Low Serum Thyrotropin (Thyroid-Stimulating Hormone) in Older Persons Without Hyperthyroidism

doi:10.1001/archinte.1991.00400010159025

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Vol. 151 No. 1, JANUARY 1991

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Low Serum Thyrotropin (Thyroid-Stimulating Hormone) in Older Persons Without Hyperthyroidism

Clark T. Sawin, MD; Andrew Geller, MD; Michael M. Kaplan, MD; Pamela Bacharach; Peter W. F. Wilson, MD; Jerome M. Hershman, MD

Arch Intern Med. 1991;151(1):165-168.

Abstract

We studied a large population (n =2575) of unselected ambulatorypersons older than 60 years to determine the prevalence of alow serum thyroid-stimulating hormone (TSH) level, ie, of lessthan 0.1 mU/L using a sensitive assay, a level suggestive ofhyperthyroidism in younger adults. One hundred one persons (3.9%)had a low serum TSH level. About half of them (51/101) weretaking thyroid hormone. Of the remainder, 44 were not hyperthyroidand did not become so during up to 4 years of follow-up. Forty-oneof the 44 euthyroid persons had a serum thyroxine level of lessthan 129 nmol/L; repeated testing showed a serum TSH level ofmore than 0.1 mU/L in the three euthyroid persons with a serumthyroxine level of more than 129 nmol/L. Only six were hyperthyroidor became so during the follow-up period; all had a serum thyroxinelevel of more than 129 nmol/L. Routine clinical examinationwas not a sensitive indicator of hyperthyroidism and did notpermit discrimination from euthyroidism. A low value of serumTSH alone, while it had high sensitivity and specificity forhyperthyroidism, had a low positive predictive value (12%) forthis diagnosis; addition of the thyroxine assay raised the predictivevalue fivefold to 67%. A low value of serum TSH is far morecommon in older persons than is hyperthyroidism. Low valuesin euthyroid persons are accompanied by a clearly normal serumT4 concentration (<129 nmol/L) or by a serum TSH level ofmore than 0.1 mU/L on repeated testing. We recommend measurementof the serum TSH thyroid concentration, using a sensitive assay,as the initial step in testing any older person for possiblehyperthyroidism. Measurement of the serum T₄ concentration orthe free T₄ index on the same sample would be needed only inthe approximately 2% with a serum TSH level of less than 0.1mU/L; alternatively, the TSH assay in these could be repeatedat a later time.

(Arch Intern Med. 1991;151:165-168)

Author Affiliations

From the Medical Services, Boston (Mass) Veterans Affairs Medical Center (Drs Sawin and Geller and Ms Bacharach); Wadsworth Veterans Affairs Medical Center (Dr Hershman), Los Angeles, Calif; the Endocrine Department, New England Medical Center Hospital, Boston, Mass (Dr Kaplan); and the Framingham (Mass) Heart Study (Dr Wilson).

Footnotes

Accepted for publication July 9, 1990.

Reprint requests to 150 S Huntington Ave, Boston, MA 02130 (DrSawin).

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