Steven F. Hotze, M.D., is the founder and CEO of the Hotze Health & Wellness Center in Houston, Texas. In his new book Hypothyroidism, Health & Happiness: The Riddle of Illness Revealed Dr. Hotze reveals how commonly hypothyroidism is overlooked, misdiagnosed, and mistreated in women and men.
An interesting video discussion of hypothyroidism and a written discussion of the role low progesterone can play in some patients developing hypothyroidism
Jacob Teitelbaum, M.D., internist and author of From Fatigued to Fantastic!, researches treatments for Chronic Fatigue Syndrome and fibromyalgia.
In this article he argues that different people do better with different types of thyroid hormone, and you can tell which is best by what feels best to you. He advocates the addition of T3 or Armour (desiccated) thyroid for patients who do not respond to T4 alone. He also argues that a person may have low thyroid despite normal blood tests – it is conservatively estimated that over 50% of people who need thyroid hormone have normal blood tests.
Often people find they do not feel normal when given T4.
Dr Robert J Hedaya is a Clinical Professor of Psychiatry at the Georgetown University Hospital and Founder of the National Center for Whole Psychiatry.
In this article he discusses the addition of T3 or Porcine thyroid to T4 in cases where patients do not respond to T4.
Dr. Lissa Rankin, an OB/GYN physician writes:
As a gynecologist, it breaks my heart to see how many women suffer this way when we have so many tools to help them. But they don’t teach you many of these tools in medical school. Before I started practicing integrative medicine, I worked my butt off in a busy managed care practice where I was expected to see 40 patients/day. Trained at high powered academic institutions, I was brainwashed to believe what I was taught and didn’t open my mind to alternatives until I ultimately quit my job because I intuitively knew there was more we could do for women than a traditional medical practice was allowing me to offer.
An extremely interesting article from the Daily Telegraph, 27 July 2014, describes the work of a number of doctors operating outside the boundaries of conventional medicine. They have frequently been hounded by the governing bodies of the profession . The article devotes several paragraphs to the work of Gordon Skinner who died in 2013:
Skinner could not have been more vocal in what he saw as a great injustice.
A former virologist based at the University of Birmingham, he argued that, in any scientific group there was always roughly five per cent that didn’t fit into the bell curve and so couldn’t be diagnosed via a blood test. If patients were showing symptoms of hypothyroidism, he was prepared to treat them. And, as evidence of the unreliability of blood tests, he pointed to the discrepancies between what was considered normal levels of the hormone in different countries.
. . .
Dr Skinner was also criticised for regularly prescribing Armour Thyroid, a thyroid replacement taken from a pig’s gland, which contains all the active hormones you need for your thyroid to work efficiently, whereas the synthetic thyroxine that British doctors are told to prescribe contains only one, T4.
Skinner thought that many people weren’t able to convert T4 into the active hormone, T3, and therefore thyroxine was useless to them. But as Armour is no longer listed in the British National Formulary, the reference book GPs use for prescribing, many don’t know it exists, something Skinner put down to the workings of “Big Pharma”. Natural products can’t be patented, he said, and therefore were not lucrative, so GPs were discouraged from prescribing them.
A response to this article appeared in the comments below it and on the Thyroid UK website. it is reproduced below.
http://www.worldthyroidregister.com/Letters–NEW-Content-.html
An article in The Wall Street Journal, “U.S. Track’s Unconventional Physician” (Sara Germano & Kevin Clark) focusses on the work of an “unconventional” endocrinologist, Jeffrey S Brown, who believes that hypothyroidism can be caused in young athletes by the stress of the sport. Questions are raised as to whether Brown’s treatment of this in some star athletes might constitute “doping” in sport.
http://online.wsj.com/news/articles/SB10001424127887323550604578412913149043072
However, patient advocate Mary Shoman takes issue with the article, which she calls “a poorly researched, innuendo-filled article” on her About page – “Editorial: Controversy Over Diagnosing Hypothyroidism”. She asks “several nationally-known practitioners with expertise in thyroid and hormone balance to share their thoughts regarding this story”.
Follow this link to The Safe and Effective Guide to Prescribing Thyroid Hormones: Guidelines for Doctors drawn up by the British Society of Ecological Medicine, convened by Dr Sarah Myhill.
http://drmyhill.co.uk/
Thyroid – the correct prescribing of thyroid hormones
There are four reasons why UK citizens are not subject to “best practice” with respect to prescribing thyroid hormones. All relate to the prescribing of thyroid hormone for underactive thyroid glands (hypothyroidism).
The threshold for thyroid stimulating hormone (TSH) is set too high.
When levels of thyroid hormones in the blood start to fall, the pituitary gland increases its output of thyroid stimulating hormone (TSH), which kicks the thyroid into life and increases output of thyroid hormones. If the thyroid gland starts to fail, this is reflected by levels of TSH rising. The question is at what point should the prescription of thyroid hormones begin?
The normal range for TSH in this country varies enormously from one laboratory to another. This means in some locations in the UK a thyroid prescription would not be given until the TSH rose above 5.0mlU/l.
As a result of research, the normal range for TSH in America has now been reduced so that anybody with a TSH above 3.0 is now prescribed thyroid hormones. This research has shown that people with a TSH above 3.0 are at increased risk of arterial disease (a major cause of death in Western culture), insulin resistance (and therefore diabetes), inflammation and hypercoagulability (sticky blood). Indeed, there is a recommendation afoot in America to further reduce the threshold for prescribing to 2.5mlU/l.
What is completely illogical is that in UK the target TSH level for patients on thyroid replacement therapy is often stated as being less than 2 or even less than 1.5. This is a ridiculous anachronism!
We should reduce the threshold for prescribing thyroid hormones to <3.0mlU/L or better still 2.5mlU/l.
There is a further inconsistency in BTS guidelines. The level of thyroid hormones in pregnancy is critical for foetal development. For pregnancy the target for TSH is a level below 2.5mlU/L. Furthermore requirements during pregnancy increase, so thyroid function should be checked every three months. What is the logic of only prescribing thyroid hormones to a non-pregnant woman with a TSH of above 5.0 but if pregnant 2.5?
Population normal range versus individual normal range – they are not the same
The population normal range for levels of thyroid hormone in the blood is not the same as the individual normal range. We differ as individuals in our biochemistry as we differ in our looks, intelligence and morphology. This biochemical variation should be taken into account when it comes to prescribing thyroid hormones.
The population normal range of a Free T4 is 12 – 24pmol/L. A patient, therefore, with blood levels of 12.1 would be told they were normal because they are within the population reference range. But actually that person’s personal normal range may be high. They may feel much better running a high T4 of say 22, i.e. nearly twice as much but still within the population reference range.
Research done originally in UK, and now repeated in America, clearly shows that the individual normal range of thyroid hormones is not the same as the population reference range. In order to find out who these individuals are, patients have to be assessed clinically as well as biochemically. In actual UK clinical practice this is rarely done except by a few physicians conversant with this issue.
Some people feel better on different preparations of thyroid hormones
In theory, if the patient has been shown to be hypothyroid, then all their symptoms should be improved with synthetic sodium thyroxine. In practice, this is not always the case – there is no doubt that clinically some patients feel very much better taking biologically identical hormones such as natural thyroid (a dried extract of pig thyroid gland which is a mix of T4 and T3). Indeed, before synthetic thyroid hormones became available, all patients were routinely treated with natural thyroid. The purity and stability of these preparations has been long established, indeed much longer than synthetic thyroxine!
Part of the reason why people feel better taking natural bio-identical hormones is that some people are not good at converting T4 (which is relatively inactive) to T3 (which is biologically active). However, this does not explain the improvement in every case. It is difficult to explain why there should be an additional effect, but for many people it is the difference between drinking cheap French plonk and good quality Spanish Rioja. The alcohol content is the same, but the experience completely different!
According to Dr A Toft, Consultant Endocrinologist, Edinburgh, “It would appear that the treatment of hypothyroidism is about to come full circle.”
“In patients in whom long-term T4 therapy was substituted by the equivalent combination of T3 and T4 scored better in a variety of neuropsychological tests. It would appear that the treatment of hypothyroidism is about to come full circle”. Ref: Endocrine Abstracts 3 S40, T3/T4 combination therapy. AD Toft, Endocrine Clinic, Royal Infirmary, Edinburgh, UK.
Some people only feel well using pure T3
At present we do not have biochemical tests to predict who these people are! A reverse T3 test may help but may not. If symptoms are typical of hypothyroidism but not responding to T4 or T4/T3 mixes, then a trial of pure T3 may be in order. T3 is short acting and must be taken at least 3, possibly 5 times daily. The smallest size tablet is prescription only tertroxin 20mcgms (equivalent to 100mcgms of T4). A starting dose would be 10mcgms split into 3 doses – tricky! I suggest crushing half a tablet, and using a wet finger tip to take a third of the powder three times daily. One may know within a few days if this was making a difference but a proper trial would be a few weeks. For details, see Paul Robinson’s excellent book on the subject – Recovering with T3: My Journey from Hypothyroidism to Good Health Using the T3 Thyroid Hormone.
For more detailed discussion see[[1]] where the importance of pure T3 is explained in terms of transport of T3 across cell membranes.
The timing of dosing may be critical
Paul Robinson, in his excellent book T3 hypothyroidism, has made the interesting observation that our circadian rhythms, essential to health, are determined by when hormones are produced. Since they work synergistically we need them to be produced at the same time. Timing is triggered by the pituitary gland, the conductor of the endocrine orchestra! It starts with TSH levels rising sharply at midnight and is followed by increases in T4, T3 and cortisol later in the night. As they come together they trigger wakefulness. Paul found out for himself, and proved it to his satisfaction through blood tests, that his health was further improved by taking his morning dose of T3 at 5.30am. See his website [[2]] for his account of this.
Monitoring treatment just by using a TSH can be misleading
In his article (follow the link below in Related Articles) Peter Warmingham cogently explains how just a TSH is not a good way to monitor replacement therapy. It is vital to measure levels of free T4, ideally free T3 as well, and assess the patient clinically – ie how do they feel? Are there any clinical symptoms of under or over dosing?
Finally anyone who is hypothyroid for reasons other than autoimmunity, is likely to be iodine deficient. See Iodine – what is the correct daily dose?
Why are we seeing an epidemic of thyroid disease?
A whole range of chemicals have been shown to be goitrogenic and/or suppressors of the HPA axis and/or suppressors of thyroid hormones uptake and/or suppressors of T3 uptake. These include perchlorates (washing powder), phthalates and bisphenol A (in plastic wrappings), pyridines (cigarette smoke), PCBs and PBBS(fire retardants in soft furnishing), UV screens (sunblocks and cosmetics), and many others. For a full list see http://oted.oxfordmedicine.com/cgi/content/abstract/2/1/med-9780199235292-chapter-322
Related Articles
Related Tests
Thyroid profile: free T3, free T4 and TSH
This article has been taken, with her permission, from the website of Dr Sarah Myhill. (Bolding by HCS)
http://drmyhill.co.uk/drmyhill/index.php?title=Thyroid_-_the_correct_prescribing_of_thyroid_hormones&printable=yes
SAN FRANCISCO–Desiccated thyroid extract (DTE), derived from crushed preparations of animal thyroid glands, is a safe and effective alternative to standard T4 therapy in hypothyroid patients [bolding by HCS], a new study finds. The results were presented Monday at The Endocrine Society’s 95th Annual Meeting in San Francisco. [June 15-18, 2013]
In adults, untreated hypothyroidism leads to poor mental and physical performance. It also can cause high blood cholesterol levels that can lead to heart disease. The condition is treated with Levothyroxine, a synthetic (laboratory-made) form of T4 that is identical to the T4 the thyroid naturally makes. Before the advent of synthetic thyroxine, patients with hypothyroidism were treated with DTE, which contains both T4 and the active thyroid hormone T3. Many patients claim they do not feel as well on T4 alone without the additional T3 hormone.
“While thyroid experts recommend T4 alone for treatment of hypothyroidism, until now there have not been any randomized double-blind studies to compare the clinical effectiveness of synthetic T4 with DTE,” said Thanh Hoang, of the Naval Medical Center in Portsmouth, Virginia. “We found that DTE is a safe and effective alternative to the standard T4 therapy. Furthermore, DTE caused modest weight loss compared to T4 alone.”
In this study, researchers investigated the effectiveness of DTE compared to Levothyroxine (L-T4) in 70 hypothyroid patients. Patients were randomized to either DTE or L-T4 for 16 weeks and then crossed-over for the same duration. Study subjects underwent biochemical and neurocognitive tests along with measurements of symptoms and mental health at baseline and at the end of each treatment period.
DTE therapy did not result in a significant improvement in quality of life, but did cause modest weight loss and nearly half of the study patients expressed preference for DTE over L-T4.
Posted with permission from The Endocrine Society, Washington DC