Hello Everyone and thank you for coming to my blog. Today we will talk about people who take thyroid hormone medication, but still suffer from symptoms of hypothyroidism. For those who do not know one of my personal goals/habits is to read at least one scientific article each day. Also, the largest percentage of patients at my clinic, are those who suffer from hypothyroidism. I came across an article a few days ago I’d like to share with everyone. I feel this article is a terrific summary of where the medical community is in treating most hypothyroid patients, but it also acknowledges a method for helping patients which I think is extremely valid. Let me explain the current thyroid situation simply.
If you are diagnosed hypothyroid it means you have had an elevated TSH (typically >5). You are then given T4 only therapy in the form of levothyroxine or Synthroid. They dose the medication to get the TSH “in range” which typically means between 0.5 and 5.0. The teaching for endocrinologists and general practitioners is that if you do this, people feel better and their symptoms go away. For some people the symptoms go away and everyone is happy. For others, you are left in a struggle with your doctor telling you everything is fine or looks great (they really mean the TSH test looks fine/great) when you still struggle with symptoms like fatigue, brain fog, dry hair, dry skin, and difficulty losing weight. The patients who get medicated and still have symptoms are the ones who end up in my office asking for help, often through tears of frustration.
The following article was published in the Canadian Family Physician in volume 57 June 2011 and is entitled “Central hypothyroidism” by Dr. Kristin Clemens, Dr. William Payne, and Dr. Stan Van Uum. This article asserts that basing medication dosage on TSH alone may not work in all patients. Remember, the central dogma of thyroid care is all medication is dosed based solely on the TSH test. This article is challenging that central dogma and saying it may not be the best way to do things in some cases. Let’s take a peek at this article.
This is a case study of a 43 year old man who has headaches, memory impairment, erectile dysfunction, and constipation. If you read the paper you will know this patient has a lot going on including other hormone problems besides the thyroid. I also know that this is a case of central hypothyroidism rather than primary hypothyroidism. However, I think the case is still extremely relevant. What happens is the patient is given levothyroxine therapy and feels better. They test the TSH and it is found to be low (0.06) so they back off the medication. When they back off the medication the TSH comes back to a more normal number (1.96) but the patient has symptoms of constipation, cold intolerance, and increased weight. These doctors go farther than most I see. Most people are pushed out the door and their symptoms swept under the rug as soon as that TSH achieves “normal”. These doctors are doing something that is obvious and necessary but is often forgotten. These doctors are paying attention to the symptoms in their patient.
The next thing the doctors did was test the free T4 and free T3 and they were found to be low. They raised the medication to achieve normal free T4 and free T3, but a fairly low TSH (0.15) and again the patients symptoms went away! I think the “editor’s key points” sum up the recommendations fairly well.
“The role of thyroid-stimulating hormone (TSH) alone in monitoring treatment of patients with central hypothyroidism is limited; aim for the maintenance of free T3 and T4 levels in the upper half of the normal range, with adjustment of treatment based on patient’s symptoms.”
Let me highlight what I love about this article in bullet format to be as clear as possible.
- Care for patients with hypothyroidism should take into account more than just the TSH level.
- Care for patients with hypothyroidism should take into account the free T3 and free T4 levels.
- Care for patients with hypothyroidism should take into account patient’s symptoms.
Another point in this article is that the symptoms of hypothyroidism can get confusing when combined with other hormone problems like the adrenal hormone cortisol and sex hormones like testosterone, estrogen, and progesterone. This particular patient had problems with the thyroid, adrenals, and testosterone. This is by no means uncommon even though it is often missed as the low thyroid gets the attention and doctors miss the adrenal and/or sex hormone problem.
In conclusion, proper thyroid care involves listening to patient symptoms, not being overly reliant upon the TSH test, and considering other factors (such as adrenals and sex hormones) that can confound the thyroid problem. I hope you enjoyed the blog post.
Dr. Warren
