Treating thyroid patients like children – Dr Malcolm Kendrick

This is a very refreshing article by a well known UK doctor.  Such were the truths it revealed that many of the (at the time of writing) 264 replies came within the first two days after it was posted on his blog. Patients were virtually screaming (forgive the pun) with joy that at last somebody had recognised how they feel.

We do have some doctors in Singapore who recognise how we feel when T3 is missing but it seems that their hands are becoming increasingly tied with regard to helping us deal with it.

Some extracts from the article are posted here with permission but please read the whole article – Dr Kendrick speaks for so many of us. If only he could speak to the Ministry of Health!

Dr Kendrick admits:

To be honest, until about a year ago I had no real idea what T3 was either, but I have learned quite a lot since.

He certainly has. This paragraph really caught our attention (bolding by HCS):

The lab tests, especially for TSH, are far from 100% reliable, to say the very least. In fact the man who developed the test in the UK, at Amersham International in Wales, has told me that the test is virtually worthless in many cases (especially continuous testing when patients are taking thyroid hormone replacement).

And yet more good sense, which echoes what many of us at Hormone Choice Singapore have experienced (bolding by HCS):

Far more telling, from my point of view, is the fact that hundreds, indeed thousands of patients report that, although their blood tests were normal, they felt terrible, and that they have felt so much better when they have been given ‘excess’ T4 and/T3, or NDT (natural desiccated thyroid). Whilst there is no doubt that some of them are, to quote a medical colleague, ‘not tightly wrapped.’ I have spoken to many, many, people who are calm, rational and reasonable, and their stories are compelling. A hellish existence that was ‘cured’ by Dr Skinner and his like. I refuse to believe that all of these patients are ‘somatising’ fruitcakes.

Read the whole article at:

And comments at:



Revising guidelines for testosterone testing could more accurately diagnose deficiency

One of the issues under discussion among patients and doctors in Singapore is how to determine when there is a need to treat men with supplemental testosterone therapy.  This new study shows that levels of free testosterone are more informative than total testosterone levels

European Society of Endocrinology     16 May 2015

A new study presented at the European Congress of Endocrinology in Dublin suggests that some men suffering from testosterone deficiency may be missed under current clinical guidelines while others are misdiagnosed with testosterone deficiency. The researchers call for a revision of the clinical guidelines to ensure that men are receiving the best possible care.

Testosterone deficiency, also known as male hypogonadism, can lead to decreased libido and infertility, but it has also been associated with a higher risk of developing metabolic syndrome, diabetes and osteoporosis. In men, testosterone levels gradually decline with age. In recent years, an increasing number of ageing men are presenting with symptoms suggestive of hypogonadism and testosterone levels that are around or below the lower limit for young men. To date, the diagnosis of hypogonadism in these middle-aged and elderly men and their management remains controversial.

Researchers at the University of Manchester, UK and the University of Leuven, Belgium (represented by Dr Leen Antonio) used data from the European Male Aging Study (EMAS) to determine the relative importance of total and free testosterone measurements in diagnosing testosterone deficiency in aging men.

Testosterone exists in the body in two states; bound to proteins (98 % of total testosterone) and non-protein bound or free (2% of total testosterone), the latter being the biologically active fraction. Current clinical guidelines suggest that testosterone deficiency is diagnosed by measuring total testosterone levels. However Dr Antonio’s study shows that levels of free testosterone are more informative.

Only free testosterone can enter cells and is responsible for testosterone action. When men get older, total testosterone levels decrease while the levels of the protein that binds it increases. This means that the level of free testosterone decreases more than the total testosterone with age.

Dr Antonio, “We show that middle-aged and elderly men with normal total testosterone levels but low free testosterone levels have more symptoms of hypogonadism compared to normal men than those with normal free but low total testosterone – these men currently miss out on treatment because they are not diagnosed with testosterone deficiency.”

“On the other hand, men with low total testosterone but normal levels of free testosterone do not suffer from testosterone deficiency, yet are misdiagnosed with the condition and can be treated with testosterone inappropriately.”

Dr Antonio and colleagues propose that new guidelines should recommend measuring free testosterone, in addition to total testosterone, in the evaluation of men with hypogonadal symptoms.


Real evidence based medicine

Trish Greenhalgh and Neal Maskrey

Trish Greenhalg is Professor of Primary Care Health Sciences and Fellow of Green Templeton College at the University of Oxford. She has twice won the Royal College of General Practitioners Research Paper of the Year Award and in 2001 received an OBE for services to Evidence Based Medicine.

Neal Maskrey is an Honorary Professor of Evidence-informed decision making at Keele University and consultant clinical adviser in the Medicines and Prescribing Centre, National Institute for Health and  Care Excellence, UK.

In this video, these experts explain the concept of real evidence based medicine (EBM) as it should be applied to real patients.

Note particularly 6.30 to 7.47

. . . if you look at the research literature on expert judgement you will find  that experts . . . don’t mechanically follow rules. They do something much more intuitive and much more rapid and what they then do is they come to a rapid decision and then they go back and unpack why they got to that decision and they justify it by using the evidence  . . . one of the things that clinicians say again and again is “I don’t want to be tyrannised by these guidelines. I don’t want my patients to be tyrannised by these guidelines.” And it seems that their clinical judgement is being challenged by these guidelines and what we want is for the clinical judgement to be supported by the guidelines so EBM will be delivered in a much more nuanced and granular way than people sometimes assume it should be.

Also 7.57 to 8.30

There are, of course, in every consultation two people involved in making the decision. The clinician has their own expertise and the patient has their own expertise.

How sad that, while the rest of the world is reassessing the concept of Evidence Based Medicine, Singapore is taking the backwards step of applying the guidelines in exactly the mechanical way that these experts feel should be avoided!


The evidence must come not from tests but from a thorough observation of the patient

Emeritus Prof Sir Gordon Arthur Ransome (1910-1978)

Today one of the four colleges at the Duke-NUS Graduate Medical School is named after Emeritus Prof Sir Gordon Arthur Ransome, remembered by many as the founder of modern medicine in Singapore and admired as an outstanding and brilliant clinician. His contributions to medicine in Singapore went back to 1938, when he was made Associate Professor of Medicine at the then King Edward VII College of Medicine. He also founded the Singapore Academy of Medicine and was its first Master.

The following is taken from an oration to mark Prof Ransome’s retirement in 1971: The life and times of Gordon Arthur Ransome by Seah Cheng Siang in Annals of the Academy of Medicine, January 1972, Vol. 1 (Bolding by HCS)  

Foremostly, Professor Ransome taught by example. Himself a well-trained clinician, he has handed down to hundreds of doctors, clinical methods which were learnt from his teachers and also those innovated by his own increasing experiences.

In taking a meaningful medical history, he has on many occasions, and still does so now, sit by the bedside, eliciting point by point the story of the patient’s illness, with students watching on. From the history and adopting Lord Horder’s methods, a list of possible diagnoses to account for the presenting symptoms, is then compiled.

In front of the students, Professor Ransome will then examine the patient meticulously. A very careful inspection from head to foot is followed by an examination in minutia of the different systems. . .

From the signs culled, and with the results of some laboratory tests, he has nearly in every instance been able to arrive at a definitive diagnosis. A firm diagnosis by this method and not by intuition, is always teachable. He converted many a doctor from practising intuitive diagnosis into exercising a perceptive scientific method.

Another interesting insight into his powers of diagnosis comes from Sir Gordon Arthur Ransome  by Beng Yeong Ng and Jin Seng Cheah in Annals Academy of Medicine May 2008, Vol. 37 No. 5 (Bolding by HCS)

 He taught from first principles and emphasised the importance of the use of the 5 senses in the practice of medicine. He placed importance on the art of listening, the essence of the artistry of bedside medicine. Effective listening involves all the senses, not merely the ears. To succeed in healing, a doctor must be trained, above all else, to listen. His skills as a diagnostician were renowned. He believed that X-rays findings tended to lag behind the physical signs. Without any laboratory tests, he was able to arrive at an accurate diagnosis just by taking a comprehensive history and examining the patient skilfully. He was nicknamed “kosong” (meaning “zero” in Malay) as he would give a student zero marks for poor performance in clinical examination. 

This letter from Dr Quek Koh Choon, one of Prof Ransome’s former students, appeared in the Sunday Times on 26 April 2015 and again highlights the importance Prof Ransome attached to observation – note “Tests and investigations were needed only to confirm the diagnosis. (Bolding by HCS) 

If Professor Gordon Arthur Ransome were alive today, he would be pleased to see how Singapore has become a great medical centre (“Prof hopes S’pore becomes medical hub”; last Sunday). 

I was privileged to have been taught by him, and to also have had the opportunity to work with him.

He taught me that the practice of medicine is not just a science, but also an art. He emphasised the need to observe the patient as he came into the consultation room – to watch his gait and facial expressions – and also advocated listening to the patient well.

These days, many patients say that many doctors are not listening enough to their complaints, and that they are quickly dismissed to undergo a battery of tests and investigations.

Prof Ransome did not think it wise to resort quickly to investigations. He believed that a great deal could be learnt from a patient’s history, and that astute observation and a thorough examination were key in clinching the diagnosis. Tests and investigations were needed only to confirm the diagnosis.

I used to accompany Prof Ransome on his ward rounds, and he surprised me when, at the end, he invited me to sit down with him and asked for my opinion of the various cases.

I was the most junior doctor then, and the experience certainly jolted me and taught me to value mutual respect among fellow colleagues and to be open to consider an opinion, even from a novice.

Prof Ransome treated all patients with respect and kindness, and did his best for them no matter what their status and background were. Once, he was called to attend to a VIP while examining a patient in a C ward. He said that the VIP had to wait as he was still attending to his patient.

He was a doctor devoted to the practice of medicine. He did not care much for accolades and prestige. Patients were his priority.

He was truly one of the great founders of modern medicine in Singapore. His inspirational values should be remembered by all who follow in the tradition of good doctors and healers.

Quek Koh Choon (Dr) 

We can only guess at what Prof Ransome would have thought of today’s Ministry Of Health insisting that all diagnosis be based only on test results and supposedly evidence based medicine. One can sense his disappointment and hear him cry, “What about the patient? The patient will tell you what’s wrong if you just listen! Just listen – with all your senses! I am giving you zero!”


Curing hearing loss with hormone therapy

By Dr Nor Ashikin Mokhtar        5 April 2013

Several physicians and researchers have attempted to treat hearing loss with a hormone called aldosterone, which is produced in the cortex of the adrenal glands.

Who would have thought that a hormone could help reverse hearing loss? I certainly would not have made the connection if not for one of my patients who came to see me after having visited several ear, nose and throat (ENT) specialists, who could not help her with her hearing problems.

As I have an interest in the use of bio-identical hormones, I did some research of my own in this area. I was pleasantly surprised to find that several physicians and researchers have already done some work in treating hearing loss with a hormone called aldosterone.

It was gratifying for both me and my patient when we found that bio-identical replacement of aldosterone helped to reverse her hearing loss.

This can give hope to many other people, especially the elderly, who face poor quality of life issues due to progressive loss of their hearing.

Hearing loss

It has always been thought that one of the inevitable consequences of getting older is losing your hearing.

Many elderly (or just slightly older) people find it increasingly difficult to hear conversations around them. They keep having to ask people to repeat what they’re saying, they turn up the volume of the television and radio, and they can’t even hear themselves speak sometimes.

Hearing loss can have significant consequences on a person’s quality of life. When you can’t hear, your communication with family and friends suffers, as everything has to be repeated or shouted.

You also find that there is less enjoyment in the things that you used to love, such as music or movies. This can leave you feeling frustrated or helpless.

Hearing loss is most commonly caused by injury to the hair cells lining the middle ear. These tiny hairs are responsible for transmitting sound to the brain. These hair cells can be damaged by exposure to excessive noise or decreased blood flow due to atherosclerosis, hypertension or diabetes.

If, like my patient, you are at your wits’ end because you have already seen numerous ENT specialists who were unable to help you, you may want to consider bio-identical hormones. This may be the solution to help you stop or even reverse your hearing loss.

What is aldosterone?

Aldosterone is a steroid hormone from the mineralocorticoid family and is produced in the cortex of the adrenal glands.

This hormone plays a role in regulating kidney function and in controlling levels of two signalling chemicals – potassium and sodium – in the nervous system.

This is the first clue that aldosterone is important for hearing: potassium is needed in the inner ear, where a potassium-rich fluid converts sounds into signals that the nervous system can identify.

Therefore, aldosterone helps to maintain a healthy level of potassium in the body, which in turn, helps to maintain hearing.

However, as people age, the amount of aldosterone produced in the body decreases, because the adrenal glands do not work as well as they should.

At the same time, potassium levels fall as well. This may explain why age-related hearing loss develops, because low aldosterone could affect hearing both in the inner ear and in the part of the brain that processes sounds.

There is some scientific evidence to back this up. A study in mice several years ago found that aldosterone added to the drinking water of the mice had the same effect as glucocorticoid drugs for reversing hearing loss.

Research has also been carried out in humans. Scientists from the International Center for Hearing and Speech in the US measured levels of aldosterone in people with severe hearing loss and found that they have half the amount of aldosterone compared to people with normal hearing.

However, too much aldosterone in the body is not healthy either. Large amounts of aldosterone, caused when a benign tumour grows on the adrenal cortex, can lead to high blood pressure and low serum potassium values.

Bio-identical replacement

If low aldosterone is thought to contribute to hearing loss, then a logical intervention would be to replace the hormone in the body.

Dr Jonathan V. Wright is one of the physicians in the US who uses bio-identical replacement of aldosterone to treat hearing loss in his patients, and he claims to have had success with this therapy.

Bio-identical hormone therapy is also known as “natural hormone therapy”. Bio-identical hormones are not synthetic hormones, but they are made in a laboratory using a plant chemical extracted from yam and soy.

The difference between bio-identical hormones and synthetic ones are that the former behave exactly like the hormones our body produces.

Dr Wright prescribes bio-identical aldosterone to his patients in “physiologic” quantities, meaning amounts that are normally present in the body (no more than that). He found that this therapy had success in more than half of his patients suffering from hearing loss.

Aldosterone therapy is believed to not only restore hearing significantly within rapid time (from a couple of weeks to a couple of months), but is also effective in patients who had lost their hearing many years ago.

Other physicians are looking at different supplement-based interventions to help with hearing loss. Vitamin B12 and folic acid, as well as vitamin D, are among the micronutrients that are believed to boost hearing.

Gingko biloba and vinpocetine supplements are also believed to increase blood flow, which helps improve hearing. More research will have to be carried out to investigate the safety and efficacy of these supplements.

Meanwhile, bio-identical aldosterone therapy may be helpful for people with hearing loss who have not found success with other treatments.

When using bio-identical aldosterone therapy, it is important to monitor the levels of aldosterone, potassium and sodium in the body to ensure that they remain within normal levels.

Not just anyone can prescribe bio-identical hormones, so be sure to speak to a qualified physician or pharmacist, particularly one specialising in anti-ageing medicine or bio-identical hormone therapy. –




S’pore Losing Medical Tourists to Neighbours

At a time when the number of tourists coming to Singapore has dropped and the Singapore Tourist Promotion Board is planning to launch a $20 million campaign to boost tourism, the drop in the number of medical tourists to Singapore is contributing to the problem.

This article from The Straits Times by Marissa Lee discusses the danger of Singapore losing out to neighbouring countries in the market for medical tourism. Patients currently coming here for bioidentical hormone replacement therapy (BHRT) could be among those who “walk” (fly).

Hormone Choice Singapore has spoken to a number of people living in neighbouring countries who currently come here for their BHRT treatment. They say that if this becomes unavailable in Singapore, they will be going to Kuala Lumpur or Bangkok.


The reasons your doctor may miss your thyroid issues

This article describes two studies which, yet again, show that thyroid blood tests may not accurately reflect what is going on in the body.

Taken with permission from “Easy Health Options”,  1 November 2014 (bolding by HCS).


When your thyroid functions properly, your health blossoms. But you have to know what to do if it falters or it becomes too active.

Otherwise, serious illness can complicate your life.

Ironically, as you age and become a senior citizen, it may benefit your health to have your thyroid slow down a bit.

Aging thyroid

Research shows that an active thyroid in older people can lead to depression. And just because a blood test seems to show that your thyroid is operating normally, your thyroid can still malfunction and leave you vulnerable to emotional turmoil.

A study at Erasmus Medical Center in Rotterdam, the Netherlands, shows that if you are in your late 70s or in your 80s, a very active thyroid that, according to blood tests, is still at the upper limit of what is considered normal can increase your risk of diminished emotional well-being.

“We found that older individuals with thyroid activity at the high end of the normal range had a substantially increased risk of developing depression over the course of an eight-year period compared to individuals who had less thyroid activity within the normal range,” says researcher Marco Medici. “This suggests that people with even minor changes in thyroid function may experience similar mental health effects as those with overt thyroid disorders, including hypothyroidism and hyperthyroidism.”

The research looked at health data from about 1,500 people with an average age of 70. At the beginning of the research, the scientists measured their TSH (thyroid stimulating hormone) levels and then periodically evaluated their emotional health with a detailed questionnaire.

When the 8-year study started, no one in the research had symptoms of depression. But as the research wore on, the scientists found that people with more active thyroids endured more incidences of depression.

“These results provide insight into the powerful effects thyroid activity can have on emotions and mental health,” Medici says. “This information could influence the process of diagnosing and treating depression, as well as treatments for individuals with thyroid conditions.”

Your thyroid and your heart

If you’re overweight and you have diabetes, a poorly operating thyroid means trouble for your heart. Research at the New York Institute of Technology (NYIT) College of Osteopathic Medicine shows that for a growing number of people, a low level of thyroid hormone in your heart can impair the function of the cardiac muscle and possibly lead to heart failure.

In lab tests, the NYIT scientists found that the administration of low doses of the thyroid hormone T3, stopped heart disease in the presence of diabetes.

“This treatment prevented the abnormal changes in gene expression, tissue pathology, and heart function,” says researcher A. Martin Gerdes.

Other studies have shown that high blood pressure and heart attacks are linked to lower thyroid hormone in the heart muscle and can increase the risk of serious heart complications.

“The clinical implications are profound and far-reaching because it suggests that the heart disease associated with diabetes may be easily preventable,” says Gerdes. “And importantly, the dose we gave of T3 hormone did not significantly change the serum (blood) thyroid hormone levels but it was enough to make all the difference in the heart tissue.”

Measuring thyroid

Your thyroid level is usually determined with a blood test. But the NYIT study showed that the level of thyroid in heart cells doesn’t always reflect what a blood tests shows. In other words, while your blood test for thyroid function can look fine, you can still be suffering from heart problems caused by a lack of thyroid hormone in cardiac tissue.

Gerdes points out that when blood leaves the heart’s chambers and mixes with the rest of the circulating blood it is severely diluted as it mingles with the body’s entire supply of plasma (It’s about a 20 fold dilution.)  That dilution can keep thyroid hormone from reaching the heart’s tissues. Consequently, his studies have shown that low-dose thyroid hormone replacement can effectively and safely protect diabetics from heart disease.

“A low thyroid condition can cause heart failure by itself,” he says. “The fundamental question we should be asking about patients with heart failure is: how much is due to the diagnosed disease and how much is due to low thyroid levels in the heart? There clearly needs to be more awareness with regard to research examining the impact of low thyroid hormone levels in the heart and the role this condition plays in acceleration of heart failure.”

Gerdes is still doing experiments to further understand precise methods to track low thyroid hormone levels in the heart muscle. But he has come up with a dependable way to use thyroid hormone to protect your heart.

“There’s so much fear of overtreatment (with hormones) and inducing arrhythmias that physicians in general completely avoid treating heart patients with thyroid hormones,” Gerdes says. “But we have established a clear treatment and monitoring program in this study that is safe and can be used in people.”

So if you have diabetes and heart issues, you need to find a healthcare practitioner who is familiar with this research and protocol. Or is at least willing to learn.

Our Holy Miracle of the Infallible TSH Test

A beautiful video which sums up the ‘approved’ approach to thyroid treatment.

The Ministry Of Health insists that the Thyroid Stimulating Hormone (TSH) test is the be all and end all and punishes those doctors who question it. Meanwhile, many patients with normal TSH levels continue to feel unwell.