Stop the Thyroid Madness

I went to medical school for awhile in London and, it being the late 1960s (and London), I really don’t remember much about it. The school, that is.

However, two lessons from a certain professor have always remained with me:
1. If you listen to your patient carefully enough, and use your diagnostic skills, she’ll tell you her diagnosis. You won’t need anything else. Just listen! (By the way, this idea is widely attributed to the early 20th century physician Sir William Osler, but I was an impressionable med student in the classroom of a speaker who sounded and looked like Winston Churchill…in a white coat.)

2. Never use lab tests (blood tests, x-rays, etc.) to make a diagnosis, but rather to confirm the conclusion you reached by listening.

These are important concepts. This professor had contempt for doctors who ordered battery after battery of tests, hoping that “something” showed up–that the lab in fact would come up with an explanation for a patient’s symptoms.

Unfortunately, the trend among US physicians has been to order more and more, and still more, tests. New patients arrive at WholeHealth Chicago bearing reams of normal and endlessly repetitive tests, frustrated that they’ve been told nothing is wrong with them–and that they should be grateful for it, despite how they actually feel.

The point of this health tip is a great patient story (coming below) that illustrates this mistaken reliance on lab tests, which is pushed to extremes where the thyroid gland is concerned.

First, though, here’s a short course on the admittedly challenging topic of thyroid hormones, which you need to understand so you can help your doctor diagnose you. As a quick refresher, your thyroid sits in the front part of your neck and acts literally as your body’s gas pedal. Too much thyroid hormone output is like placing the clutch in neutral and pressing down on the gas pedal. Too little and everything s-l-o-w-s down.

The main symptoms of too little hormone (hypothyroidism) are fatigue, cold hands and feet, dry skin and hair, menstrual irregularities and infertility, and weight gain. If this sounds like just about everyone you know, understand that hypothyroidism is extremely common, especially among women, and that it seems to run in some families.

Often though, when patients relate these low-thyroid symptoms to their doctors (as my recent new patient did with several physicians) they’re told everything is normal because the test results are normal.

But thyroid tests are notoriously unreliable and even their so-called “normal ranges” are a source of disagreement among physicians themselves.

The most widely used thyroid test, the TSH (thyroid-stimulating hormone) test, doesn’t measure thyroid hormone levels. TSH is released by your pituitary gland, a sort of master gland tucked beneath the brain. It controls your thyroid, among other glands.

A high TSH test result means the pituitary is sending out a gusher of hormone, trying to flog your low-producing thyroid into making more of its own hormone. TSH levels are the gold standard test for hypothyroidism. Got it? Pituitary sends out extra TSH trying to stimulate your sluggish thyroid to make more hormone.

Thus, a high TSH=low thyroid.

For years it was thought that any TSH result above 5.0 merited giving the patient thyroid replacement hormone. Later on, some doctors (myself among them) said, “5.0 is too high. Let’s start treatment at 2.5 instead.” What this means is that the tens of millions of people between 2.5 and 5.0 who were once told their thyroids were fine really should be handled like Toyotas and all “recalled” for treatment.

To complicate matters, we know that stress of any sort (like going to a doctor’s office and being told everything’s fine) will fatigue your pituitary anyway, reducing its TSH output. Thus, a low TSH–say below 2.5–doesn’t completely rule out hypothyroidism because both of them, pituitary and thyroid, are underfunctioning. For some reason, this concept confuses a lot of doctors who have it etched into their brains that the TSH must be elevated to diagnose hypothyroidism.

The second test measures T4 (thyroxine), an actual hormone made by your thyroid. But even this test is often inaccurate, because T4 is an inactive, “storage” form of the hormone and needs to be converted to a second hormone, the active T3 (tri-iodothyronine), to function effectively. Unfortunately, the T3 test is rarely ordered by doctors, and even its normal range is subject to dispute. A low, or low-normal T3 in a patient who has all the signs and symptoms of hypothyroidism should be enough for a doctor to start treatment, but most will not, married to the erroneous idea that the TSH must be high.

So the theme here, as my professor said years ago, should be “Don’t treat test results. Treat your patient.” If she’s describing symptom after symptom of underactive thyroid, give her some thyroid hormone (low doses are very safe) and see if she gets better.

Here’s a real story about all this thyroid madness: A patient in her mid-30s came in a few weeks ago and described to me all the classic low-thyroid symptoms: fatigue, cold hands and feet, dry skin and hair, etc. She knew she had thyroid problems, but her thyroid tests had revealed nothing.

Most of her siblings were taking thyroid hormone and she really wanted to try it before subjecting herself to her second and very expensive infertility treatment (remember, thyroid hormones dramatically affect fertility). She’d been trying to get pregnant for some time, gone to an infertility specialist, and was now moving along the standard infertility treatment treadmill.

“I told my doctor that I thought I was hypothyroid not only because of my symptoms and my sisters, but also because my mom couldn’t get pregnant until she started on thyroid, and then she had six of us all in a row.” Yet because of her normal TSH, her doctors had told her that her thyroid was fine.

On hearing about our patient’s mother, my assistant Liz’s eyes widened and she said something like, “If Dr. E. doesn’t write you the thyroid prescription, I will!”

So of course our patient left the office with a thyroid prescription. Six weeks later she sent me an e-mail that she was pregnant (as you can imagine, these e-mails make my day).

If you like stories like this, feel you’ve been ignored in your quest to try thyroid hormones, or just want to learn more about the thyroid controversy, there’s a wonderful website called Stop The Thyroid Madness.

Browse it and you’ll see that not only do doctors miss the low-thyroid diagnosis, but also—because they’re victims of intense pharmaceutical advertising just like you–have been prescribing the second-best treatment: a synthetic hormone instead of the best treatment, an inexpensive, natural one.