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Patients should seek medical evaluation if they experience: Persistent symptoms despite adequate levothyroxine replacement (confirmed by normal TSH) Rapid thyroid enlargement or development of thyroid nodules Difficulty swallowing or breathing related to thyroid enlargement Symptoms suggesting thyroid hormone over-replacement (palpitations, tremor, anxiety, heat intolerance) Regular monitoring of thyroid function is essential for patients with Hashimoto's disease

The adherence picture adds another wrinkle

Within two years, the patient returned to their original weight or higher and regained similar levels of heart disease and diabetes within that time frame