I went to medical school in London for awhile and quite honestly didn’t learn much. But it was the 1960s and if you were going to be anywhere on the planet, central London was the place to be. The fact that the hospital to which I was assigned had a pub in its basement (where everyone, even a few patients, would gravitate around 4 pm) alerted me to the fact I wasn’t in Kansas anymore.
I finished my term with precisely two pieces of memorable knowledge. First, I was endlessly reminded by fellow students, “We’re not at all like you Americans. Medical students here learn to be gentlemen first, doctors second.” This was usually delivered in a waft of beer breath, so I couldn’t take it too seriously, but I liked the line. It went well with the phony British accent I was developing.
Second, and this from a highly respected (and genuine knighted “Sir”) inebriate with a W.C. Fields nose: “Lab tests. American doctors with their lab tests. If you listen to your patient long enough and use your brain, you’ll make the diagnosis without any of that foolishness.” And the equally valid corollary, “Never rely on a lab test for your diagnosis. Let the lab test confirm your diagnosis, not make it.”
These simple rules never did manage to cross the Atlantic. As a result, millions of women (and many men as well, but women are primarily affected) experience a wide spectrum of underactive thyroid symptoms yet perpetually hear, “Well, I know your symptoms do sound like low thyroid, but see for yourself–your tests are normal.”
Symptoms, causes, and sufferers
Fatigue, gradual weight gain and inability to lose it, dry skin and dry hair with hair thinning (and thinning of the outer third of your eyebrows), facial puffiness, mental sluggishness, cold hands, cold feet, being always the coldest one in a group of people, constipation. Having had low thyroid once myself, I can report it’s a strange sense of internal coldness. You’re outside and it’s in the 90s, yet you feel cold inside.
After age 40, it’s estimated about 25% of people have symptoms of diminished thyroid function, called hypothyroidism. There are two causes. First, a condition called Hashimoto’s thyroiditis, an autoimmune disorder in which the immune system starts creating antibodies against the thyroid gland (and only the thyroid gland), slowly but relentlessly destroying it. Most doctors won’t treat Hashimoto’s until hormone levels fall into the abnormally low range
Second, a controversial condition called thyroid fatigue. In this case, the gland is simply pooped out, exhausted (often along with your adrenal glands) from having received incessant fight-or-flight stress messages along the emergency path from your brain…via your master gland, the pituitary, which controls both thyroid and adrenals.
It’s been the medical profession’s over reliance on the familiar TSH test (thyroid-stimulating hormone), developed in the 1960s, that’s led to so much missed hypothyroidism. (You may need to read this next paragraph twice. It confuses medical students, too.) TSH is released by the pituitary to stimulate the thyroid to make more of its hormone. The pituitary has a hormone-sensing system, so when thyroid hormone levels are low TSH goes up to stimulate the thyroid to make more hormone.
Remember the rule: if you have a high TSH, your thyroid hormone is low. By the way, the opposite is also true. Too much hormone (hyperthyroidism) lowers TSH levels, sometimes as low as zero. Uh, except not always.
Depending on the lab your doctor uses, the official normal range for TSH is generally between 1.0 and 5.0. If your TSH is above 5.0, you’re declared hypothyroid (have low thyroid) and started on thyroid replacement hormone. To this day, if you go to the doctor with every single symptom of hypothyroidism listed above and your TSH is 4.9, you’ll be told, “Let’s keep an eye on it” and leave the office untreated, feeling just as crappy as when you arrived.
It’s even worse if your hypothyroidism is due to thyroid fatigue, because in this situation, your pituitary, having been bombarded with stress messages from your brain, is fatigued and depleted as well. So you’ll have all the symptoms of low thyroid and a “mysteriously” low TSH. Your doctor may shake his head in wonderment, “I agree. You sure look hypothyroid, and your hormone levels are on the low side, too, but your TSH is so low, why, you’re almost hyperthyroid.” You hand him an article from the internet. “Thyroid fatigue? Never heard of it.”
Recent research in laboratory testing has uncovered three important breakthroughs that haven’t filtered down to most conventional labs and therefore to most primary care offices.
- The upper limit of normal for TSH should be lowered from 5.0 to 2.5 If this were enacted, the millions of patients with TSH ranges between 2.5 and 5.0 who’d been told they were normal would actually be diagnosed as hypothyroid. Most people feel best when their TSH is somewhere between 1.0 and 2.0.
- When hypothyroidism is even remotely suspected check hormone levels and check for the presence of antibodies indicating Hashimoto’s. The presence of these antibodies alone, even with seemingly normal hormone levels, is enough to warrant starting thyroid replacement therapy. When thyroid antibodies are present, thyroid function will eventually diminish. Why postpone treatment?
- Since there’s really no lab test for thyroid fatigue, we need to return to an old- fashioned but reliable means of testing thyroid function–namely, measuring basal body temperature. This is your temperature just as you emerge from sleep. Readings of 97.6 degrees or lower were, for your grandmother’s doctor, diagnostic of hypothyroidism, and she’d receive a bottle of Armour thyroid from her pharmacist to restore her thyroid hormone levels.
It’s estimated that tens of millions of people have undiagnosed mild hypothyroidism, all because their physicians weren’t in Professor (Sir) Carrick’s lecture hall that morning as I listened to the elderly bleary-eyed old debauchee raise his finger skyward and ring out with, “Treat the patient, not the lab test!”
It’s a pity we don’t.
David Edelberg, MD
15 thoughts on “Six Commonly Missed Diagnoses: Subtly Underactive Thyroid”
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I read an article entitled “Ten Signs U Have Hyothyroidism” in a magazine. Of the ten symptoms listed, I had eight. I told my Dr and was dismissed with, “You DON’T have hypothyoidism.” There was no discussion, no query or concern that I might be suffering with an illness so easily fixed. I am poor & have no other options but the same Dr. I am disgusted with the WHOLE medical field & professions. Cuz yeah this is only the TIP of the iceberg.
Thank you Dr. E! I am going to get a thermometer today and start tomorrow morning. Maybe I can get the endrochrinologist to listen to me once I have these readings.
See Jill’s note above yours; take your basal temperatures; read Janie Bowthorpe’s website and find someone to prescribe natural thyroid
I have been complaining of hypothyroid symptoms my entire life. All of my blood work and antibodies are within normal range. I have a large cyst (3 cm) on the left lobe of my thyroid, 2 small cysts on the right lobe and an enlarged thyroid. I have never had normal menstrual cycles (which has been blamed on PCOS), it took me 4 years to conceive, I have tingling in my hands and feet and they are constantly cold. I am always tired no matter how long I sleep, dry skin, stomach issues, brittle nails, hair loss, puffy bags under my eyes and anxiety. My biopsy on my cyst came back normal but no one has any answers for me! Are there other tests that the endocrinologist can run? Should I get a second opinion. I am tired of being tired and I just want some answers.
I concur with Michele Salustro-Doll’s commentary. I cannot thank Dr. Kelley enough for her thorough consultation on my first visit to Whole Health. I have been suffering for years. My basal temperature readings for five days were all below 97.6. Within days of starting the thyroid medication, I began to feel better. My hands and feet no longer feel so cold that they almost have a burning sensation associated with extreme cold. I feel like my body is able to maintain a normal temperature, even throughout these winter days. I feel my overall health has generally considerably improved.
Reading over the past decade 100’s of books and articles on health, this is the first that I’ve heard about thyroid fatigue.I’ve just been told that my blood test thyroid levels are in the normal range even thouugh it was my Dr’s idea to test based on the symptoms that he percieved.Based on the ‘new’ information,this merits a second look.Thank-you for all that you are doing to educated us.
L R H
do you recommend Armour thyroid replacement medication and why?
when is the best time to take that temperature?
Would it be possible to get some study citations to show my doctor along with your article?
Some people run low temperatures without thyroid fatigue. You’d need to also have some of the symptoms listed above
Apparently a missed communication. Marla’s notes were for me to review during your next office visit with me. Since this hasn’t occurred, simply e mail me your pharmacy number
Hi I have had doctor visits where they took my temperature and it read 97. something degrees. Is this thyroid fatigue? They always ask is it normal for me and since it has happened several times I say “yes I think so”Can thyroid fatigue be intermitent?
I think you just told the thyroidal story of my life! I’ve had problems since childhood, have been “within the range of normal” but close to the edge. My sister, too, and doctors told her “we’ll keep an eye on it.” Sigh!
How ironic to read this. In January I saw you, complaining of several of the above symptoms. I had a lab test for hypothyroidism and took my basal temp for five days – all were below 97.6. Marla accepted the temperature records, and I am still awaiting a verdict. Perhaps now?
I have Thanked the Good Lord, Many many times over in the last 6 days, for the fact that Dr Edelberg Wrote Healing Fibromyalgia and for this knowledge coming forth. This has led me to the Whole Health Clinic and being given started on a low dose of Armour Thyroid. I cannot tell you how amazingly DIFFERENT and LESS fatigued , I am and have been. I was only able to read part of the book due to struggling with Fibro “brain fog” and I was able to record my basal body temperature. I regestered 94 and less than 96 for over 2 weeks consistantly. After seeking physicians for the past 13 YEARS, for help and a diagnosis of WHY I felt so miserable all the time, and being told EXACTLY THAT : ” your thyroid tests are NORMAL, on the LOW side, but nonetheless NORMAL”, I have suffered tremendously with insomnia, pain, unbearable debilitating fatigue and horrible muscle cramps and that COLD feeling. Now, just SIX DAYS after starting armour thyroid , I cannot describe the changes taking place!! I had never weighed more than 150 lbs my entire adult life. Yet, in 2001 when my Fibro was relatively newly diagnosed, I began a steady incline of pounds that I could not seem to stop piling on. One month I gained 34 lbs. Another time I gained 28 pounds in 10 days. Life for me has been Horrible. I have been well over 250 lbs for the past 5 years and severely depressed. NOTHING I did would make the scale budge. Now, I have tremendous hope that this is my turning point. That somehow I will have a way with being PROPERLY Treated FINALLY, to be on the road to better health and weight loss will follow as I am able to exercise and move more. THANK You , and BLESS you for your work.. Michele