Endocrinology and Metabolism
Canadian Society of Endocrinology and Metabolism
Last updated: April 2026
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Once target control is achieved and the results of self-monitoring become quite predictable, there is little gained in most individuals from repeatedly confirming this state. There are many exceptions, such as acute illness, when new medications are added, when weight fluctuates significantly, when A1c targets drift off course and in individuals who need monitoring to maintain targets. Self-monitoring is beneficial as long as one is learning and adjusting therapy based on the result of the monitoring.
Sources:
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, et al. Monitoring glycemic control. Can J Diabetes. Apr 2013;37(1):S35-9. PMID: 24070960.
Davidson MB, et al. The effect of self monitoring of blood glucose concentrations on glycated hemoglobin levels in diabetic patients not taking insulin: a blinded, randomized trial. Am J Med. Apr 2005;118(4):422-5. PMID: 15808142.
Farmer A, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ. Jul 2007 21;335(7611):132. PMID: 17591623.
O’Kane MJ, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. May 24 2008;336(7654):1174-7. PMID: 18420662.
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Thyroid ultrasound is used to identify and characterize thyroid nodules, and is not part of the routine evaluation of abnormal thyroid function tests (over- or underactive thyroid function) unless the patient also has a large goiter or a lumpy thyroid. Incidentally discovered thyroid nodules are common. Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction. Imaging may be needed in thyrotoxic patients; when needed, a thyroid scan, not an ultrasound, is used to assess the etiology of the thyrotoxicosis and the possibility of focal autonomy in a thyroid nodule.
Sources:
Bahn RS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. May-Jun 2011;17(3):456-520. PMID: 21700562.
Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. Nov-Dec 2012;18(6):988-1028. PMID: 23246686.
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T4 is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels regulate pituitary secretion and blood levels of TSH, as well as the effects of thyroid hormone in multiple organs. Therefore, in most people a normal TSH indicates either normal endogenous thyroid function or an adequate T4 replacement dose. TSH only becomes unreliable in patients with suspected or known pituitary or hypothalamic disease when TSH cannot respond physiologically to altered levels of T4 or T3. Patients should have access to additional testing, as required.
Sources:
Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. Nov-Dec 2012;18(6):988-1028. PMID: 23246686.
Related Resources:
CSEM Review and Response: Testing and Management of Primary Hypothyroidism
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Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense. It is therefore important to confirm the clinical suspicion of hypogonadism with biochemical testing. Current guidelines recommend the use of a total testosterone level obtained in the morning. A low level should be confirmed on a different day, again measuring the total testosterone. In some situations, a free or bioavailable testosterone may be of additional value.
Sources:
Bhasin S, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. Jun 2006;91(6):1995-2010. PMID: 16720669.
Wu FC, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. Jul 8 2010;363(2):123-35. PMID: 20554979.
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Positive anti-TPO titres are not unusual in the ‘normal’ population. Their presence in the context of thyroid disease only assists in indicating that the pathogenesis is probably autoimmune. As thyroid autoimmunity is a chronic condition, once diagnosed there is rarely a need to re-measure anti-TPO titres. In euthyroid pregnant patients deemed at high risk of developing thyroid disease, anti-TPO antibodies may influence the frequency of surveillance for hypothyroidism during the pregnancy. It is uncommon that measurement of anti-TPO antibodies influences patient management.
Sources:
De Groot L, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. Aug 2012 ;97(8):2543-65. PMID: 22869843.
Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. Dec 2012;22(12):1200-35. PMID: 22954017.
Surks MI, et al. Age-specific distribution of serum thyrotropin and antithyroid antibodies in the US population: implications for the prevalence of subclinical hypothyroidism. J Clin Endocrinol Metab. Dec 2007;92(12):4575-82. PMID: 17911171.
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Metanephrines are consistently secreted in pheochromocytomas and paragangliomas (PPGL), whereas catecholamine production is intermittent. The risk of false-negative results is therefore high when plasma catecholamines are used as a first-line screening test (sensitivity 85% and specificity 81%). Current guidelines recommend metanephrines (plasma or urinary) as the preferred initial screening test for PPGL.
Plasma metanephrine testing however has limitations including posture related variability, as patients should ideally be supine for at least 20 mins before sampling via a pre-installed intravenous catheter. Additionally, the samples must be transported on ice because metanephrines are unstable in whole blood if they cannot be processed promptly by the laboratory. This instability is not an issue in urine as collection occurs in acidified containers. These preanalytical challenges make urinary metanephrines a more practical alternative for outpatients as failure to meet these conditions increases the risk of false positives for plasma metanephrines. Both plasma and urinary metanephrines have high sensitivity for screening (99% and 97% respectively) and combining these tests do not improve diagnostic performance.
Joint recommendation with the Canadian Association of Medical Biochemist
Sources:
Eisenhofer G, et al. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev. 2023 Sep 15;44(5):862-909. PMID: 36996131.
Pommer G, et al. Preanalytical Considerations and Outpatient Versus Inpatient Tests of Plasma Metanephrines to Diagnose Pheochromocytoma. J Clin Endocrinol Metab. 2022 Aug 18;107(9):e3689- e3698. PMID: 35767279.
Sbardella E, et al. Pheochromocytoma: An approach to diagnosis. Best Pract Res Clin Endocrinol Metab. 2020 Mar;34(2):101346. Epub 2019 Oct 22. PMID: 31708376.
Shen Y, et al. Biochemical diagnosis of pheochromocytoma and paraganglioma. In: Mariani-Costantini R, ed. Paraganglioma: A Multidisciplinary Approach. Codon Publications. [Internet]. 2019. [cited April 22, 2024].
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Short stature is defined as height more than 2 SD below the mean (or <2.3rd percentile) for age and sex, assessed using WHO growth charts for Canada. Common nonpathological causes include familial short stature and constitutional delay of growth and puberty. Pathologic causes (e.g. systemic illness, malnutrition, endocrine and genetic causes) should be investigated when growth velocity is reduced on serial measurements over at least 6 to 12 months. Growth hormone (GH) deficiency is rare and should only be suspected when the child’s height is greater than 2 SD below the expected mid-parental range with normal weight, and reduced growth velocity.
Random GH levels should not be ordered: secretion is pulsatile with significant diurnal fluctuations, sleep dependent and influenced by exercise, fasting, intercurrent illness and stress making single measurements unreliable. Diagnosis of GH deficiency requires formal stimulation testing, only indicated in selected circumstances and under endocrinology guidance. IGF-1 level is more stable and may be used as a surrogate marker. However, low IGF-1 is non-specific and can result from malnutrition, systemic illness, liver dysfunction, inflammation, pubertal delay, diabetes or hypothyroidism. GH deficiency is unlikely when IGF-1 is above the mean for age and sex, in a child with normal growth velocity and bone age.
Joint recommendation with the Canadian Association of Medical Biochemist
Sources:
Canadian Pediatric Endocrine Group. WHO Growth Charts for Canada. [Internet]. Revised March 2014. [cited March 2026].
Collett-Solberg PF, et al. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Horm Res Paediatr. 2019;92(1):1-14. Epub 2019 Sep 12. PMID: 31514194.
Krishnamoorthy P, et al. Optimizing paediatric specialist referrals for short stature in an era of multiple growth hormone indications. Paediatr Child Health. 2024 Jun 6;29(5):306-310. PMID: 39281357.
Richmond E, et al. Testing for growth hormone deficiency in children. Growth Horm IGF Res. 2020 Feb;50:57-60. Epub 2019 Dec 14. PMID: 31865218.
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In 2013, the Canadian Society of Endocrinology and Metabolism (CSEM) created a Quality Improvement Committee and charged it with the task of collaborating with Choosing Wisely Canada to establish recommendations relevant to the care of endocrine and metabolic disorders. The committee has a membership of 8 practicing endocrinologists from across Canada and whose combined clinical experience is well in excess of 100 practice-years. A survey to solicit suggestions for areas of practice that would fit with CWC’s mandate was sent to all members of CSEM. The results were discussed by the committee and grouped and crafted into a short list of recommendations (and examined for alignment with the US Choosing Wisely initiative). The recommendations list was also informed by data about utilization from parts of Canada and an understanding of the frequency with which endocrine disorders occur. The short list was then subjected to a modified Delphi process for ranking and the 5 recommendations selected had the highest mean priority score and the most consistency of opinion for committee members. They were finally agreed upon by consensus. Recommendations 1, 2, and 4 were adopted from the 2013 Five Things Physicians and Patients Should Question list with permission from the Endocrine Society.
Sources:
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, et al. Monitoring glycemic control. Can J Diabetes. Apr 2013;37(1):S35-9. PMID: 24070960.
Davidson MB, et al. The effect of self monitoring of blood glucose concentrations on glycated hemoglobin levels in diabetic patients not taking insulin: a blinded, randomized trial. Am J Med. Apr 2005;118(4):422-5. PMID: 15808142.
Farmer A, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ. Jul 2007 21;335(7611):132. PMID: 17591623.
O’Kane MJ, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. May 24 2008;336(7654):1174-7. PMID: 18420662.
Bahn RS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. May-Jun 2011;17(3):456-520. PMID: 21700562.
Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. Nov-Dec 2012;18(6):988-1028. PMID: 23246686.
Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. Nov-Dec 2012;18(6):988-1028. PMID: 23246686.
Related Resources:
CSEM Review and Response: Testing and Management of Primary Hypothyroidism
Bhasin S, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. Jun 2006;91(6):1995-2010. PMID: 16720669.
Wu FC, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. Jul 8 2010;363(2):123-35. PMID: 20554979.
De Groot L, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. Aug 2012 ;97(8):2543-65. PMID: 22869843.
Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. Dec 2012;22(12):1200-35. PMID: 22954017.
Surks MI, et al. Age-specific distribution of serum thyrotropin and antithyroid antibodies in the US population: implications for the prevalence of subclinical hypothyroidism. J Clin Endocrinol Metab. Dec 2007;92(12):4575-82. PMID: 17911171.
Eisenhofer G, et al. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev. 2023 Sep 15;44(5):862-909. PMID: 36996131.
Pommer G, et al. Preanalytical Considerations and Outpatient Versus Inpatient Tests of Plasma Metanephrines to Diagnose Pheochromocytoma. J Clin Endocrinol Metab. 2022 Aug 18;107(9):e3689- e3698. PMID: 35767279.
Sbardella E, et al. Pheochromocytoma: An approach to diagnosis. Best Pract Res Clin Endocrinol Metab. 2020 Mar;34(2):101346. Epub 2019 Oct 22. PMID: 31708376.
Shen Y, et al. Biochemical diagnosis of pheochromocytoma and paraganglioma. In: Mariani-Costantini R, ed. Paraganglioma: A Multidisciplinary Approach. Codon Publications. [Internet]. 2019. [cited April 22, 2024].
Canadian Pediatric Endocrine Group. WHO Growth Charts for Canada. [Internet]. Revised March 2014. [cited March 2026].
Collett-Solberg PF, et al. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Horm Res Paediatr. 2019;92(1):1-14. Epub 2019 Sep 12. PMID: 31514194.
Krishnamoorthy P, et al. Optimizing paediatric specialist referrals for short stature in an era of multiple growth hormone indications. Paediatr Child Health. 2024 Jun 6;29(5):306-310. PMID: 39281357.
Richmond E, et al. Testing for growth hormone deficiency in children. Growth Horm IGF Res. 2020 Feb;50:57-60. Epub 2019 Dec 14. PMID: 31865218.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
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