Common thyroid mistakes: treat the patient... not the labs

After reading an article titled “Understanding Thyroid Problems” by Susan Carlton in the August issue of Good Housekeeping magazine, I felt compelled to sit down immediately and comment on it. This article was seriously misleading.

Carlton discusses the different forms of hypothyroidism, including Hashimoto’s an autoimmune hypothyroid disease in which the body produces antibodies that attack the thyroid gland. She also briefly talks about hypothyroidism not caused by Hashimoto’s, but does not explain this type of thyroid disease. In addition she neglects to mention studies which showed that people with a mildly elevated TSH or a low thyroid level had a greater risk of heart disease and heart attacks.

Carlton then gets into the testing debate. Before I comment on that- let me say this- more often than not, there is a debate about diagnoses, testing and treatment in all aspects of medicine. I often tell my patients that they could go to ten different doctors and get ten different opinions. It doesn’t necessarily mean that only one is right- BUT that physicians have different approaches to diagnosing and treating illnesses. Many of my patients come to me after they have seen different physicians and have had thousands of dollars’ worth of tests but are offered no treatment. Oftentimes they are told their thyroid is “borderline” or normal and the same tests are repeated for years. The question to ask is this “if I am suffering from a variety of symptoms consistent with hypothyroidism, with no relief, could treating my thyroid help my condition?” Only you and your physician can decide the answer. But to ignore symptoms or test results is dangerous.

Carlton goes on to discuss the issue of testing for TSH levels and how over time the normal ranges have changed. The American Association of Clinical Endocrinologists have recommended that the range for TSH be between .3-3.0 lowered from the previous range of .5-5.0. She discusses testing for antibodies to the thyroid and for T4. However, she neglects to mention other important tests: free t3, free T4 and reverse T3. TSH is produced by the pituitary. It tells the thyroid gland to produce T4. T4 is inactive- it must be converted to the active thyroid hormone T3 or the inactive thyroid hormone reverse T3. Reverse T3 binds to the same receptor sites as T3 and therefore if there is too much reverse T3, the active T3 will not be able to bind to the receptor sites and the patient will present with symptoms of hypothyroidism. And they could have normal TSH and T4 results. The diagram below was taken from the internet and explains in detail thyroid function.

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Even more importantly, Carlton places too much emphasis on test results. I have seen many patients who feel perfectly fine, and their blood tests indicate a serious illness. I have also seen patients with debilitating symptoms of Chronic Fatigue Syndrome and Fibromyalgia whose blood tests are normal. As physicians, we need to listen to the patient and not rely solely on blood tests. Talking about thyroid results without knowing the symptoms of the patient is useless.

As for treatment options, Carlton discusses Synthroid (T4, levothyroxine or levothyroid) and dessicated thyroid. She does not discuss the difference between the two. There are many different preparations of thyroid- some contain T4, some T4 and T3 and some just T3 (liothyronine). There are brand and generic preparations and there are compounded preparations. Not only does Carlton not mention all the different preparations, she fails to discuss why one would be chosen by a physician over the other.

Over the past twenty-one years I have seen many patients with Chronic Fatigue and Fibromyalgia. Jaimie came to me with a prolonged history of Chronic Fatigue Syndrome. She also had hypothyroidism and was treated with Synthroid (T4) with no improvement. When I ordered her reverse T3, it was elevated. I changed her medication to a T4/T3 combination drastically improved her symptoms. Her energy returned, her sleep improved and her depression was alleviated.

Some of these patients were placed on Synthroid with minimal or no improvement. Many of these patients had elevated reverse T3s. Adding a T3 preparation to their Synthroid or changing to a T4/T3 combination helped alleviate some if not all of their symptoms. In addition, I have seen many patients with elevated reverse T3s or persistently elevated levels of TSH on no medications and with treatment showed a significant improvement. Hypothyroidism is only part of CFIDS and Fibromyalgia, but not treating the thyroid could prolong symptoms.

Dr. Dean Mitchell
Mitchell Medical Group, NYC & Long Island

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