By John V Dommisse, MBChB, FRCP(C)
Nutritional & Metabolic TeleMedicine, Tucson, AZ, USA
www.JohnDommisseMD.com
John@JohnDommisseMD.com
Announcement about this paper
The diagnosis and treatment of hypothyroidism (all types and grades) are both in a very sorry state at this time in medical history. Most patients are dissatisfied with the way they feel but are told by physicians that their blood tests (often only the thyroid stimulating hormone, TSH, level is measured) are normal and any symptoms they have are due to depression, over-eating, or some other patient-blaming condition. Anyone unfamiliar with this state of affairs need only go to an Internet site like http://Thyroid.About.Com ~ or the paperback book compiled by the editor of that website, Mary Shomon ~ to see the hundreds of dissatisfied patients trying to find the answer to their difficulties. There are also signs of dissatisfaction by certain physicians, as reflected in the papers by Chopra (1997), DeGroot (1999), Ferretti et al (1999), Ridgway, Canaris, et al (2000) and O’Reilly (2000); and in the popular book by Ridha Arem, ‘The Thyroid Solution’ (1999).
By placing more emphasis on the accurate measures of the actual thyroid hormones, the serum free-T4and free-T3 levels, than on the 3rd-generation TSH, I have, since early 1989, been optimizing the thyroid function of all my hypothyroid patients, many of them former patients of endocrinologists who use the TSH as the ‘holy grail’ of thyroid diagnosis. This is how I have come to know that, in most instances, the patient is right and the endocrinologists are wrong: The patient is usually being undertreated (because of an unfounded fear of osteoporosis) and incorrectly treated, with T4 only.
Summary/ Abstract
The hypothesis of this paper is that hypothyroidism, in its various forms and degrees, is often undiagnosedin its grade-3 primary, secondary and tertiary central, and nonthyroidal illness hypothyroidism versions; and undertreated in its grades 1 and 2 primary-hypothyroidism versions. An extensive review is presented, which is then coupled with logical argument and clinical experience to clarify the hypothesis.
The current standard and alternative approaches to the diagnosis and management of hypothyroidism, and their logical inconsistencies and inadequacies, are discussed. Methods employing the free thyroid hormone levels (FT4 and FT3), and a lower normal range for the thyroid stimulating hormone level, are described, which help optimize the newly-developed diagnostic strategies. Their superiority over the standard conventional and alternative approaches are suggested.
Diagnostic strategies and treatment methods are described which refute traditional objections to measuring the FT3 serum level and to treating with varying combinations of both T4 and either T3 or T4/T3 combination hormone preparations. Introduction
While overt hypothyroidism is easily diagnosed by physicians, the primary illness can be less apparent in its early or so-called 'subclinical' stages (Ross, 1991a; Arem, 1999); and secondary and tertiary (Pinchera et al, 1991) and non-thyroidal illness/ 'euthyroid-sick' syndrome (Palazzo & Suter, 1990; Chopra, 1997; DeGroot, 1999) hypothyroidism are also overlooked by the current conventional diagnostic approach, which frequently relies exclusively on the ultrasensitive serum thyroid stimulating hormone (TSH) level. It is important to recognize that the ultrasensitive TSH is an indirect test with a 'normal range' that is useful for diagnosing grades 1 and 2 primary hypothyroidism only (see 'The Grades of Primary Hypothyroidism', below). In the United States, an FT4 level is sometimes obtained, and occasionally a total-T3 level, but an FT3 level, the only accurate indicator of this much-more-active hormone's function, is rarely obtained.
Patients with 'subclinical' hypothyroidism who have the qualifying proposed serum thyroid hormone profile discussed below, almost always have multiple classical symptoms and signs of hypothyroidism. As one authorship has stated, "The presence or absence of symptoms, in both hypothyroidism and 'subclinical' hypothyroidism, depends more on the clinician than on the patient." (Fowler & Stubbs, 1992). In other words, even 'subclinical' hypothyroid patients have symptoms (making the term a misnomer); it is just that the physician frequently doesn't elicit the symptoms and signs. This view is backed by the papers of Staub et al, and Zulewski et al, respectively, which clearly showed significant changes in a clinical symptom index, the Billewicz scale, in 'subclinically' hypothyroid women of mean age 50, compared to age-matched controls (Staub et al, 1992); and showed significant correlation with serum free thyroxine and TSH levels (Zulewski et al, 1997).
Many physicians regard hypothyroidism as far more common than is generally acknowledged. This article will detail how patients who are being treated are actually undertreated, because of excessive reliance on the ultrasensitive serum TSH level for monitoring, and the use of a single thyroid hormone, thyroxine (T4), in its treatment. Additionally, there are excessive fears of precipitating or aggravating osteoporosis. Evidence for this is equivocal and shared by concerns of both natural and iatrogenic hypo- and hyperthyroidism causing it (Adlin et al, 1991; Ross, 1991b; Franklyn et al, 1994; Hart, 1995; Uzzan et al, 1996; Bauer et al, 1997) (and, presumably, undertreatment of either being a risk factor as well). The conservative American College of Physicians has recently found enough evidence of the widespread nature of hypothyroidism to recommend that, and since women are 9 times more likely than men to become hypothyroid, women over 50 years of age should be screened for it once every 5 years (Helfand & Redfern, 1998). In an editorial rebuttal, renowned thyroidologist David Cooper argues for a more aggressive approach to case-finding, and treatment of milder degrees of hypothyroidism (Cooper, 1998) and cites powerful support (Surks & Ocampo, 1996; Arem & Escalante, 1996), including the American Thyroid Association (Singer et al, 1995).
A recent estimate of the widespread prevalence of primary hypothyroidism suggests a figure of 9-10% in the United States. This estimate was limited only to active, uncorrected grades 1 and 2 primary hypothyroidism, based on a survey of serum TSH levels on 26,000 adults at a health fair (Ridgway, Canaris, et al, 1997). Only about 10% of those thus identified as hypothyroid admitted to being diagnosed and ~ by definition, inadequately! ~ treated, despite the long_term health risks associated with the condition. Results of the study were presented at the Oct. 1997 annual meeting of the American Thyroid Association held in Colorado Springs and are presumably in medical press. Theseresearchers also discovered a strong relationship between an underactive thyroid and elevated serum cholesterol levels, as other workers also have (Fowler & Stubbs, 1992; Hart, 1995; Dillman, 1991; Miura et al, 1994; Dullaart et al, 1995).
The current conventional approach to diagnosis does not allow for optimal diagnosis and treatment. We propose a new approach that is more logical and perspicacious, and which imitates the basic physiology of thyroid function. This approach includes attention to grade-3 primary hypothyroidism, subtle forms of secondary/ pituitary and tertiary/ hypothalamic central hypothyroidism, and many cases of nonthyroidal-illness hypothyroidism. We also submit the view that most treated cases are in fact undertreated, and propose here a logic-supported treatment-approach that eliminates this situation. It goes without saying that, if true, undiagnosed, untreated and undertreated cases of hypothyroidism would cause massive morbidity, mortality, and suffering.
Broda Barnes's book 'Hypothyroidism: The Unsuspected Illness' (1976) is used by many natural medicine physicians in their approach to hypothyroidism in the US. The book suggests that 64 diseases are caused or aggravated by (mostly-undiagnosed) hypothyroidism, and that hypothyroidism afflicts approximately 40% of the population. The 40%-figure seems high but, if successfully-treated grades 1 and 2 primary, all grade-3 primary, subtle forms of secondary and tertiary, and many cases of non-thyroidal-illness hypothyroidism are added to the 10% of the population uncovered in the health fair survey (above) who are either untreated or inadequately treated grades 1 and 2 primary hypothyroidism cases, the figure must surely jump to at least 20%, of which only a small percentage is being treated.
The validity of the 'euthyroid sick' syndrome was first questioned in the 1980's. It had become common for psychiatrists to find that, in refractorily_depressed patients who had been passed as euthyroid by endocrinologists, serum T3 levels were low (Joffe et al, 1985) and T3 administration, more so than T4, actually "enhanced the effectiveness of the antidepressants" (Joffe & Singer, 1990). In 1990, Palazzo and Suter (Palazzo & Suter, 1990) also published their earlier questioning of the so-called 'euthyroidism' of the 'sick euthyroid' patients they were seeing in an intensive-care unit.