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Thyroid Replacement

"I've already had my thyroid checked and my doctor said that it's normal"

When people call or visit from all around the country, they will frequently tell me that they are desperate because they feel like they suffer with many of the symptoms of low thyroid but the doctor checked their thyroid and every thing is "normal."

Yet, one month later, the person has lost 12 pounds, feels like a new person, and is taking thyroid medicine prescribed by me after I did find an abnormality. So, what's different? Why do I find thyroid problems where other physicians do not?

The problem is with TSH. Most physicians only look at TSH to decide if someone is low on thyroid.

Videos of me telling the hightlights of thyroid replacement



Most physicians still rely on TSH and only on TSH (with no regard for symptoms or other tests when it comes to the diagnosis of low thyroid)

First, let's talk about the confusion. Here's an articl that describes the stategy that most physicians still follow: For evidence read this article about the measurement of thyroid function. This article says that your physician should check your TSH and unless that number is very low or very high, that number alone should be used to determine if you have low or high thyroid. This is exaclty analagous to looking at the thermostat to determine the temperature or the room.

The pituitary makes TSH which tells the thyroid to turn on. When TSH is high, the pituitary is asking for more thyroid (indicating thyroid levels are low in the blood). When the TSH is low, then the brain has enough thyroid and is not asking the thyroid gland to make as much.

But, just like your themostat can be set on 60 and the temperature in the room can be 90 degrees, the pituitary may generate a TSH of 4 and the body may be very low on thyroid.

Here are a few up-to-date articles that challenge the idea of ONLY using TSH to diagnose low thyroid:

1.Evidence for a Narrower Reference Range for TSH.

"Importantly, data indicating that African-Americans with very low incidence of Hashimoto thyroiditis have a mean TSH level of1.18 mU/liter strongly suggest that this value is the true normal mean for a normalpopulation. Recognition and establishment of a more precise and true normal range for TSH have important implications for both screening and treatment of thyroid disease ingeneral and subclinical thyroid disease in particular.

2 Here's an article that shows that the upper limit of normal for the reverence range (reference range) is not the same as the cut off for clinical decision making.

3. This article suggests that 2.4 or 3.0 may be a more accurate level for the upper limit of normal for TSH (instead of 5.0). Also suggests that there are millions of people with untreated hypothyroidism (and 70% of adults are overweight in the USA--hmmm--could there be a correlation?)

4. Sometimes the TSH that is made is not even active. See the section on central hypothyroidism.

"Central hypothyroidism is a rarely encountered entity representing less than 1% of all cases of hypothyroidism. It results from a wide variety of pathologic conditions that impair pituitary TSH, secondary hypothyroidism, and/or hypothalamic thyrotropin-releasing hormone (TRH), tertiary hypothyroidism production, or secretion resulting in a decline in function of the thyroid gland. Common causes of central hypothyroidism include pituitary tumors, empty sella syndrome, trauma, postpartumpituitary necrosis (Sheehan's syndrome), hypophysitis, whole-brain radiation, and a variety of infiltrative diseases (see Table 1 ). Of considerable diagnostic importance is that the biologic properties of the TSH secreted in secondary hypothyroidism are often altered (because of impaired TRH action on TSH formation)resulting in forms of TSH that have markedly reduced bioactivity while retaining normal immunoactivity. This phenomenon often results in falsely normal TSH values reported in patients who are otherwise biochemically and clinically hypothyroid. Therefore, the utility of serum TSH measurements by immunoassay in accurately assessing thyroid status is essentially lost either for establishing the initial diagnosis or monitoring the adequacy of T 4 replacement therapy in patients with secondary hypothyroidism."

This article says that only 1% of the population has central hypothyroidism; I think that number is greatly underestimated because few physicians actually look for central hypothyroidism.

How Keeping Thyroid in the Upper End of Normal Can be of Benefit

Thyroid should be optimized by adjusting to the upper 20% of normal in the person with fatigue, obesity, depression, or risk of dementia. This article documenting that women in the lower 20% of NORMAL have about twice as much risk of dementia as do women in the upper 20% of normal gives evidence for this strategy. The real test of a physician is this: "Do his patients get well?" Most of my patients (with obesity, depression, fatigue, and difficulty concentrating) get well when thyroid is adjusted this way (in conjunction with other strategies).

So How Do You Make the Diagnosis of Low Thyroid (Hypothyroidism)

here's a clue: LISTEN TO THE PATIENT! I've found that most people with low thyroid will sit there and almost recite the chapter from the medical books books about low thyorid. Then I check free T3, free T4, and TSH.

Sure, if I treated everyone with a low free T3 with thyroid, without regart do symptoms, then I would be overtreating people. But if someone tells me that they sufer with depression, fatigue, constipation, brain fog, decreased libido, losing eye-brows on the outer edge, fibromyalgia, weight-gain--if they have several of these symptoms, and free T3 is low, and TSH is on the upper end of the "normal" range, then why should I not give them a trial of thyroid replacement?

Free T3 and Free T4 should be measured. I do not use TSH as the way to follow thyroid function. I think TSH is best used to monitor pituitary function. In the past, TSH was the best way to measure the need for thyroid and to follow the amount of medication given, but I think that new evidence and better ways of measurement now suggest otherwise.

Here's an article about the effects of replacement of both T3 and T4.

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Peace & health,


Charles Runels, MD

dr runels