function in Pregnancy is raised to 4.0. There is insufficient evidence to recommend screening all women for postpartum thyroiditis. Every year, 2.6% of subclinical hypothyroidism patients without elevated TPO antibodies and 4.3% of subclinical hypothyroidism patients with elevated TPO antibodies progress to overt hypothyroidism13. If you need medical advice, please contact a health care professional. Women previously known to be TPO antibody positive should have a TSH performed at 3 and 6 months postpartum or as clinically indicated33. Because hCG can weakly stimulate the thyroid, the high circulating hCG levels in the first trimester may result in a low TSH that returns to normal throughout the duration of pregnancy. What role does the thyroid gland have in our bodies? We also analyzed TSH measurements in the range of 2.51 to 4.00 mIU/L, in keeping with the 2011 pregnancy guidelines of the American Thyroid Association.11 We defined initiation of thyroid hormone therapy during pregnancy as the filling of a prescription for levothyroxine, desiccated thyroid or liothyronine after conception and before delivery. Thyroid disease and coronavirus (Covid-19), FAQs about thyroid disease and Coronavirus (Covid-19), Your questions about COVID-19 and the immune system in thyroid patients. Thyroid. The guidance is subject to further changes as guidelines are updated. Guidance updated April 2017 (Dr M Crane, Dr S Forbes and Prof M Strachan) 2 TPO - Thyroid peroxidase Autoimmune thyroid disease is associated with both increased rates of miscarriage, for which the appropriate medical response is uncertain at this time, and postpartum thyroiditis. Victoria BC V8W 9P1 TSH levels must be interpreted with caution in hospitalized individuals. Almost any condition that can make a person ill can cause Sick Euthyroid Syndrome and the elderly are more susceptible because of multiple co-morbid conditions15. {"type": "chips","options": [{"text": "Other languages"},{"text": "COVID-19 vaccine"},{"text": "COVID-19 testing"},{"text": "Travel information"},{"text": "Financial supports"},{"text": "COVID-19 data"},{"text": "Connect by phone"}]}, Employment, business and economic development, Birth, adoption, death, marriage and divorce, Environmental protection and sustainability, Emergency Preparedness, Response & Recovery, Continuing Professional Development (CPD) Credits, Guidelines Eligible for Incentive Payments, Rheumatological and Musculoskeletal Systems, Free Thyroxine (fT4) and Free Triiodothyronine (fT3), Hypothyroidism in Pregnancy and Postpartum, Hyperthyroidism in Pregnancy and Postpartum, Controversies in Care: Universal Screening During Pregnancy​, Controversies in Care: Treatment of Pregnant Women with Subclinical Hypothyroidism, Table 1: Symptoms and Signs of Thyroid Disease, Appendix 1: BC Laboratory Algorithm for Thyroid Tests, Monitoring: Hypothalamic or Pituitary Disease, Treatment of Women with Subclinical Hypothyroidism, www.divisionsbc.ca/kootenay-boundary/our-impact/team-based-care/race-line, Appendix 1: BC Laboratory Algorithm for Thyroid Tests (PDF, 167KB), If a woman is pregnant or planning pregnancy, TSH testing is indicated if she has specific risk factors (see, personal history or strong family history of thyroid disease, previous thyroidectomy or radioactive iodine ablation, drug therapies such as lithium and amiodarone, dietary factors (iodine excess and iodine deficiency in patients from developing countries); or, certain chromosomal or genetic disorders (e.g., Turner syndrome, Dry eyes, conjunctivitis, proptosis or dysconjugate gaze, If free thyroid hormones are ordered without TSH, a clinical indication is required. You should then contact your GP and arrange to have a thyroid blood test, If you have had thyroid cancer and are already on doses of levothyroxine that keeps your TSH level suppressed, you will probably not need to increase your levothyroxine but you should discuss this with your GP or specialist, If you have an overactive thyroid (hyperthyroidism). ‘Thyroid function tests’ can be measured in a standard non-fasted blood test. Download and print this guidance. In this context, a normal fT4 generally excludes hyperthyroidism14, 20. We look at some of the common questions we receive about how to cope better with fatigue, Dr Petros Perros answers some of your concerns about Covid-19 and thyroid disease, Learn about how thyroid testing is used to diagnose and manage thyroid disorders, Dr Petros Perros answers questions about thyroid disease and the immune system, Read about symptoms of an underactive thyroid (hypothyroidism) and how this thyroid disorder is diagnosed and managed. Consult with a specialist (lab physician, internist or endocrinologist). Is the Covid vaccine safe for people with thyroid disorders? One study found that hyperthyroidism diagnosed within 3 months of delivery was most often caused by postpartum thyroiditis while hyperthyroidism diagnosed after 6.5 months was caused by Graves’ disease36. Note: We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. ‘Thyroid function tests’ can be measured in a standard non-fasted blood test. In the course of a normal pregnancy, TSH may be low in the first trimester, when human chorionic gonadotropin (hCG) peaks.
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