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Desiccated thyroid in the management of hypothyroidism:  Part III

Desiccated thyroid in the management of hypothyroidism: Part III


Posted by Thomas Repas, DO, FACP, FACE, CDE  January 8, 2009 10:45 AM

Most people would not dream of directing a cardiologist how to perform cardiopulmonary resuscitation during a cardiac arrest. They also would not come in to see the surgeon with a specific outline on how to do the procedure. Most would decline to have their surgery done in the same way and with the same techniques as in the 1970s. Despite this, many intelligent, otherwise reasonable people have no hesitation trying to “teach” me about the thyroid. Many of these same people also request to have their thyroid disorder managed similar to how we did decades ago.

Why is this?

There are several reasons. For one, despite the advances made in technology, scientific knowledge and outcomes over recent decades, modern medicine has failed many patients from a humanistic perspective. It is not too much to expect for questions to be answered and treatment options explained. Everyone desires to be listened to and heard. There is nothing more discouraging than when one’s symptoms are ignored. I have witnessed this myself when I and family members have been patients. It is extremely frustrating. Not surprisingly, some pursue alternative options.

Some believe in a more natural approach towards health. Their goal is to minimize the synthetic, processed and man-made. I actually understand this philosophy very well. My family and I grow a large portion of our vegetables organically. We enjoy the sense of connection with the land and the seasons. We take pride in knowing that we participated in the sustainable production of our food. If someone presented to us a well-crafted, scientifically valid argument as to why there is no benefit to organic vs. conventional gardening, we would smile, nod and keep doing what we are doing. We garden organically as much on philosophical grounds as any other reason.

For me to argue for patients to change someone’s belief system based on science is equivalent to attempting to convince them to change their religion or political party on the same grounds. It would be futile as well as absolutely inappropriate.

Health care is different, however, because there is the potential for harm as well as benefit. I am obliged to inform my patients about the positive as well as negative potential consequences of one option over another. This is true no matter if we are discussing alternative vs. more mainstream therapies. However, I realize that I am only one advisor among many. My duty is to provide the most accurate information possible. Patients are free to choose for themselves how they would like to proceed.

Finally, last week I saw a woman who had been on desiccated thyroid for decades. I explained that we now prefer levothyroxine instead of desiccated thyroid. I also quickly pointed out that her thyroid-stimulating hormone has been perfect, between 0.7 mIU/L and 1.0 mIU/L over the last several years. She had no symptoms; it was difficult for me to argue with success. After discussing and asking her what she wanted to do, she left my office still on desiccated thyroid.

Comment by Tom Repas DO FACP FACE CDE -- June 12, 2009 12:24 PM

Hello all - I continue to read the comments posted on this and related threads.

I appreciate everyone sharing their insights and experiences. I haven't responded to every single posted comment because the sheer volume makes it impossible.

I also get the impression that no matter what else I might add, it would be futile and encourage only further attacks.

I confess to purposely choosing a subject which many are passionate about — and which many of my peers avoid discussing at all.

However, if we take our respective positions, dig our heels in and never talk to those with differing opinions, how will medical care ever progress and improve?

Rather than avoiding talking about such topics, I usually prefer to meet them head on and encourage — not discourage — conversation. I'll do that even if I know that everyone does not agree with me. I could have written about something or taken a position that everyone agrees with — but that would have been too easy.

Several endocrinologist colleagues have told me I'm crazy for writing about such a sensitive issue and in a way that I know would be sure to make me a target.

They are probably correct — but then I've never been known to be one who takes the easiest route, simply because is it easy. Don't forget, I run ultramarathons in my spare time because marathons are "too easy."

We might not agree on many things but I appreciate everyone sharing their thoughts, opinions and experiences. It actually has helped me in discussing this issue with patients in my own practice.

You have been heard — loud and clear.

Thank you all again for commenting.

(Please DO NOT accuse me of being patronizing — I sincerely do appreciate your comments, even if they differ from my own).

Comment by Max -- May 15, 2009 07:27 PM

" strive to be as much an expert on the science and physiology as possible. However, it is my patients who teach me daily what it is like to actually live with their diagnoses"

It is the "symptoms" that the patients are trying to live with as the "diagnoses" is far too often mis-diagnosed.

Comment by Gary Pepper, M.D. -- February 14, 2009 02:21 PM

Earlier, (http://www.metabolism.com/2009/01/21/dear-dr-repas/) I wrote a letter to Dr. Thomas Repas, explaining why I disagreed with his publication which opposes combination treatment for hypothyroidism (using t3 in addition to the traditional t4 therapy). I never received a reply to my letter. Somehow I wasn’t surprised.

His latest article appearing in the February 10, 2009 edition of endocrinetoday.com, goes even further in attacking the use of combination treatment, specifically as it applies to desiccated thyroid (Armour). He poses the question, “So why do I and most other endocrinologists refuse to use dessicated thyroid?”. He also states, “I believe that desiccated thyroid is antiquated therapy and should no longer be used.” His position then is that using Armour thyroid and similar preparations is an unacceptable medical practice. In fact, the last sentence of his editorial, states that desiccated thyroid preparations are unacceptable for treatment.

Dr. Repas bases his argument on the idea that the amounts of thyroid hormone in desiccated thyroid preparations are more variable than synthetic thyroid preparations. This is true but irrelevant. For the average person, variations in the time medication is taken, the rate the medication is absorbed from the stomach, and the general health of the person taking the medication which alters the metabolism of the thyroid hormone in the tissues, makes the variations in hormone levels in these preparations meaningless for clinical purposes. What Dr. Repas misses is the big picture, which is that for good health the human body requires a more complex form of thyroid hormone replacement then an unchanging daily amount of pure t4. A therapy like Armour which combines t4 with t3 is closer to what a normal thyroid secretes. Not everyone responds but in my experience the vast majority of unsuccessfully treated hypothyroid patients who continue to experience symptoms compatible with thyroid hormone deficiency, these symptoms respond very favorably to Armour thyroid.

In my letter to Dr. Repas from January 2009, I pose various key questions about thyroid hormone metabolism in the body. I challenge any endocrinologist to answer these questions in a meaningful way. Until we have a clear understanding of what comprises the perfect form of thyroid hormone replacement, I find it unacceptable to have physicians with opinions which differ from mine, telling me what is appropriate therapy for my patients.

Thyroid hormone replacement therapy is often complex and takes time and collaboration between physician and patient, to come upon the best treatment solution. Those endocrinologists and other physicians who prefer to over-simplify their approach to treatment with a rigid adherence to a single dose of pure t4, in my opinion, are only fooling themselves.

Gary Pepper
Editor-in-Chief, metabolism.com

Comment by Kent Holtorf, MD (continued) -- February 3, 2009 04:45 PM

8–89.
10. Chopra IJ, Huang TS, Beredo A, et al. Evidence for an inhibitor of extrathyroidal conversion of thyroxine to 3,5,3’-triiodothyronine in sera of patients with nonthyroidal illnesses. J Clin Endocrinol Metab 1985;60:666–72.
11. Peeters RP, Wouters PJ, Kaptein E, et al. Reduced activation and increased inactivation of thyroid hormone in tissues of critically ill patients. J Clin Endocrinol Metab 2003;88:3202–11.
12. Chopra IJ, Chopra U, Smith SR, et al. Reciprocal changes in serum concentrations of 3,3’,5-triiodothyronine (T3) in systemic illnesses. J Clin Endocrinol Metab 1975;41:1043–9.
13. Iervasi G, Pinitore A, Landi P, et al. Low-T3 syndrome a strong prognostic predictor of death in patients with heart disease. Circulation 2003;107(5): 708–13.
14. Peeters RP, Wouters PJ, van Toor H, et al. Serum 3,3’,5’-triiodothyronine (rT3) and 3,5,3’-triiodothyronine/rT3 are prognostic markers in critically ill patients and are associated with postmortem tissue deiodinase activities. J Clin Endocrinol Metab 2005;90(8):4559–65.
15. Wartofsky L, Burman K. Alterations in thyroid function in patients with systemic illness; the ‘‘euthyroid sick syndrome’’. Endocr Rev 1982;3(2):164–217.
16. Hennemann G, Everts ME, de Jong, et al. The significance of plasma membrane transport in the bioavailability of thyroid hormone. Clin Endocrinol 1998;48:1–8.
17. Vos RA, de Jong M, Bernard HF, et al. Impaired thyroxine and 3,5,3’-triodothyronine handling by rat hepatocytes in the presence of serum of patients with nonthryoidal illness. J Clin Endocrinology met 1995;80:2364–70.
18. Chopra IJ, Solomon DH, Hepner GW, et al. Misleadingly low free thyroxine index and usefulness of reverse triiodothyronine measurement in nonthyroidal illnesses. Ann Intern Med 1979;90(6):905–12.
19. De Jong M, Docter R, Van Der Hoek HJ, et al. Transport of 3,5,3’-triiodothyronine into the perfused rat liver and subsequent metabolism are inhibited by fasting. Endocrinology 1992;131:463–70.
20. Mooradian AD, Reed RL, Osterweil D, et al. Decreased serum triiodothyronine is associated with increased concentrations of tumor necrosis factor. J Clin Endocrinol Metab 1990;71(5):1239–42

Comment by Kent Holtorf, MD (continued) -- February 3, 2009 04:37 PM

or emotional stress, inflammation, calorie restriction, depression or chronic illness (all of which are extremely common), the TSH is further suppressed despite diminished active thyroid levels, making the already unreliable TSH an extremely poor indicator of an individual’s thyroid status (see serum thyroid hormones graph). Consequently, the inaccuracy of the TSH as an indicator of thyroid function is poor at best and extremely unreliable if a patient suffers from numerous common conditions so a normal TSH cannot be used as a reliable indictor in the overwhelming majority of patients.

In the serum hormones graph, you will notice that with low energy states (includes chronic illness, fibromyalgia, chronic fatigue syndrome, depression, etc) TSH and T3 decreases while T4 increases. This is due to the fact that T4 and T3 have different membrane transporters and in the periphery, the transporter for T4 is much more energy dependent, with significant loss of effective transport with reduced mitochondrial ATP, which is shown to occur in the above conditions. Thus, significantly less T4 is taken up into the cell under these conditions, resulting in increased serum T4 level, despite significantly low cellular T3 levels. This continues until the TSH suppressing effects result in decreased T4 production. This explains why a large number of studies clearly show replacement with T3 is far superior to T4 with any such conditions and any physician that uses T3 preparations knows that about 80% of patients will have better clinical response with a T3 containing preparation than straight T4.

Even just looking at a condition like fibromyalgia, numerous studies show these patients are hypothyroid despite “normal” blood tests and that supplementation with T3 is significantly effective. One example is Neeck G, Riedel. Thyroid Function in Patients with Fibromyalgia Syndrome. J Rheumatology 1992;19(7): 1120-1122. Via TRH testing, it was shown that 100% of the FM patients tested were abnormal, again despite normal TFT’s. Such studies are ignored because it does not fit into the simple algorithm.

I also refer you to the review for further info and references (available at www.holtorfmed.com) Hormones in Wellness and Disease Prevention: Common Practices, Current State of the Evidence, and Questions for the Future. Erika T. Schwartz, Kent Holtorf Primary Care: Clinics in Office Practice December 2008 (Vol. 35, Issue 4, Pages 669-705).

1. Peeters RP, Geyten SV, Wouters PJ, et al. Tissue thyroid hormone levels in critical illness. J Clin Endocrinol Metab 2005;12:6498–507.
2. Docter R, Krenning EP, de Jong M, et al. The sick euthyroid syndrome: changes in thyroid hormone serum parameters and hormone metabolism. Clin Endocrinol (Oxf) 1993;39:499–518.
3. Fliers E, Alkemade A, Wiersinga WM. The hypothalamic-pituitary-thyroid axis in critical illness. Best Practice & Research Clinical Endocrinology & Metabolism 2001;15(4):453–64.
4. Chopra IJ. Euthyroid sick syndrome: Is it a misnomer? J Clin Endocrinol Metab 1997;82(2):329–34.
5. van der Poll T, Romijn JA, Wiersinga WM, et al. Tumor necrosis factor: a putative mediator of the sick euthyroid syndrome in man. J Clin Endocrinol Metab 1990;71(6):1567–72.
6. Stouthard JM, van der Poll T, Endert E, et al. Effects of acute and chronic interleukin- 6 administration on thyroid hormone metabolism in humans. J Clin Endocrinol Metab 1994;79(5):1342–6.
7. Corssmit EP, Heyligenberg R, Endert E, et al. Acute effects of interferon-alpha administration on thyroid hormone metabolism in healthy men. Clin Endocrinol Metab 1995;80(11):3140–4.
8. Nagaya T, Fujieda M, Otsuka G, et al. A potential role of activated NF-Kappa B in the pathogenesis of euthyroid sick syndrome. J Clin Invest 2000;106(3):393–402.
9. Bianco AC, Salvatore D, Gereben B, et al. Biochemistry, cellular and molecular biology, and physiological roles of the iodothyronine selenodieidinases. Endocr Rev 2002;23:3

Comment by Kent Holtorf, MD -- February 3, 2009 04:26 PM

Agree with Eric, Patricia Barnes and others; the piece demonstrates a lack of understanding of thyroid physiology with a blind acceptance to a simple algorithm and model of thyroid physiology. With the treatment of hypothyroidism, the Endocrine Society appears to many to preach blind acceptance to algorithms where treatment is not offered despite clear signs and symptoms of hypothyroidism if the TSH is normal instead of teaching physicians an in-depth understanding of underlying physiology and limitations of the TSH that would give them the ability to be good clinicians. There are, of course, exceptions, but too many endocrinologists and others turn to adamantly blaming patients who don’t fit into their black and white algorithm.

The TSH is thought to be the most sensitive marker of peripheral tissue levels of thyroid, and it is erroneously assumed by most endocrinologists and other physicians that, except for unique situations, a normal TSH is an indication that the person’s tissue thyroid levels are adequate. A more thorough understanding of the physiology of hypothalamic-pituitary-thyroid axis and tissue regulation of thyroid demonstrates that the widely held belief that the TSH is an accurate marker of the body’s overall thyroid status is clearly erroneous in numerous conditions.

The TSH is inversely correlated with pituitary T3 levels but with physiologic stress, depression, aging and inflammation, increasing pituitary T3 levels are associated with diminished cellular and tissue T3 levels and increased reverse T3 levels in the rest of the body due to the fact that the pituitary is both anatomically and physiologically unique, reacting differently to inflammation and physiologic stress than every other tissue in the body (1-20). Pituitary tissue and cells responds to inflammation and stress with increasing tissue and cellular T3 levels while local mechanisms result in diminished cellular and tissue thyroid levels in the rest of the body (1-20). (can review different properties of type I and II deiodinase) Thus, with physiologic stress, depression or inflammation the pituitary T3 levels do not correlate with T3 levels in the rest of the body so the TSH is not a reliable or sensitive marker of an individual’s thyroid status.

Serum levels of thyroid hormones:

Due to the differences in the peripheral and pituitary’s response to physiological stress, depression, dieting, aging and inflammation as discussed, most individuals with diminished tissue levels of thyroid will have a normal TSH.

A low normal T4 can be a marker of diminished tissue levels but due to the fact that diminished cellular uptake of T4 and a reduced T4 to T3 conversion that commonly occurs will increase serum T4 levels while reducing tissue thyroid levels, the serum T4 or Free T4 level is generally a poor and insensitive marker of tissue levels of thyroid (6-17). Thus as with TSH, a normal T4 should not be used as reliable evidence of adequate tissue thyroid levels and these are only useful in extreme conditions. (see serum thyroid hormones graph at http://www.holtorfmed.com/article_info.php?articles_id=2

Doctors are taught that if active thyroid (T3) levels drop, the TSH will increase. Thus, endocrinologists and other doctors tell patients that an elevated TSH is the most useful marker for diminished T3 levels and that a normal TSH indicates that their thyroid status is “fine”. As can be clearly seen in the thyroid hormones and aging graph, the average TSH level declines (not increases) with diminishing T3 levels, demonstrating the lack of correlation of TSH and active thyroid levels, making TSH a poor marker for active thyroid levels and thyroid status of an individual. The inaccuracy of using TSH as marker is evident even under the best scenario with healthy asymptomatic individuals in the best correlation possible because with any physiologic

Comment by Margaret -- February 3, 2009 06:32 AM

Was Penicillin not invented many years ago.???? I have suffered an underactive thyroid for 16 years. I was never told of an alternative to Eltroxin. I have not been fully well for years. I work full time and I have to walk 8 miles a day I also swim and visit the gym regularly. I live on a healthy diet which is 1000 calories per day. I have never asked anyone to help me lose weight but it would have been nice if someone had of thought to tell me why I cant instead of my GP informing me there are no fat women in the jungle. I would tend to be very careful what you say about things from years ago. I know of a recovering Alcoholic who would be dead without the fellowship of AA which has never changed in many years and there is nothing to mach it. give us a break listen to us.

Comment by Eric (continued) -- February 2, 2009 10:37 AM

levothyroxine sodium and the hypothermia differential diagnostics are written to improve the patient's health.

I can only hope that some court will order the rewrite of the hypothyroidism guidelines in the same manner that the Infectious Disease Society of America is now doing in an agreement with the Attorney General of Connecticut -- (1) no past guideline author may participate, (2) all, not selected, medical science must be considered, (3) the committee meetings must be open to the public, and (4) the committee must have an ombusman that is mutually chosen. If this were done in the greater hypothyroidism realm, then patients with deficient post thyroid operations to create and use T3 would not continue to suffer.

Comment by Another Jane -- February 2, 2009 06:27 AM

Why no mention of synthetic T3?

Comment by S. -- February 1, 2009 10:50 PM

I've been on Armour Thyroid since 1966. An incompetent doctor took me off of it in 1979. I was off thyroid completely for five years and I finally went to a doctor who let me titrate my dosage. I went up to 4 grains a day, because that's where I felt better. The doctor who did this told me I had myxedema and was about a month or two from going into a coma and dying from lack of thyroid.

I also had several periods during that time that were late by a week or two. I realize now I was having extremely early miscarriages because of my lack of thyroid hormone.

My mother had Hashimoto's as well, which attacked her at the same age mine did — 10 or 11 years old. She started taking it in 1930.

My grandmother had an overactive thyroid and she was bossy as hell. My mother's sister's children, two of them have hypothyroid. This runs in the family.

We aren't lazy, and we aren't crazy. We are sick and we know it. We are not happy. Doctors like you need to shut up and listen to what your patients tell you. You obviously have not read the label on Armour Thyroid, either. It says "United States Pharmacopoeia, Biologically Assayed." That means it's tested to be consistent in dosage.

Since you won't listen to your patients, I think you need a new job. You should abandon the medical field, as you are not listening to what your patients are telling you.

Comment by Eric -- February 1, 2009 08:29 PM

A study by Saravanan, et al., found that 13% of all those treated for hypothyroidism are unhappy with their therapy. In the US, that is 1.7 million people. If any industry had a 13% failure rate, they would rapidly be bankrupt.

The reason why the thyroid tests often fail is that they do not test for any of the mimics of hypothyroidism peripheral metabolism of T4 to T3 and the cellular reception of T3. As Dr. Ridgway, past president of the Endocrine Society, stated in a public FDA meeting that T3 in the cells' nuclei is more important than T4 in the serum. Active T3 in the nuclei is not tested, but the relatively inactive T4 in the serum is. And even further removed from T3 in the nuclei is the thyroid stimulating hormone (TSH). Thus the standard thyroid panel tests for the input of the thyroid gland (TSH), the output of the thyroid gland (T4), and potentially thyroid gland anti-bodies. Testing for T3 is not done. Testing for reverse T3, a product of the regulatory action of the peripheral conversion is not tested. There is no test indicative of the usage of T3 by the cells' nuclei. There is no test for the efficacy of peripheral conversion or cellular hormone reception. Consequently, endocrinology's claim of being able to differentially diagnose the symptoms of hypothyroidism is false. They can only determine the efficacy of the thyroid gland — not any of the quite mandatory post thyroid gland operations.

Medical science has known of these post thyroid operations for the past 39 years. Refetoff found that some patients with the symptoms of hypothyroidism were resistant to levothyroxine sodium back in the 50's. Later he and others discovered peripheral cellular hormone reception in 1967. Braverman, et al., discovered peripheral hormone conversion of the relative inactive T4 to the active T3 in 1970. In spite of this medical science, medical practice does not give patients the proper knowledge to make an informed consent or a valid consent. Instead, physicians are instructed by the endocrinology establishment to diagnose the levothyroxine sodium patients as having "nonspecific symptoms" or "functional somatoform disorders." In other words, medicine is too inept to know medical science or you only think you are suffering from these symptoms. Both are quite false.

It is rather curious that there have been numerous studies to show that the active thyroid related hormone, T3, is ineffective. However, when one examines these studies, they are either rigged, employ improper logic and/or statitics, and employ or inspire overconclusions.

The most basic problem in this niche of medicine is linguistic the lack of clarity that is created by the lack of definitions for important terms. Such clarity has been the standard of care since the 18th Century. More recently, the American Association of Clinical Endocrinologists has declared in its guideline for guideline authorship, that all critical and readily misuderstood terms must be defined. If hypothyroidism were defined and that definitions were used consistently, then we would not have this problem. People with deficient post thyroid hormone operations that create and use T3, would be properly diagnosed and treated. However, the AACE and others' guidelines for hypothyroidism eschew such definitions. If hypothyroidism is defined narrowly (as the AACE and the American Thyroid Association do as a deficient secretion by the thyroid gland) then the hypothyroidism guideline would not apply to post thyroid deficiencies. If it were defined broadly (as the British Thyroid Association does) then the post thyroid deficiencies must be included in the recommendations for differential diagnostics and therapies (which the BTA does not do).

When one compares the medical practice guidelines for hypothyroidism with the differential diagnostics for hypothermia, one comes away with the feeling that the hypothyroidism guidelines are written to sell

Comment by What are we supposed to believe -- February 1, 2009 01:58 PM

I don't know if doctors are in the pockets of pharmaceutical companies, I don't know if there is a political or monetary reason to continue using the TSH, or recommend levothyroxine. But I can understand why many people believe it to be so.

It just beggars belief that so many patients continue to complain of symptoms of a disease they are already diagnosed with, but instead of trying another licensed treatment, they are told the symptoms are caused by some other catch all condition such as CFS, or depression, or told it is all in their heads?

It makes no logical sense, and so people do continue to look for a reason for it, money and politics are the obvious ones...

Comment by Dave Kruse -- January 31, 2009 12:25 AM

Dear Dr. Repas,
If you don't think the patients know what they are talking about, how about you talk to Dr. John Lowe that wrote The Metabolic Treatment of Fibromyalgia or better yet read it. He would gladly debate you.
Or talk to Dr. David Brownstien of West Bloomfield Michigan, who at one time held similiar beliefs as you.
I am serious, either read The Metabolic Treatment of Fibromyalgia or talk to these guys. Dr. Lowe would destroy your "scientific beliefs"
Oh by the way did you read these studies,
The British Medical Journal 293:808-810.
Are biochemical tests of thyroid function of any value in monitoring patients receiving thyroxine replacement?
Fraser WD, Biggart EM, OReilly DJ, Gray HW, McKillop JH

Serum TSH in assessment of severity of tissue hypothyroidism in patients with overt primary thyroid failure: cross sectional survey Meier C, Trittibach P, Guglielmetti M, Staub JJ, Muller B.

Journal of Clinical Investigation 96:2828-2838
Replacement therapy for hypothyroidism with thyroxine alone does not ensure euthyroidism in all tissues…
Escobar-Morreale HF, Obregon MJ, Escobar del Rey F, Morreale de Escobar G

Or do these studies not count because they were not in major American journal? By the way these people are passionate because they got their lives back after suffering for years and years. You are telling them they are full of misinformation, when it seems that you are.

Comment by Patricia Barnes, MPH -- January 30, 2009 06:51 PM

Dear Dr. Repas:

The TSH test DOES have some benefit in diagnosing thyroid disorders in someone who is not on any thyroid replacement; however, it should not be used to determine treatment levels as this will always leave the patient undertreated.

Your whole argument is based on the idea that a low TSH= a hyperthyroid state, but this is not the case.

The pituitary, by design, is very sensitive to circulating thyroid hormone. It reacts very differently to the once daily supplemental dosing than it does to the normal daily production of hormones.

Free T3 and Free T4 should be used to monitor treatment as these are the actual circulating and available thyroid hormones. I have seen many people have a low TSH coupled with below range levels for their free t3 and free t4. These people are hypothyroid not hyper.

Research and patient experience have shown that Free T3 best correlates to clinical euthyroidism.(Fraser, 1986)

You patronize patients when you equate their commitment to adequate treatment to some form of "deeply held belief" or magical thinking. Patients on supplemental thyroid hormone want their thyroid hormones monitored, and not the less useful pituitary hormone called TSH.

Research is clear that in older adults TSH declines with age without any rise in circulating thyroid hormone (Carlé 2007). Older adults are secreting less TSH, but they are not hyperthyroid, their pituitary function is just declining.

When you see patients with a low TSH who refuse to reduce their dosage, they are not committed to being in a hyper state, they just don't want to be under treated. A hyper state is very uncomfortable, no one would remain in that state voluntarily, not even for this magic weight loss you suggest.

I'll say it one more time — treating by TSH alone will leave the patient undertreated. Ignore the TSH once a patient begins treatment and monitor free thyroid hormone levels. I'll bet if you looked at those levels in the patients you assume are hyper, you would find that their free t3 and free t4 is still in the normal range.

Comment by Deni -- January 30, 2009 03:49 PM

I am so glad l found these ''threads'' l am Trapped in the NHS symstem in the Uk. To cut along story short I told the doc l had thyrotoxicosis.. they ignored my symptoms.. 3 years of high doses of antithyroid meds plus block and replace 3 years later a TT 18 months later l am still ill!! Many many symptoms many blood tests and still ''l'm in range'' and they who shall do no harm look at me as if l've invented a new disease!! I am wasting the best years of my life been kept on levothyroxine alone! All my family with me, lm too sick to make plans as l never know when l will be letting them down l'm too ill to attend planned holidays events etc etc. I could go on and on but wont.....10 years lve felt like crap and l cant see anything changing for me with the NHS l should be in my prime l so much want to be me again. This is sheer neglect.

Comment by Tami -- January 30, 2009 02:32 PM

Thank heavens for the internet. There are several thyroid groups and forums out there where we as patients can learn from each other. We're certainly not learning how to get well in the Dr.s office. The author of this article confirms that.

Docs, if you'd just add the free T4 and free T3 labs to the TSH, you'd find for yourselves Levothyroxine alone isn't cutting it for any patient still complaining about hypothyroid symptoms. Throw in labs for cortisol and sex hormones if you really want to do some good. They're all inter-related you know.

We, the public, are learning more and more every day. We're learning from each other what works. You should do the same. Right now, your missing multiple oportunities to help people. How many patients do you have who take their Synthroid faithfully every day, but still complain they feel bad? Too many for sure. Do yourselves and them some good. Learn from those of us who've found a better way. Armour is a life saver, Adrenal Fatigue is real, and Bio-Identical hormones work.

Comment by Fig -- January 30, 2009 11:21 AM

Felt great on Armour for years but due to high T3 and still low T4, was sent to an endocrinologist like you who NEVER ADDRESSED the fact this problem is indicative of adrenal issues, instead whipped me off Armour and onto Synthroid, proclaiming the virtues of Synthroid and how much better life would be. Would NEVER consider anything but the almighty Synthroid. Now my adrenals are TRASHED, my thyroid problems kept increasing, my dose raised to 200 mcg and still tests like I need more... plus all the hypo symptoms are worse! I finally found a REAL MD who is addressing the adrenals, switched me back to Armour, and hallelujah - the hypo symptoms are slowly regressing again... DON'T BE SUCKED INTO THE PHARMACEUTICAL TRAP! My very knowledgeable MD doctor NEVER sends patients to endos, prefers to deal with this herself, to avoid the pick up the pieces and repair work she has to do following the ignorant endocrinologists' damaging, narrow-minded ways...

Comment by Shirley -- January 30, 2009 10:42 AM

To days generation of Dr. and Endocrinologist are brainwashed by the Pharmacutical sales reps who pad their pocket books. They only prescribe what puts money in their personal pockets. It is a disservice to their patients. I've been on Armour Thyroid for years and feel great. Why prescribe a synthetic that poisons our bodies when the natural works? $$$$$$$$$$

Comment by Sean -- January 30, 2009 10:15 AM

My wife was diagnosed with hypothyroidism 5 years ago and she has experienced the worst hair loss I have ever seen for someone her age. Her PCP put her on Synthroid, but her hair kept falling out. So we went to an endocrinologist who put her on more Synthroid and things got worse. After that, we saw a specialist at a research hospital, a man who helped invent the TSH test, and he put her on a little less Synthroid. And even though her TSH test had been fine all along, her hair continued to fall out. Then she started to have panic attacks. Six months ago, she started taking Armour. Now her hair is growing back and the panic attacks are gone.

Comment by Liz -- January 30, 2009 08:43 AM

You are wrong. We do not want to teach you. We want you to listen. Taking Armour thyroid is not about losing weight and avoiding dieting. It it is about keeping my job, my friends and my life. It is not about being holistic or natural. It is about the treatment that is best for me as an individual. Why do doctors treat us as if we are all the same when we are so obviously not.

Comment by Another MD -- January 30, 2009 06:19 AM

I find it hilarious that the "patients" in this commentary know more than the "doctor" about thyroid disease, especially at the tissue level. Keep after him, he may eventually see the light. I'm an MD who has given up on the allopathic route because of the tunnel-vision induced by our training. I'm hypothyroid (Hashimoto's) and hypoadrenal (after years of synthroid), being treated by a naturopath. Glad I got here.

Comment by Sue -- January 29, 2009 11:33 PM

My mother has been on thyroid medication for 55 years. She was given radiation to her tonsils at 12 years of age when 1950s doctors thought radiation was the answer to everything. She produces no thyroid hormones as her gland is in effect, dead. In her life, she's been on 3 dessicated thryoid meds (2 of which are no longer manufactured) and 2 synthetic thyroid hormones. On the synthetic hormones, I didn't have a mother. She would stay in her room, sleeping or crying and telling me she wished she would die. After much tweaking, her doctor finally put her back on Armour. For the years since, she is has been her old self - a vibrant woman.

Just because science hasn't discovered a link yet, doesn't mean the link isn't there. That would mean all the mysteries of endocrine science have been solved. I'm sure even you, as a doctor and a scientist, are not so arrogant as to believe that everything that will ever be known about how the thyroid and its hormones work has already been discovered. That would be as silly as saying that just because a scientist hasn't seen an undiscovered species of fish, that such fish do not swim in the sea.

My mother's thyroid disorder was man-made, so it is an interesting (though unfortunate) coincidence that this week I was diagnosed with hypothyroid as well and a TSH of 26. While I won't do a knee-jerk reaction and demand Armour from day one, I'm proud of my mother for demanding better treatment. Her doing so, along with all the other Armour users, means I have choices if synthetics do not work for me.

Comment by E -- January 28, 2009 07:03 PM

“Most people would not dream of directing a cardiologist how to perform cardiopulmonary resuscitation during a cardiac arrest.” If cardiopulmonary resuscitation helped with weight-loss and it were being performed on someone desiring that you can bet they would. In fact, they’d probably sit up to do so!

Dr, with all due respect, and though I like your analogy about natural gardening this is not about an attraction to ''natural.'' It's about an attraction to weight control! And any medication with T3 has a better reputation for accomplishing that.

Thank you for writing this series. I hope more drs do the same in the future.

Lastly: To all doctors who are now catering or might be contemplating catering to those suffering from some sort of eating and/or emotional disorder, like the examples here (Janie) please keep the following in mind: While one person might be sitting in your exam room trying to bamboozle you into writing that script...another might be sitting out in the waiting area having not slept last night worrying whether his/her thyroid that got removed last week is cancer or not.

Please don’t let that latter person down.

Comment by From a Doctor -- January 13, 2009 08:49 AM

"Find a doctor who helps make you FEEL better, not just make your labs better because once given this diagnosis, you are likely to carry it for a long, long time. There is more than one drug, there is more than one lab test, and there is a "just right" doctor for everybody."

http://www.endocrineweb.com/hypo2.html

Comment by clarificationneededplease -- January 12, 2009 10:56 PM

when you said:However, taking so much thyroid hormone such that the TSH is fully suppressed can be dangerous, especially if given over the long term.

Does this mean that thyroid cancer patients are in danger from the current standard practice of keeping them at a suppressed TSH? At what point do they drop dead from that suppression? And do you tell them they are being harmed from that suppressed TSH?

Also, can you tell me why - if a person is taking a full replacement of thyroid hormone (sometimes needed in the management of autoimmune thyroid disease)...why would the pituitary be telling the thyroid to do anything anyway?

Comment by Janie -- January 12, 2009 06:08 PM

Dr. Repas, we agree on something! You are absolutely correct that "tunnel vision results in misdiagnoses and delayed treatment!" Bravo!

Because that is exactly what Endocrinologists have done to patients for five miserable decades: misdiagnosed us and delayed our treatment.

You have repeatedly misdiagnosed, delayed or undertreated us because 1) you rely on and worship a pituitary hormone lab test which measures the ability of the pituitary hormone, not the ability of cells to receive what they need and which leaves patients undiagnosed for years before it rises high enough to reveal the hypo, or undertreated once on medications (because like you said, "normal" may not be "optimal", 2) you put your complete faith in the pharmaceutical lie that a storage hormone is an adequate treatment and that patients can live on conversion alone, 3) as you continue to put your faith in levothyroxine, you ignore clear continuing symptoms of hypothyroidism while on levothyroxine, and tell the patient to "eat less", "exercise more", or " see a Psychiatrist"...and 4) you have failed to recognize the widespread problem and reality of adrenal fatigue and low cortisol in the very patients who have been subjected to the tunnel vision of 1-3.

You state you have no problem using acupuncture because it's "effective", even if the action of these therapies is not fully understand. Yet, each and every patient here is trying to tell you that what you call antiquated or not proven by science has been quite "effective" in changing their lives.

What is "antiquated" is the belief that an ink spot on a piece of paper equals "hyperthyroid" when there are absolutely no symptoms of hyper to match the suppressed ink spot.

And to state that ''this and that'' needs to be proven in a "large, randomized, placebo-controlled, double blind trial" means patients will continue to be sick, will continue to have their lingering hypo symptoms bandaided with anti-depressants, statins, blood pressure meds and more, and will continue to fall in mass amounts into adrenal fatigue....all while waiting on that "large, randomized, placebo-controlled, double blind trial." That is disgusting, Dr. Repas.

If anyone has chosen Endocrinology because it is a field they are "passionate" about, then you need to be school instructors, not doctors. Because what we as patients need is not just passion about a field from doctors, but passion for LISTENING to the patient and OPEN-MINDED that maybe, maybe the patient may know what he or she is talking about. We not only live in our own bodies, we do have brains. You do not have complete ownership of intelligence.

And by the way, it's not just "alternative care" practitioners who are finally understanding that desiccated thyroid works, that the TSH does not, and that adrenal fatigue needs to be treated. I find that offensive. There are MD's, DO's and even some Endocrinologists (imagine!!) who are finally getting it.

If it is ''your patients who teach you daily about what it is like to actually live with their diagnoses''...then LISTEN TO THEM, not simply "science". We are "your patients" and we are trying to tell you that this is far more than "dogma, personal belief systems or strongly held opinion". We are telling you by our "experience":

1) that levothyroxine leaves nearly ALL of us with continuing hypothyroid symptoms, and which doctors routinely miss or bandaid with other meds
2) that the TSH lab test has left most of us in hypothyroidism for years before it rose high enough to reveal it
3) that dosing by the TSH while on meds continues to result in lingering hypo symptoms,
4) that the "antiquated" desiccated thyroid has changed our lives, especially if we dose it a certain way,
5) that we have figured out many other issues that need correcting
6) that a large body of us now have adrenal fatigue with low cortisol, an

Comment by Let Us Know If You Need A Good Doctor -- January 12, 2009 05:19 PM

If you or a family member ever need thyroid treatment by all means let us know. We know of several doctors across the country who are well versed in treating thyroid patients in the proper manner. I guarantee you that if your life, marriage, profession-which you hold in such high regard, income and quality of life starts going downhill you will be the first one searching for the real answer. We will be happy to help you gain all that back with the name of a good doctor. I'm sure your thinking would change mighty quickly if all these things were happening to you so someone you love. I highly doubt you will give up everything you have in favor of your standard TSH/Synthroid treatment plan.

Comment by Vicki Spacek -- January 12, 2009 03:31 PM

How many years has Coke Cola been around? Is that dogma? No, it works as Armour Thyroid works. Been there done the synthroid and was allowing my doctor to poison my way to my death bed. Do you know how many doctors like you that I have FIRED because they think natural thyroid medicine is barbaric? If you were my doc, this is what I would say. Listen closely, YOU ARE FIRED!!!! Only reason I am giving you this much attention is because maybe just maybe, you might listen and realize natural thyriod works and maybe just maybe your patients will benefit from it and maybe just maybe one of your patients might praise you in the way you feel you should be praised. Little ego stroke might help you see the light and quit killing these people. Bad karma is created when you are informed of something you are doing wrong and continue to do. So if you are feeling a little unlucky lately, just look at all this karma you are building up. Hey, if you do become hypothyroid, let me know I know a GREAT doctor that will actually listen and help you even if you don't have all the answers!

Comment by Dear Doctor -- January 12, 2009 03:17 PM

You sir, need to give up your medical license NOW and find job that suits you better. Remember, first DO NO HARM. You are harming patients with your belief system and causing disease by using Synthroid!

Comment by DONNA REGAN -- January 12, 2009 03:15 PM

Doctor, you say you don't want to offend anyone's PERSONAL BELIEF SYSTEM. We're not talking about religion here. My belief is based on FACT: Scientific data and factual results. Armour made me and every single person I know feel healthier. T4 made me & others I talk to at my in-person support group & online group (thousands of people) sick. Sub-standard medical care in the endocrine field has made that branch of medicine a "JOKE" among us patients who compare the heinous errors Endos make in our care. We note the arrogance and denial we come across constantly. These are facts. This is real. Your own rebuttal letters show me you are not enlightened. You'd rather argue a point than actually listen and help. By the way, my "Endo" gave me T4 and totally crashed my adrenal system and almost killed me. Never tested me even tho the manufacturers of T4 & Armour state in their literature and websites that step 1 is always check adrenals. Guess my doctor missed that section in medical school.

He also learned other things like: RULE #1: Never, under ANY circumstances do you listen to Patient, measure only by TSH, RT3 isn't real & the other favorites we discuss frequently amongst ourselves when we laugh & cry about how poorly we've been treated. You people are NEVER going to change. But luckily, there are some great doctors coming up and they are going to put all of YOU OUT OF BUSINESS. I think whenever a physician does not relate or consider what a patient is stating, it is time to reevaluate on both ends: Time for the patient to walk away and time for the Doctor to think about an alternative career because caring for people is not an appropriate career.

Comment by ivy -- January 12, 2009 02:44 PM

''If I followed the line of reasoning, “if you have the symptoms then you must have the disease,” that would mean that every person with depressed mood must have depression. They should be started immediately on an anti-depressant without looking for other causes.

Absolutely not! Never!! No!!!''

That's funny, because many of us have had the experience of pointing out to our doctors that we still had depression when on synthroid, and we were given antidepressants rather than more thyroid hormones. Incidentally, most of us found our depression magically lifted when we found doctors who would treat us by symptoms instead of TSH.

Do you read the words you write??? Cookie cutter medicine and TSH worship keep patients sick. It's so simple to just listen to your patients and educate yourself.

Comment by tiredoftheblindarrogance -- January 12, 2009 01:49 PM

I don't have much to say other than the medical system has turned their backs to us patients who DESERVE not to be sick and mistreated. You are just a cog in the wheel of money that flows freely from those of us who do not have it by way of mistreatment, and mismanagement of our thyroid conditions.

I have to take something the rest of my life. The synthetic CRAP I have been put on has destroyed my life, as well as the incompetent/uncaring McDonalds doctors that shuffled me in and out of their fast food line offices for years.

And yet, they still get paid, generously, by my insurance, by the doctors office, and so do the drug companies. $5 a month for the rest of my life. That's alot of money....................no wonder we are still sick....If I keep telling someone like you I just don't feel right, you can milk me for so much more money, by throwing more antidepressants, and various other crap.
WAKE UP! Re-educate yourself, and your peers in this industry.....PLEASE.
TSH is not spelled GOD to people like us. and it's worked. Imagine that.

Comment by thereyougoagaindoc -- January 12, 2009 01:04 PM

I read through some of your post. mostly scanned it because it's the same old stuff. We call endos "synthroid nazis"...did you know that? Because we've heard it from others like you. Endos are notorious for bad thyroid treatment. And thank god some of us have enlightened doctors who actually care about keeping us well. But you're always going to be a doc who believes "TSH rules". you''e too scared to listen and learn from these patients. First, TSH can never rule in autoimmune thyroid diseases. Too many variables. 1/3 of Hashi's folks have TSH receptor antibodies. do you know what those do? do you test for them? If they are blocking or binding TSH receptor antibodies how do you know that TSH is accurate anyway? how do you know that your patient doesn't have antibodies to thyroid hormone in serum and thus needs more thyroid hormone than usual to compensate?

And if a person has been suffering hypo symptoms for many years, can their pituitary gland be affected? Or are you saying that particular gland is somehow immune to the effects of hypothyroidism and always works well? And where are those scientific studies that say a TSH in range correlates to the body's lack of hypothyroid symptoms? I haven't seen them. But there are studies that say TSH does not correlate to the severity of hypothyroidism. Do you know what "brain hypothyroidsim" is? and if the HPT axis isn't working properly, how does the body let you know the tissues aren't getting enough thyroid hormone? Could it be SYMPTOMS? Or signs like high cholesterol? Just how many hypo symptoms must a person have before you decide to maybe test their Free T3 and if it is low in range...just how low in range must it be before you consider a therapeutic trial of thyroid hormone? Is a 30 day trial of low dose thyroid horomone less dangerous than the anti-depressants and asthma medications and heart medications and pain medications the docs have put us on because it couldn't be our thyroid because our TSH was in range?

And do you always test for cortisol? Have you ever used the diagnostic code for "hypo adrenals" or do you only recognize Addison's? I don't even need to ask that one do I? - because you think we're stupid enough not to recognize excess cortisol symptoms.

I...and the others...are truly wasting our typing energy. But we tried - but you aren't listening. You are worshipping at the altar of TSH and modern medicine...and don't want to believe that something could be terribly terribly wrong with that belief.

However I too believe that if something is true, that science will bear it out. But it has to be good science..and not tainted by pharmaceutical influence. Maybe you could do a study: Does a person report less hypo symptoms (and you probably need someone to send you a complete list because most docs don't know them) on desiccated thyroid extract who has their Free T4 and Free T3 above the midpoint of the range versus a person on Synthroid with their TSH in range. In other words...is TSH or Frees values a better measure of thyroid hormone response in the body? Maybe do that study on TSH vs. Free values with synthetics first? but oops...can you even get a person's Free values above mid-range on synthetic medication...or what is that I read about some folks reaching a state of hypo that their enzymes don't work so they can't even convert maybe true? Sure, we've love to see scientific studies that bear out what we happy Armour/ignore TSH/monitor Frees/check for enough cortisol patients know. It is you doctors (and Synthroid mfg) that are afraid of the science on this one. Hey - do you need some volunteers for the group "My TSH is suppressed on Armour, my Frees are in the upper 1/3 of the range, and I have no hypo symptoms (and no hyper symptoms) and I feel really really good"? I think I know where you might find some.

Comment by Chris (continued) -- January 12, 2009 11:11 AM

should have access to the most effective, safe, cost-contained ones possible and smaller drug companies should be able to fairly get their products on the market and not worry about false claims or Congressional corruption because some smaller company producing a better drug threatens their profit margin. Free market economy is not happening currently, where better drugs produced by companies with less political power and financial strength get forced out of the market or never come to market because of the monopoly of a few companies.

http://www.lieffcabraser.com/synthroid.htm

http://thyroid.about.com/library/weekly/aa043001a.htm

“My duty is to provide the most accurate information possible.” Then why don’t you start doing that?!

Start by telling them all the wonderful benefits of natural thyroid. Let the patient decide. As prior patients have written you here, make sure they get any adrenal issues addressed first or NO thyroid medication will work properly. Forest labs, to their credit, has a big cautionary note about adrenals on their front page. “Precautions: Thyroid hormones, either alone or combined with other medications, should NOT be used for the treatment of obesity and should NOT be taken by patients with uncorrected adrenal cortical insufficiency, untreated thyrotoxicosis, or apparent hypersensitivity to thyroid hormones.”

I don’t see the Synthroid manufacturer addressing that adrenal issue!

I also found that your rationale in your earlier posts is written the same way, with very similar verbiage to, the Synthroid sales pitch page on why patients should stay on Synthroid. Coincidence? Or are you getting some type of benefits and/or compensation for pushing Synthroid?

“Finally, last week I saw a woman who had been on desiccated thyroid for decades. I explained that we now prefer levothyroxine instead of desiccated thyroid. I also quickly pointed out that her thyroid-stimulating hormone has been perfect, between 0.7 mIU/L and 1.0 mIU/L over the last several years. She had no symptoms; it was difficult for me to argue with success. After discussing and asking her what she wanted to do, she left my office still on desiccated thyroid.”

So, this woman had no symptoms on desiccated thyroid and you STILL wanted to switch her to levothyroxine? Why exactly? If that isn’t a perfect example of you caring more about some kickback from a drug manufacturer than the patient’s well being, I Don’t know what is! If it is working, why change? And to educate you Dr. Repas, TSH is NOT the golden standard of thyroid testing. The fact that you think it is, tells me that you are woefully ignorant on thyroid disease. TSH only tells us what is floating around in the blood, NOT what is being bound or taken up and used by the cells. If a person has cellular resistance (very common), can’t convert T4 to T3 due to liver issue, toxins, or a host of other issues (also common), all the T4 in the work isn’t going to help.

I say BRAVO to this patient for being smarter than her doctor and taking control of her health by walking out when she knew he intended not to help her.

So much for "first do no harm"!

Comment by Tom Repas DO FACP FACE CDE -- January 12, 2009 11:09 AM

people do not want to hear a lecture on the data or evidence-based medicine; they simply want to feel better.

Evidence based medicine has its limitations. It is impossible to design a study to evaluate every conceivable clinical situation. I strongly agree that an individual’s unique personal experience should not be marginalized or ignored. It is impossible to know what it is like to experience a medical disorder unless you have it. Even if you do have a specific diagnosis, it does not mean that your experience will be exactly the same as everyone else’s.

I strive to be as much an expert on the science and physiology as possible. However, it is my patients who teach me daily what it is like to actually live with their diagnoses. It has truly been a privilege for me to listen to their stories, share my insights and be involved in their care. I treat everyone the same: the way I would like myself and my own family to be treated. I do this even if we do not see completely eye to eye. I am both grateful and humbled that they have chosen to come see me when they could easily have gone to someone else. I may not have all the answers, but I try the best I can. This is all that any one of us can do.

If I have offended any of you by any of my comments, I apologize. I never intended to convince you to come over to my way of thinking. My only goal is to explain why it is that I and many other endocrinologists take the positions that we do.

Thank you all for reading and commenting. This has been one of the more rewarding series of posts I have written. It certainly has provided me with much food for thought. I hope that it has been the same for you.

Do not forget: January is Thyroid Awareness Month!

Comment by Tom Repas DO FACP FACE CDE -- January 12, 2009 11:08 AM

be sure, TSH has its set of problems like any laboratory assay. Many endocrinologists, including myself, question the supposed “normal” reference range of many laboratories. “Normal” is not equivalent to “optimal.” Earlier TSH assays had problems with accuracy. However, this problem is much less with the newer generations of TSH assays. Of course, we cannot use TSH in patients with hypopituitarism. I have also seen TSH results affected by interferences such as heterophile antibodies. However, these latter two situations are rare.

Human beings often like to think that we are smarter than our bodies. However, as much as we would like to, there is no escaping physiology. There is no better sensor of our thyroid status than a functioning hypothalamic-pituitary axis. Thus far, TSH is the most reliable means we have devised to assess this. Not believing in TSH because it conflicts with how you would like your thyroid to be managed is simply rationalizing your point of view. It is not supported by our previous decades of scientific research.

If TSH should be thrown out as a tool to manage patients with thyroid disease and we should rely purely on symptoms and clinical findings, that must be proven. Ideally, this would be done in a large, randomized, placebo-controlled, double blind trial. Until then, TSH will remain standard of care.

The opinion that endocrinologists are not the experts in thyroid or other endocrine disease, is also one to which you are entitled. Endocrinologists do not have a monopoly on the diagnosis and treatment of endocrine disease. There are many capable primary care and other practitioners. Nevertheless, most endocrinologists chose our subspecialty because it is something we are interested in and passionate about. We have made it our life’s work to understand the endocrine system and to apply such knowledge to the benefit of our patients. For me, endocrinology is not only a career, it is a calling. Endocrinologists do not have all the answers, but we continue to search for them.

Everyone is free to choose whom we would like to see for health care. Nevertheless, anyone who chooses to go to a practitioner with no training, questionable science and non-evidence based treatments does so at their own risk.

I have seen a number of patients directly and indirectly harmed by misguided hormonal therapy. I remember the patient who was advised to see an endocrinologist by her primary care physician. Her symptoms were fatigue, weight gain, depressed mood and muscle weakness. Her sister “did not believe in endocrinologists” and convinced her to instead see her alternative care practitioner. The patient was diagnosed with “adrenal fatigue” and prescribed T3 and hydrocortisone. Her symptoms did not abate, even despite being advanced to 50 mcg of T3 and 40 mg of hydrocortisone in divided doses per day.

It was not until she experienced an osteoporotic fragility fracture that she was brought to the attention of conventional medicine. After stopping her thyroid and hydrocortisone, it was realized that she still had cortisol excess. Her diagnosis was not “adrenal fatigue.” It was quite the opposite, she had pituitary Cushing’s disease. Treating Cushing’s disease with hydrocortisone is analogous with attempting to put out a fire with gasoline.

This is just a single example. I have seen dozens and dozens of other cases. Most of the time, I believe that the harm inflicted was not intentional. It was due to a sincere but misguided understanding of endocrinology.

Nevertheless, even though I do not share some of the opinions expressed by alternative care practitioners, I believe that mainstream practitioners can learn from them. Many alternative care practitioners take time to listen. Their patients feel valued, heard and appreciated. Although alternative medical practitioners do not have a monopoly on this style of practice, often this is why they are in such demand. Most

Comment by Tom Repas DO FACP FACE CDE -- January 12, 2009 10:47 AM

not have the science to back it up, then it cannot be considered any more than an opinion, until proven otherwise. I am skeptical of any therapy, no matter whether it is “alternative” or it is the latest and greatest expensive new FDA-approved drug being marketed by a pharmaceutical company. The challenge for all of us is to be skeptical without becoming dogmatic.

I envy the strength of your convictions. I wish mine were as strong. I practice differently today than I did five years ago. I hope that in five years I will be practicing differently yet again. As new data and understanding emerges, we need to throw out old ways of thinking; no matter how near and dear they are to us.

I always question why and how we do things. I question my own practice most of all. Is this the best way for me to manage this patient? Could there be a better way?

My medical school training was as a D.O. (Doctor of Osteopathy). Therefore, it is my tendency has always been to be open-minded towards alternative or holistic approaches. However, my residency and board certifications are through M.D. programs. I can truly say that I have walked in both worlds. Truth in medicine and particularly endocrinology is rarely “black and white” or “either/or” but rather many shades of gray. Nonetheless, I need science to support my opinions. I cannot change my position based on someone’s passionate testimony alone, as much as I sincerely wish I could.

I believe that in order to have an informed conversation with my patients, it is essential for me to be aware of other points of view. I do not know if I am alone in this, but out of curiosity and interest, I occasionally read the alternative medical literature, even if I do not agree with all that is written there. After all, today’s “alternative” medicine occasionally becomes tomorrow’s accepted “mainstream” therapy. I do not want to be the last to hear of a potential new treatment option.

When not practicing endocrinology, I run ultramarathons of 50 miles or more (I have no logical scientific explanation for that!) I often experience self-induced chronic muscle pain. Despite my belief in evidence based medicine, I have no problem receiving acupuncture or massage therapy. The mechanism of action of these therapies is not fully understood by Western medicine. However, these modalities are effective and in the hands of a skilled and trained practitioner, unlikely to cause harm. The subjective benefits alone are sufficient for me to continue.

The problem is that hormonal therapy, if given in excess amounts or to patients who do not need it, has the potential to cause harm.

Despite my statement that “desiccated thyroid hormone is antiquated therapy,” in practice I am more pragmatic than that. If a patient is responding to therapy and they are not being rendered hyperthyroid, it is difficult to argue against that, other than on principle. However, doing something based on principle alone without objective data is not enough for me.

Otherwise, who would be the one who is dogmatic?

The concern I have is when individuals are initiated on therapy without monitoring or are titrated to levels higher than is safe, based on symptoms alone. Mild hyperthyroidism, say a TSH down to 0.1 in an individual who is not frail, elderly and who does not have cardiovascular disease or osteoporosis, probably will not cause any harm, at least over the short term. Because thyroid hormone has stimulating properties, I am not surprised when many people feel better when the thyroid dose is higher than we usually prescribe. However, taking so much thyroid hormone such that the TSH is fully suppressed can be dangerous, especially if given over the long term.

Saying “we don’t believe in TSH,” is your opinion to which you are most certainly entitled. However, this belief has no foundation in science or our current understanding of the hypothalamic-pituitary-thyroid axis. To

Comment by Tom Repas DO FACP FACE CDE -- January 11, 2009 01:33 PM

As I read through the comments on the past few posts, I see that unfortunately many, if not most, are full of misconceptions and commonly held fallacies about the endocrine system. Hormonal therapy is not magic endocrinology is not alchemy. However, a number of your comments suggest that it might be. I could take time to point out each and every one of these mistaken beliefs but it would be best if I did not.

My objective is to discuss and inform, not to insult anyone’s strongly held personal belief system.

I realize that no matter what I write or say, I could never change some of your strongly held opinions. Many of you are already offended enough by what I have written simply because it happens to conflict with your own position. Many appear unwilling to contemplate that another reasonable perspective is even possible. If I pointed out every error in your science or logic, it would serve only to offend you further. That is not the purpose of writing these posts so I decline to do so. My intent was only to explain why many endocrinologists take the position that we do.

I stand by my position that just because someone has the symptoms of hypothyroidism or any other disorder, does not mean absolutely that they have it. The temptation for me to fall into this trap myself is great. I am an endocrinologist after all. It is in my nature to look at the world through hormone-colored glasses. However, I have learned through experience that having the symptoms and actually having the diagnosis are two separate things. It is unrealistic to believe that every single disease or group of symptoms has an endocrine explanation.

If I followed the line of reasoning, “if you have the symptoms then you must have the disease,” that would mean that every person with depressed mood must have depression. They should be started immediately on an anti-depressant without looking for other causes.

Absolutely not! Never!! No!!!

There are many causes of feeling poorly, the thyroid being only one of them. It is never unreasonable to consider other possible diagnoses before initiating treatment. A good clinician knows that and is willing to take the time to consider all possibilities. Tunnel vision results in misdiagnoses and delayed treatment. Anyone who suggests otherwise is being close minded.

Believing in something, no matter how strongly or how passionately, does not mean that it is true. Faith and testimony have their place in religious belief. Endocrinology, however, is a science and not a religion. Thus, it must be judged by the methods of science.

I fully concede that science is one belief system among many. It has its own merits and limitations like any other belief system. Medicine is as much a healing art as it is a science. The best of our knowledge and technology will fail if it is not delivered in a manner that is empathetic, understanding and kind. However, science remains the best system we have to discover new knowledge and objectively test the theories that we have about the physical world.

If you do not agree that science is a valid method of investigation, I do not know how to respond. It would best for us to agree that we disagree and leave it at that.

Refusing to consider that it is possible for there to be different but still reasonable opinions is being dogmatic. Many of you have been very dogmatic in your comments. However, conventional practitioners have been as guilty of false assumptions based on weak science and dogma as anyone else. Doing something “because that’s the way we’ve always done it,” is not acceptable. There is nothing worse than dogma to stand in the way of progress.

We must not confuse dogma with skepticism. Some skepticism is useful and necessary. We should never believe everything that we are told. It is good to ask questions. That includes questioning what conventional as well as alternative practitioners say. If a claim does

Comment by Chris -- January 10, 2009 02:28 PM

"Despite this, many intelligent, otherwise reasonable people have no hesitation trying to “teach” me about the thyroid. Many of these same people also request to have their thyroid disorder managed similar to how we did decades ago."

Wow, what an arrogant attitude you have! If your patient feels s/he needs to "teach" you, it is time you reevaluate the level of care you are giving that patient, because clearly what you are doing is NOT working! A good doctor knows that you will learn more from your patients than anything you will ever teach them. Any good doctor will always be open to learning from their patients, unless of course they think they are God. Your statement says more about what kind of doctor you are than any of your patients.

Pig thyroid has worked well for a 100 years. There is plenty of research on it. I likely read more medical research than you. Pigs and humans have very close physiology, which is why research into stem cells from pigs to cure diseases and grow body parts is so promising.

Patients who are not doing well on synthetics and dealing with myopoic doctors who let their egos (and kickbacks from pharmaceutical companies) interfere with their ability to provide adequate care, are suffering needlessly. That is the real travesty. I am in medical school and am determined to be the exact opposite of the kind of doctor you represent. It is due to my own health issues and horrible care I received that led me to decide to go into the medical field and try and make a difference.

Maybe if we had laws that were more patient friendly and allowed patients financial compensation against doctors who only follow drug company protocols and refuse to treat symptoms, would we start getting a better level of care. Millions in this country alone are suffering needlessly and instead of care they egomaniacs who only care about making $$ and not helping them.

I read your parts I and II also. Do you realize, if Forest Labs decided to sue you, they would have a very good case for libel and defamation based on the false statements you made regarding their Armour product and its consistency? Synthroid already lost the battle in how they were suppressing studies and marketing their product. Maybe I will call Forest and let them know to check out what you wrote. I really have to wonder about what your motivation is in this three-part series, since it clearly is not to provide the best medical care to your patients.

“For me to argue for patients to change someone’s belief system based on science is equivalent to attempting to convince them to change their religion or political party on the same grounds. It would be futile as well as absolutely inappropriate.”

Okay, that is just a flat out false! There is NO science behind saying synthetic thyroid meds are better than natural. NONE! The thyroid makes numerous hormones in addition to T4 like T3, T1, T2 and as many as 29 hormones based on the research I have read. Just because a drug company who profits from rigging studies says it is so, doesn’t mean it is true that theirs is the more effective drug. To say the thyroid only needs T4 is equivalent to saying the human body only needs water to live and no food or any nutrients. You would be dead in a month.

I have plenty of friends who work for drug companies from the research departments to sales, so I am very familiar with the shenanigans that go on in the name of profit. How about all those internal studies that show the danger of drugs like Synthroid that the public never hears about, doc? It doesn’t sound like your intent is to provide options or educate your patients, but instead to ram your dogma down their throats, exactly what you say you are not doing. You might as well force your political beliefs on them because really, the large drug industry controls a whole sector of public policy, so it isn’t a big leap. I have nothing against drugs or profit, but I believe patients

Comment by DONNA REGAN -- January 10, 2009 01:57 PM

For me, doctors have been far more detrimental mentally & physiologically to me than my Hashimoto's Disease would have been HAD I met a competent doctor at any point over the last 20 years. Synthroid almost KILLED me. Doctors didn't even know the connection between thyroid and adrenals & how testing adrenals FIRST is paramount. The most pain has been derived from close-minded, ignorant docs who learn obsolete nonsense in medical school and never learn from their patients and work as a team to heal said patient. Then big pharma plays its role as they buy off each doctor & docs start pushing a horrible med like SYNTHROID on patients, knowing ARMOUR is a better choice. T4 Levothyroxine versus: Armour which contains T1, T2, T3, T4 and Calcitonin...Doesn't take Einstein to calculate that ARMOUR is better in every way. Do you think we were going to all be silent while we are made to suffer by rampant medical ignorance or rise up to speak the truth and change what is wrong. Maybe we will change the endo community and force them to learn, care and do the right thing by us, the PATIENT. It's happening right now. Why don't you wake up NOW and become a physician who cares about making thyroid patients better? And one who refuses to espouse erroneous, harmful nonsense and start learning the facts. In this country even an idiot can become president. There are too many idiots who are endos and you Sir can improve your standing by learning at least a modicum about the field of medicine you chose to be a part of. As it stands, us patients know a HECK of a lot more than you do.

Comment by Trish -- January 10, 2009 01:38 PM

Isn't it strange that thyroid patients generally feel so much better on Armour and most M.D.'s either refuse to prescribe it or claim to have never heard of it. T4 just does not adequately replace natural thyroid hormones.

Comment by DangTiredofDocsLikeYou -- January 10, 2009 12:59 PM

When you have lived with untreated hypothyroidism for 15-25 years because the many many docs you went to looking for help all worshipped TSH and ignored your many many symptoms and thus your quality of life was diminished then and your present health compromised because of the permanent consequences of long-term untreated hypothyroidism - then, and only then, will you have the right to think you know more than I do about hypothyroidism.

And when you finally got diagnosed (dang those TSH receptor antibodies that your TSH low until you were almost dead) and then had to ignore more doctors who tried to keep you sick by continuing to worship TSH....so you self-treated and achieved better health than you ever had before...then, and only then...will you have the right to tell me how best to treat hypothyroidism.

And since you don't have this type of experience, I suggest you need to shut up and start listening to these patients who obviously know more than you know. It also sounds like an apology is in order but I know doctors to well to think that might actually be forthcoming. And I would bet money many thyroid patients have studied more on this hypo/treatment subject than you ever have. Our next breath depended on it. So we have gone back to all the old medical books and abstracts regarding hypothyroidism and Armour because the honest truth is - they knew far more about it then than they do now...both symptom-wise and treatment. You really think "new" medicine is better? You need to do some reading on the subject. Americans are dying because of over-treatment and bad treatment. Many of us here were probably on numerous medications with side effects. Now we take our thyroid hormone - desiccated thyroid extract - and that's it. Yes, less money for all the doctors we used to see. and the pharmaceutical companies are losing money too. And sadly, many of us must take hydrocortisone for our poor worn out adrenals that Your NEW diagnostic standards and treatment caused. Wake up. You are supposed to "do no harm" and these patients here are clearly telling you that if you're diagnosing or treating to TSH -and only with synthetics and refusing to use desiccated thyroid extract - you are harming...and probably killing. Do you need to rethink your position?

Comment by Ericka -- January 10, 2009 11:59 AM

Nearly 20 years ago I was an active woman in her 20s who started coming down with chronic fatigue and other raging hypothyroid symptoms. Both my mother and grandmother have a history of thyroid problems, but according to my TSH I was "normal". Believe me, it's not "normal" to sleep for more than 10 or 12 hours and still be completely exhausted every single day.

When my TSH finally showed hypothyroid about 5 years ago, I was put on levothyroxine which did absolutely NOTHING for my symptoms, but did bring my TSH back into "normal" range. Unfortunately, this did not help my quality of life one iota and told my doctor this, but got no further help. So I had to educate MYSELF on thyroid and adrenal function.

I have since found that my body was unable to convert the T4-only levothyroxine into the active T3 that my body needs. I have since switched to Armour thyroid, which contains T4, T3, T2, T1 and calcitonin, just like my own thyroid gland is supposed to produce. I have also recently begun to support my adrenals, which is necessary in order to have enough cortisol in my system to aid in getting the T3 into the tissues and cells where it can be used.

I am finally showing signs of improvement, thanks to finding another doctor who understands all of these relationships and was willing to use therapies that may not be considered "normal" or "new" by the AMA, but work! I hope the woman who walked out of your office is able to find someone who can better help her to maintain her health.

Comment by Stephanie B. -- January 10, 2009 11:56 AM

Each time I read about the controversy over Armour thyroid I am saddened. Why should there be a controversy at all? The late Dr. Broda Barnes described the spiral into poor health that evolved with his patients in a very short time after switching them from Armour to Synthroid (or any other T4 only drug). He was open minded enough to try the "new technology" but when he saw his patients suffering he pulled the plug on it and refused to continue its use.

I am a life that was saved by Armour. In March 2000 I was diagnosed with papillary thyroid cancer that had spread to my lymph node. I had no symptoms of a thyroid issue other than a lump on my thyroid. After removal I was placed on Levoxyl and then Synthroid (the Cadillac of thyroid meds I was told). My health began to spiral downward. I felt horrible and my doctor gave me an anti-depressant. I was not depressed. I was hypothyroid. I had 2 recurrences of thyroid cancer for which I was ablated with RAI. After a total of 3 RAI's my endocrinologist told me that I had reached a max lifetime dose. It was recommended that I seek treatment using External Beam Radiation. I ran! I ordered my own labs that showed my probably cause for the 23 symptoms was a low thyroid with my Free T3 and Free T4 at the bottom of the ranges.

I sought the help of a holistic doctor and he placed me on Armour. I began to nurture the failing adrenals due to my low thyroid function and life began to return. I have been on the same dose of Armour for 3 years now and feel fabulous! On Synthroid I had a dosage change every 6-9 mos. I never felt good. All but 2 of my 23 symptoms have now been eliminated. My cancer markers came down naturally. Coincidence? I don’t think so. My doctor is in such high demand that he has had to close his practice to new patients. His partners are 5 mos out to get an appointment. Why would this be? Because there are too many doctors discounting the clinical signs of hypothyroidism because the laboratory document states that they are in some magical “range” so they must be normal. They continue to dole out levothyroxine products because they are in the pockets of the pharmaceutical industry. We are not lab tests. We are people. Yes we need to get back to the historical way of treating patients as Dr. Broda Barnes describes in his book “Hypothyroidism: The unsuspected Illness”. Why are there so many cases of Chronic Fatigue, Fibromyalgia, Diabetes, Heart Conditions and more? UNDER TREATED THYROID is a big one. Until doctors get off their pedestals and start listening, more people will suffer. You think healthcare costs are bad now…. Just wait. It is an epidemic of monumental proportion.

Comment by Armour Works! - Synthroid Doesn''t! -- January 10, 2009 11:33 AM

This is very simple, Armour works, Synthroid does NOT - period - end of story!

Comment by Venizia -- January 9, 2009 10:59 PM

Does the statement "First do no harm" mean anything. I have been a hashimotos patient for over 20 yrs. Most of the years I was on Synthroid with so many hypo symptoms no matter what dose I was on. I finally took matters into my own hands and found a doctor that knew something. Since I have been on Armour, most of my symptoms are gone. I feel human. My cholesterol went from 234 to 189. Now you tell me, why would I go back to something that made it all worse. Armour is FDA approved. Stop bad mouthing something that is working for thousands of people and read up on it. Stop helping the pharmaceutical companies. First do no harm.

Comment by Robin -- January 9, 2009 10:43 AM

What about those who do not convert T4 to T3 adequately?

Comment by Lori Connerly -- January 9, 2009 07:41 AM

Doctor, sometimes we have to go with how we feel and disregard the traditional allopathic approach it's work with Chinese medicine for 5000 years so I suspect there may be some validity to it.

When my father went to pharmacy school over 60 years ago, Armour thyroid was the standard..in my book, after 25 years of treatment with synthetic T4 and 25 years of feeling unwell, it is my gold standard...again, I can't get back the 25 years I lost being tired,cold, lethargic and brain fogged, (being told by doctors it was not my thyroid),but I can fight for a thyroid patient's right to tell their doctor they feel good and their symptoms are relieved and to be believed and supported -or to find an enlightened physician.

Comment by Climb down off your freakin ivory tower!! -- January 8, 2009 10:33 PM

"Finally, last week I saw a woman who had been on desiccated thyroid for decades. I explained that we now prefer levothyroxine instead of desiccated thyroid. I also quickly pointed out that her thyroid-stimulating hormone has been perfect, between 0.7 mIU/L and 1.0 mIU/L over the last several years. She had no symptoms it was difficult for me to argue with success. After discussing and asking her what she wanted to do, she left my office still on desiccated thyroid."

Armour thyroid has been successfully used for over 100 years! Wake up man!! You just had a patient who thumbed her nose at your "new fangled-poor substitution synthroid". How many patients actually asked to be switched to armour and you told them no? How many patients on synthroid with "perfect labs" still complaining they have hypo symptoms and you won't switch them to armour? How many patients are you under treating?

Comment by Catherine Clark -- January 8, 2009 09:44 PM

You need to educate yourself on levoxylcrap. Armour has been around for 100 years with an excellent success rate, the same of which cannot be said for synthetics. I speak from experience. No, I am not a doctor. I am an educated patient. How much do you get paid for endorsing synthetic junk? Which is exactly what it is. It does more harm than it does good. Armour has all the thyroid hormones, plus calcitonin for the bones. You should learn something from this patient who is a success on good old dessicated thyroid. Shame on you for NOT learning something. No, you cannot argue with success.

Comment by Susanna -- January 8, 2009 06:09 PM

Managing a thyroid disorder similarly to how we did decades ago works!

Why do you think that I and millions of other Synthroid users got a settlement in the class action lawsuit?

At least you listened to your patient and didn't demand that she change to inferior levothyroxine. If you had a thyroid issue, you might feel the sanme way.

Comment by Jan Doe -- January 8, 2009 05:44 PM

You ask "what is this". This is us (patients) not letting you (doctors) ruin our lives any longer that's what that is. Imagine, you learning something new!!!

Comment by Valerie Taylor -- January 8, 2009 05:12 PM

Amazing thing though. It seems the doctors that still use and recommend natural thyroid are usually the ones that are hypothyroid themselves. Ever wonder about that? BTW the last cardiologist I saw was in 1994 and he gave me less than 2 years to live, I am still pretty perky for a dead gal. But it had NOTHING to do with my thyroid , so I was told. But the major change in my dead to live situation has been leaving Synthroid and starting Armour Thyroid.

Comment by DawnxJones -- January 8, 2009 05:00 PM

'''After discussing and asking her what she wanted to do, she left my office still on desiccated thyroid.'''

Why ruin something that is working. Well done that lady. I have been on levothyroxine for decades and my health has deteriorated over that time despite my healthy eating plans and hobbies which give me exercise. Thank God there IS an alternative the levothyroxine. The heart specialist would be a little stuck if there were only one treatment recommended for a cardiac patient and it didn't suit her wouldn't he?

Please tell me you treat your patients to clinical examinations and signs for thyroid problems as well as the TSH which is not always reliable for thyroid function as the science proves if you read the papers on it.

Comment by Janie -- January 8, 2009 04:44 PM

What? You have reached such an exalted and holy level as an Endocrinologist that you can't possibly be completely wrong about thyroid treatment and LEARN from your patients?? Shame on you!

This is exactly why a huge and growing body of thyroid patients around the world are becoming vocal about their disgust of your profession! Patients are TIRED of this kind of omnipotent and close-minded attitude.

Patients are TIRED of being told that clear hypothyroid symptoms are "something else" simply because you are bound to the pharmaceutical lie about Synthroid and the old boy prejudice about desiccated thyroid.

Patients are TIRED of the schizophrenic pronouncement of "normal" because an ink spot on a piece of paper says so, and they REEK of continuing hypothyroid symptoms.

Patients are TIRED of being told that their clear symptoms of adrenal fatigue, which you are clearly clueless about, are nothing more than "iatrogenic hyperthyroidism".

You state that your duty is to provide the most accurate information possible. So are you defining "accurate" as buying the pharmaceutical hogwash that thyroxine is an adequate treatment, or that a measure of a PITUITARY HORMONE accurately reflects how all bodily tissue is receiving thyroid hormones?

Hooray that your patient last week left your office, still on desiccated thyroid. Because if she had listened, she would have been sentenced to a return of hypothyroid symptoms such as rising cholesterol, rising blood pressure, weight gain, depression, aches and pains, heart problems and/or a host of other continuing hypothyroid symptoms which nearly EVERYONE has on Levothyroxine.

You are right. We are free to choose how we want to proceed. And that is avoiding doctors who fail to listen to their patients, who don't look behind the pharmaceutical scandal of levothyroxine, who are blind to the profound problem of adrenal fatigue in thyroid patients, and who think a pituitary hormone lab is the end-all to thyroid diagnosis and treatment.

Janie

Comment by Darla -- January 8, 2009 04:29 PM

We want our thyroid managed they way they did decades ago because the new way doesn't work. Didn't work for me and others that I know. New isn't always better.

Comment by Julie Sue -- January 8, 2009 03:55 PM

Yes, heaven forbid you "learn" something new. Just because it's old doesn't make it NOT right. You are destroying lives with this attitude of not wanting to "learn" something.

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