Looking Beyond TSH in Hypothyroidism Management, With Rosemarie Lajara, MD

Despite achieving “normal” thyroid lab targets, patients with hypothyroidism may continue to experience symptoms that affect quality of life.

Rosemarie Lajara, MD, FACE, a staff physician at Southern Endocrinology and Diabetes Associates, presented on unmasking the symptom gap in hypothyroidism management at the Endocrine Society (ENDO) Annual Meeting 2026 and later spoke with HCPLive about the challenges of treating patients whose symptoms persist despite biochemical control.

Hypothyroidism is typically diagnosed and monitored using thyroid function tests (TFTs), including thyroid-stimulating hormone (TSH) and free thyroxine (free T4). For most patients, treatment with levothyroxine effectively normalizes thyroid hormone levels and improves symptoms. However, some individuals continue to experience fatigue, cognitive difficulties, and other symptoms despite laboratory values falling within the reference range.

According to Lajara, this disconnect highlights an important limitation of relying solely on laboratory measurements when assessing treatment response.

"As clinicians, we get a little focused on the labs and tend to forget how the patients are feeling, the lived experience, and we see that the labs are normalizing, and it gives us reason to believe that the patients are feeling better," Lajara told HCPLive. "But when you start asking more specific questions, the patients may verbalize, 'I'm not back to my normal self. I still feel quite fatigued. I am still having mental fog,' or some other issues that suggest the patient's thyroid function may not be optimized."

Lajara suggested part of the challenge stems from applying population-based reference ranges to individual patients. While TSH remains the primary surrogate marker used to guide treatment decisions, patients may experience symptom improvement at different points within the normal range.

"We're trying to see if population data, which is where we get our TSH from, applies to that one particular individual, and I think that's where somehow we miss the mark," Lajara said.

She noted that current treatment goals should include both normalization of thyroid function tests and improvements in patient well-being. Rather than focusing exclusively on a laboratory target, Lajara advocates for combining serial TSH measurements with ongoing assessment of patient-reported symptoms to identify an individual's optimal treatment range.

"I think it's important to keep in mind there is a range, and it's a tenfold range in what you need," Lajara said. "In my opinion, you need to do serial determinations of the TSH and try to match that with the patient's symptoms."

Although overtreatment remains a concern, Lajara emphasized the importance of considering the broader clinical picture when patients continue to report symptoms commonly associated with hypothyroidism. She encouraged clinicians to evaluate potential contributing factors while remaining attentive to the patient's experience.

"I think it's important to not be dismissive of what the patients are telling us," Lajara said.

Editor’s Note: Lajara reports relevant disclosures with AstraZeneca, Boehringer Ingelheim, Eli Lilly Company, Novo Nordisk, Sanofi and Zealand, and others.

References

1. Lajara R. BEYOND THE NUMBERS: Unmasking the Symptom Gap in Hypothyroidism Management. Lecture presented at: ENDO Annual Conference; June 13, 2026; Chicago, IL.

2. Razvi S, Mrabeti S, Luster M. Managing symptoms in hypothyroid patients on adequate levothyroxine: a narrative review. Endocrine Connections. 2020;9(11):R241-R250. doi:https://doi.org/10.1530/EC-20-0205