Download Hypothyroidism and TSH Levels: References

Hypothyroidism and TSH Levels: References
References and Information Regarding the Role of TSH Levels in
Diagnosis and Management of Thyroid Disease, Compiled by the
Alt.support.thyroid Usenet Newsgroup
Developed by the members of Alt.support.thyroid
Purpose of this collection
To show that using only the TSH level as a diagnostic tool does not identify many cases of
hypothyroidism, and that if it is used, the current acceptable range is to be questioned.
I. Medical Journals and Organizations
A. The American Association of Clinical Endocrinologists
"Thyroid Awareness Month: 2001"
http://www.aace.com/pub/spec/tam2001/presstam2001.html
Even though a TSH level between 3.0 and 5.0 uU/ml is in the normal range, it should be
considered suspect since it may signal a case of evolving thyroid underactivity.
B. British Medical Journal
1. 2000;321:1080 (28 October) Thyroid function tests: time for a reassessment - Denis St. J.
O'Reilly, consultant clinical biochemist
http://www.bmj.com/cgi/content/full/320/7245/1332
Overlap between the statistically derived normal and abnormal ranges is accepted in diagnostic
tests, giving rise to false positive and false negative results. These concepts have not been
applied to measurements of thyroid stimulating hormone. Rather than accepting that the test can
be fallible, we transfer the problem to the patient.
J. O'Reillys response to the letters about his article
http://www.bmj.com/cgi/content/full/321/7268/1080#resp5
The clinical features of thyroid dysfunction are now rarely discussed in the medical literature
andas a consequence, the impression is given that they are of little importance.
2. 1997;314:1764 (14 June) Letters
Thyroxine should be tried in clinically hypothyroid but biochemically euthyroid patients by
Gordon R. B. Skinner, Clinical virologist, R. Thomas, General practitioner, M. Taylor, General
practitioner, M. Sellarajah, General practitioner, S. Bolt, General practitioner, S. Krett, General
practitioner, A. Wright, General practitioner
http://www.bmj.com/cgi/content/full/314/7096/1764
We wish to question present medical practice, which considers abnormal serum concentrations
of free thyroxine and thyroid stimulating hormonethose outside the 95% reference intervalto
indicate hypothyroidism but incorrectly considers "normal" free thyroxine and thyroid
stimulating hormone concentrations to negate this diagnosis. Thethyroid stimulating hormone
concentrations in 80 patients considered to be hypothyroid on established criteria indicated
thatonly four patients had thyroid stimulating hormone values above the reference interval of
0.5-5.5 mU/lthe mean concentration of thyroid stimulating hormone was 2.2 (0.4) mU/l.
Responses to the above BMJ letter
http://www.bmj.com/cgi/eletters/314/7096/1764
David Derry, MD, PhD: The maxim of the day before the TSH arrived was you gave enough
thyroid until the patient was bettermedical students are taught to treat a lab test and not the
patient. This has gone a long way to alienate the patient from the doctor and seek alternative
practices for relief.
http://www.bmj.com/cgi/content/full/315/7120/1463
E. H. McLaren, Consultant physician, C. J. G. Kelly, Specialist registrar in endocrinology, M. A.
Pollock, Principal biochemist Since they [patients] complained of a considerable reduction in
their quality of life, which had not been helped by other measures, we decided that it was
justifiable to try treating two of them with 100 g thyroxine daily (after we h ad explained the lack
of scientific rationale and obtained their written consent). Much to our surprise, they both
reported a considerable improvement in their condition, while the results of thyroid function tests
remained within the reference range.
Response to the above BMJ letter by Drs E. H. McLaren, C. J. G. Kelly and M. A. Pollock
http://www.bmj.com/cgi/eletters/315/7120/1463#EL1
Nikki Tovell, informed patient, currently co-authoring a paper with Dr B. Durrant-Peatfield, 21
June 2000: Drs McLaren, Kelly and Pollack quite rightly state that it is arrogant of the medical
profession to assume that everything is known about the thyroid. Currently, hypothyroid testing
commonly only addresses T4 and TSH levels.if a patient has signs and symptoms of illness and
test results are negative, you aren't performing the right tests.
3. 1997;314:1175 (19 April) "Hypothyroidism: screening and subclinical disease" by Dr. A. P.
Weetman, professor of medicine
http://www.bmj.com/cgi/content/full/314/7088/1175
"...a high thyroid stimulating hormone concentration (>2 mU/l) was associated with an increased
risk of future hypothyroidism.The simplest explanation is that thyroid disease is so common that
many people predisposed to thyroid failure are included in a laboratory's reference population,
which raises the question whether thyroxine replacement is adequate in patients with thyroid
stimulating hormone levels above 2 mU/l."
Responses to the above BMJ article
http://www.bmj.com/cgi/content/full/314/7088/1175#responses
-- Dr. David Derry, MD, PhD, 17 Oct. 1999 there is no correlation except at extremes between
the signs and symptoms of thyroid problems and the TSH.The thyroidologists by consensus have
decided that this test is the most useful for following treatment when in fact it is unrelated to how
the patient feels. The consequences of this have been horrendous. The TSH needs to be scrapped
and medical students taught again how to clinically recognize low thyroid conditions.
-- Raymond Peat, independent research, 16 Nov. 1999: the mistaken idea of hypothyroidism's
low incidence in the population led to the acceptance of dangerously high TSH activity as
"normal."
C. European Journal of Endocrinology
1998 Feb;138(2):141-5 High serum cholesterol levels in persons with `high-normal' TSH levels:
should one extend the definition of subclinical hypothyroidism? by Georgia Michalopoulou,
Maria Alevizaki, Gregory Piperingos, Demetrios Mitsibounas, Emily Mantzos, Panayotis
Adamopoulos and Demetrios A Koutras of Athens University School of Medicine, Greece
http://www.eje.org/eje/138/eje1380141.htm
Subjects with high-normal TSH levels [2.0-4.0 U/ml] combined with ThAabs [thyroid
autoantibodies] may, in fact, have subclinical hypothyroidism presenting with elevated
cholesterol levels. It is possible that these patients might benefit from thyroxine administration.
D. The Journal of Clinical Psychiatry
1.1997;58:266_270 Exaggerated TSH Responses to TRH in Depressed Patients With "Normal"
Baseline TSH by Robert P. Kraus, F.R.C.P.(C), Elizabeth Phoenix, B.Sc.N., Merrill W.
Edmonds, F.A.C.P., Ian R. Nicholson, C.Psych., Praful C. Chandarana, F.R.C.P.(C), and Sonya
Tokmakejian, Ph.D., F.C.A.C.B.
http://www.psychiatrist.com/pasttoc/toc/june1997/266exag.htm
Subtle thyroid underfunction may be contributing to depression in some patients with TSH in the
upper half of the range usually considered normal. If so, then the TRH-ST [stimulation test] may
be more sensitive in identifying this than measurement of TSH alone.
2. A summary was published in July 1993: A Highly Successful Approach to Hypothyroidism by
John V Dommisse, MD, FRCPC
http://www.johndommissemd.com/report1a.html
It discusses the use of T3 and the big double-myth is that (a) an elevated ultrasensitive-TSH level
is always required before a diagnosis of hypothyroidism can be made; and that (b) its
nearly-complete suppression always means that at-least-adequate treatment is in place.
II. Doctors' Websites
1. Suggestions for an Approach to the Management of Thyroid Deficiency" by Dr Barry J.
Durrant-Peatfield
http://www.foxleylaneclinic.co.uk/Suggestions_1.htm
That the diagnosis is all too frequently missed is commonly the result of an incomplete clinical
appraisal in favour of the standard thyroid function tests. These tests are the real problem in
diagnostic failure since there are inherent problems in interpreting blood levels of thyroxine
and/or thyroid stimulating hormone (TSH) when blood levels may differ widely from tissue
blood levels. Since the diagnosis may very properly, and easily, be made clinically, unreliable
blood levels should NOT take precedence over clinical judgment.
2. Dr. John C. Lowe: drlowe.com Most Recent Q&As
http://www.drlowe.com/q&a/askdrlowe/mostrecent.htm
The upper half of the "normal" reference range for the TSH is contaminated with TSH values of
patients with incipient thyroid disease. In practical terms, this means that when a patient's TSH is
over 2.0, suspecting that she has thyroid disease is reasonable, although the disease may only be
dawning.
3. Thyroid Disease Far More Widespread Than Originally Thought, 13 Million May Be At Risk
by Dr. Joseph Mercola, DO 1997-2000
http://www.mercola.com/2000/mar/5/thyroid%5Fupdate.htm
The study also found that even a slight decrease in thyroid function -- what is sometimes referred
to as "subclinical" or low-level hypothyroidism -- may raise cholesterol levels. These findings
are consistent with what was reported on by the American Association of Clinical
Endocrinologists survey regarding cholesterol and thyroid disease in January of 2000. That study
found that as many as ten percent of the 98 million Americans with high cholesterol levels may
not know that their cholesterol is elevated due to undiagnosed thyroid problems.The
thyroid/heart disease/cholesterol linkage was further confirmed in the February 15, 2000 Annals
of Internal Medicine's publication of the Rotterdam Study results. The Rotterdam study found
that older women with subclinical hypothyroidism were almost twice as likely as women without
this condition to have blockages in the aorta, and were also twice as likely to have had heart
attacks.many people whose test results are dismissed as normal could continue to have symptoms
of an underactive thyroid.
4. Optimum Diagnosis and Treatment of Hypothyroidism With Free T3 and Free T4 Levels by
Dr. Joseph Mercola, DO 1997-2000
http://www.mercola.com/article/hypothyroid/diagnosis_comp.htm
Most patients continue to have classic hypothyroid symptoms because excessive reliance is
placed on the TSH. This test is a highly accurate measure of TSH but not of the height of thyroid
hormone levels.The basic problem that traditional medicine has with diagnosing hypothyroidism
is the so called "normal range" of TSH is far too high: Many patients with TSH's of greater than
1.5 (not 4.5) have classic symptoms and signs of hypothyroidism.
III. Interviews With Doctors by Mary Shomon
1. An Interview with Don Don Michael, M.D., Dec. 2000: Getting What You Need from Your
Doctor: Challenges of Thyroid Care
http://thyroid.about.com/library/weekly/aa121700b.htm
Saying that your thyroid is healthy because your number is between the little number and the big
number is easily as foolish as claiming that you are physically fit if your weight is between 75
and 260 pounds (That would probably cover 95.5% of the weights in the USA.) without knowing
anything else.
2. "Rethinking the TSH Test: An Interview with David Derry, M.D., Ph.D." July 2000
http://thyroid.about.com/library/weekly/aa072500a.htm
Many people would develop classic signs and symptoms of hypothyroidism but the TSH was
ever so slow to become abnormal, rise and confirm the clinical diagnosis. Sometimes it never
did. Finally I began treat patients with thyroid in the normal manner I was taught. I could not see
why I had to wait for the TSH to rise for me to be able to treat them.
3. An Interview with Joseph Mercola, DO, June 2000: Hypothyroidism and the Role of Armour
Thyroid, Seaweed, Exercise, and More...
http://thyroid.about.com/library/weekly/aa062600a.htm
Most traditionally based physicians have long abandoned their physical examination and
diagnosis skills and appear unwilling to believe that patients who complain of all the classic
hypothyroid symptoms are in fact truly hypothyroid if their TSH is normal. They would rather
believe a lab test than the patient sitting in front of them.
4. An interview with Dr. John Dommisse, MD, FRCP, in which he discusses treating people with
a TSH over 1, as well as the use of T3, Sept. 1999
http://thyroid.about.com/library/weekly/aa092299.htm
I ran into too many patients who had classic hypothyroid symptoms, which cleared completely
on appropriate thyroid treatment, and whose TSH was below 2.0 (but above 1.5) and with FT4
and FT3 levels in the low ends of their 'normal ranges'.Finally, I found some patients with
several symptoms and signs of hypothyroidism whose TSH was between 1.0-1.5; so I lowered
my range, for the last time, to 0.1-1.0; I now treat primary hypothyroidism with a TSH of >1.0 (if
the FT4 and FT3 are low-normal, not above the middle of their 'normal ranges').
IV. Other Websites
1. About.com Thyroid Disease Weblinks and News: "What is Normal TSH? Probably
Somewhere Around 1.0!
http://thyroid.about.com/blnwslnk.htm#normaltsh
From an About.com reader: "I work in a hospital lab and have done thousands of thyroid
profiles. I've discovered that, while normal range for TSH is 0.5-5.0, the AVERAGE TSH for
patients with no thyroid disease, is around 1.0!"
2. Mary Shomon, author of About.com Guide to Thyroid Disease and Living Well With
Hypothyroidism
"HELP! My TSH Is "Normal" But I Think I'm Hypothyroid" 11/10/97
http://thyroid.about.com/library/weekly/aa111097.htm
"In my own experience, I feel downright awful at anything above 4, and I feel great between 1
and 2, which is where my endocrinologist keeps my TSH. But some doctors would have no
problem keeping me between a TSH of 4 and 5.5, still in the "normal" range, despite the fact that
I still have the full range of hypothyroid symptoms -- fatigue, weight gain, irregular menstrual
periods, dry skin, hair falling out -- at those levels."
3. Thyroid Health Information Site: The Underdiagnosed Epidemic by Ward Dean, M.D.
http://freespace.virgin.net/smokey.quartz/this.html
Although many people exhibit symptoms of hypothyroidism, they usually dont receive treatment
for this condition if they have normal blood test readings. Their physicians often tell them that
their symptoms are due to other causes or that their problem is "all in their head." I have known
many patients who were referred to psychiatrists to treat their so-called "psychosomatic"
problems. However, when they were later given thyroid replacement therapy, they improved
dramatically.
4. A long collection of patients descriptions of where they need their TSH levels to be for them
to feel well
Http://x74.deja.com/getdoc.xp?AN=721279649 (condensed version)
Http://x74.deja.com/getdoc.xp?AN=721279178 (longer version)
Nancy N: I start to get hypo symptoms when my TSH starts moving up towards 1.0. I feel best
and have no hyper symptoms when my TSH is at about 0.13 or less.
Paula: I had hypothyroid symptoms at a TSH of 1.8, last spring, and for years before - my TSH
tests were always "normal" - but apparently that is not normal for *me*. I had a TRH stimulation
test which was resoundingly positive for hypothyroidism, when my baseline TSH was only 2.4 to
2.8.
CW: If my TSH gets above 2.0, I get all kinds of bizarre infections I do NOT get otherwise.
Marie: My latest TSH was 0.1 (under normal range) but my doctor still agreed to a trial increase
in thyroxine as I was still very symptomatic and my Free T4 and Free T3 blood tests were low
down in the normal range.I am feeling a lot better now.
LuvARabbit: my old dr., he didn't want to treat me because my tsh was 3.3 and he totally ignored
my symptoms and told me to see a shrink. Funny, with a new doc and armour thyroid, I'm doing
so much better.
V. Books
1. Living Well With Hypothyroidism: What Your Doctors Don't Tell You...That You Need to
Know by Mary J. Shomon, author of About.com Guide to Thyroid Disease, 2000 p. 252:
"The current TSH levels used by laboratories to define the "normal" range of thyroid function
and the use of the TSH test as a primary means of diagnosis need to be significantly reevaluated.
The .5 to 5.5. "normal" range for thyroid function does not give enough information for
diagnosis anymore. Research reported in the British Medical Journal found that TSH levels
above 2 are likely not normal and instead include people at high risk to develop thyroid disease.
This means that the real "normal" range is probably far narrower and more concentrated at the
lower end."
2. The Thyroid Solution by Dr. Ridha Arem, 1999p. 223:
"Increasingly, more and more physicians believe that you can be suffering from hypothyroidism
even though your blood tests, including TSH, are normal."