Carlton then goes on in the article to call thyroid disease the "disease du jour," and claimed that thyroid information and websites are a "virtual cottage industry." She also interviewed several traditional, conventionally-oriented endocrinologists, and presented their opinions as the official medical position on thyroid issues.
In her article, Carlton touched upon the major debate over the "normal range" for the TSH test. Up until late 2002, the standard reference range was 0.5 to 5.0. But since that time, the American Association of Clinical Endocrinologists (AACE) has recommended that the range be 0.3 to 3.0. Carlton, however, quotes Gilbert Daniels, MD, one of the directors of the Thyroid Clinic at Massachusetts General Hospital, who continues to use 5.0 as the cutoff, and says: "There's no compelling evidence that medication helps patients whose TSH is in the 5.0 to 10.0 range." (This controversy over the normal reference range for the TSH thyroid levels has been a point of disagreement among endocrinologists for almost a decade.)
Carlton then quotes Boston endocrinologist Jeffrey Garber, MD, who said that women are eager to start thyroid medication because they want to lose weight. (You can read my past interview with Dr. Garber, The TSH Normal Range: Why is There Still Controversy? for more on his ideas.)
Interestingly, Carlton features a comment from Phoenix endocrinologist Daniel Duick, MD, president of the American College of Endocrinology, who says that for hypothyroidism treatment: "The goal is to take the lowest dose possible to get the TSH in the 1 to 2 range." But Carlton does not explore how or why the treatment objective is a TSH of 1 to 2, but when TSH levels are above 5, or even under 10, they are also considered "normal" for diagnostic purposes by the other doctors she interviewed.
In the end, after talking to the doctors, getting retested, and still having borderline hypothyroid blood test results, Carlton concludes her article, saying: "Given my family history, my doctor recommends I check again next year. With all I'd learned about hypothyroidism, I had already decided that even if my levels had nudged up a bit, I would opt out of treatment. In the meantime, I'm drinking more java (for energy) and honing my crossword skills (for focus). As for the unwanted pounds, there's a spinning class on Saturday with my name on it."
Thyroid patients and the nation's top integrative practitioners and hormone specialists, none of whom were interviewed for Carlton's article, have expressed frustration at what they perceive to be Carlton's rather superficial and flippant treatment of thyroid disease, as well as some controversial or one-sided medical information presented in the Good Housekeeping article. Patients and doctors are sharing their concerns and criticisms in comments at the Good Housekeeping thyroid article, around the Internet, on Facebook's Thyroid Support page and in dozens of recent emails to me personally as well.
In light of the controversy, some of the nation's top integrative practitioners are speaking out. These doctors and thyroid experts -- who are considered to be on the cutting-edge in diagnosis and treatment of hypothyroidism and autoimmune Hashimoto's disease -- have agreed to share their concerns and cautions regarding Susan Carlton's discussion of Hashimoto's and hypothyroidism diagnosis and treatment in Good Housekeeping.
Erika Schwartz, MD is a Manhattan-based physican with expertise in hormonal medicine, serves as Chief Medical Officer of AgeMD, the Age Management Institute, and is a Founding Director of the Bioidentical Hormone Initiative.
What a sad state of affairs for the health of America's women. Thyroid disease -- undiagnosed and mismanaged -- is rampant. It isn't the 'diagnosis du jour,' although maybe if doctors looked and listened to the patient, it would have to become so. In my practice I see hundreds of women and men with undiagnosed and mismanaged thyroid problems. I treat the patient, not the blood test. All you have to do is ask my patients how they feel and function, decades into their treatments. They don't take thyroid to lose weight. They take T3 and T4 and they don't need caffeine or crosswords to stay mentally and physically sharp. To recommend these remedies is an insult to common sense and a disservice to all of us.
It's sad that a magazine as dedicated to its readers would run an article that is so harmful and misleading. Although the writer notes the increase in heart attack deaths associated with a TSH of 5 to 10, she ignores the major HUNT study(1), which included over 17,000 women. This study showed that women with intermediate (1.14-2.52) or "high" levels (2.5-3.5) of TSH had a 41% and 69% increased risk of heart attack death compared with women who had TSH levels in the lower range of normal (0.50-1.4 mIU/L). Women whose thyroid levels were actually abnormally low had an even greater risk of heart attack.
This is a major point to gloss over, as heart attacks are the number one cause of death in the US. As cholesterol medications called statins used for primary prevention (their most common use) decreased heart attack deaths by under 2%, this suggests that an optimized thyroid function in women with TSH of 2.5 to 3.5 would be over 30 times more likely to prevent heart attack deaths than the medications. This suggests that in addition to leaving women feeling miserable, Susan Carlton's misguided advice could result in tens of thousands of unnecessary deaths in women reading her article - a devastating effect. At least she briefly notes the importance of checking not only a TSH but also an anti-TPO antibody (the test for Hashimoto's) in women who might get pregnant. Not treating with thyroid hormone - even if TSH is normal by any standard - is associated with a 400% increased risk of miscarriage - which is totally preventable by simply giving a low-dose thyroid hormone. That's another 50,000+ preventable miscarriages per year - that are simply missed by most physicians.
Fortunately, more and more physicians are becoming aware that it is critical to treat the patient and not only the blood tests. Her argument would suggest that in the presence of overt symptoms of hypothyroidism, a woman should not be offered a treatment trial with thyroid hormone unless she's in the lowest two and half percent of the population. She may as well say that no woman should be offered any shoe larger than a size 4, as that would technically be in the normal range and no study has shown that wearing a shoe size larger than this is of any benefit. Quite sad.
David Borenstein, MD is an integrative and holistic physician with expertise in hormone balance, in private practice in Manhattan:
In my practice, I have seen hundreds of patients who have been to many other medical specialties, and were told their thyroid function was "normal." Meanwhile, they were drinking coffee, exercising constantly, and getting enough sleep, but instead of feeling more energetic and losing weight, they ended up more exhausted, fuzzy-brained, and continued to gain weight. Only by properly diagnosing and treating their thyroid dysfunction -- and addressing the underlying adrenal issues -- was I able to get them feeling well. The TSH is just one of a number of parameters -- including Free T4, Free T3, Reverse T3 and antibodies -- that must be evaluated before properly treating a thyroid patient.>> Read More Comments from Thyroid Doctors and Experts
I hope that thyroid patients do not follow her advice. If they do, they may suffer for years with fatigue, depression, weight gain, heart disease and early mortality. Numerous studies show that most doctors practice 10 to 20 years behind what is in the medical literature, and continue to adamantly defend what they were taught in medical school, even in the face of overwhelming evidence. Hundreds of studies show that the TSH is a very unreliable determinant of tissue levels of thyroid hormones. (See the National Association of Hypothyroidism website). Relying on a simple test and discounting all other signs, symptoms and tests because one test states "normal" may be easy, but doctors need to be doctors, and not lab technicians. None are so blind as those who do not wish to see.
With regard to Dr. Daniels statement that "there's no compelling evidence that medication helps patients whose TSH is in the 5.0 to 10.0 range," the Whickham study (2) followed over 2,700 people with TSH levels in the 6 to 15 range, compared to normals, for over 20 years. It was shown that those with the "mildly elevated" TSH had a 76% higher heart disease. If treated, the risk was equal to "normals." The Hunt study (1) showed that even minimal elevation of TSH within the reference range was associated with a 70% higher risk of coronary heart disease. Another study published in the journal Clinical Cardiology (3) found that low free T3, regardless of TSH, was associated with 2.5 times the risk of cardiac mortality. A large study published in the Annals of Internal Medicine demonstrated that those with low normal thyroid levels were shown to have significantly increased risk for atherosclerosis (1.7 to1.9 times normal) and heart attack (2.3 to 3.1 times normal). The study demonstrated that low normal thyroid levels (mildly elevated TSH) contribute to 60 percent of heart attacks and are more of a risk factor for heart disease than smoking, high cholesterol, hypertension or even diabetes."
Richard L. Shames, MD, is a graduate of Harvard University, trained at the University of Pennsylvania Medical School, served as adjunct clinical faculty at UCSF Medical Center, and has three decades of thyroid practice in San Rafael, California. He is author of the books Thyroid Power, Feeling Fat Fuzzy or Frazzled, and Thyroid Mind Power.
First of all, this article muddles the science of thyroid diagnosis. The millions of people suffering with a sluggish metabolism need better diagnosis, not worse. Arguing about ranges of normal for a thyroid screening test is virtually meaningless without knowing the clinical circumstances of the patients involved. A borderline high TSH result in a patient with few symptoms means something totally different than the same result in a patient suffering terribly with suspicious thyroid-like symptoms of fatigue, chilliness, constipation, and distressing dryness of skin, hair, nails or eyes. Sadly, this article's author does not make that crucial distinction. Instead, she confusingly quotes highly credentialed medical professionals about TSH test scores, without the accompanying clinical context these doctors obviously intended. In thyroid health education, this is a big no-no.
Second, and more important, this article deceptively overstates the usefulness of thyroid blood testing in general. Far too many thyroid-challenged individuals suffer needlessly, sometimes for years, all because of the "tyranny of the TSH test." Good thyroid doctors know that blood test for thyroid issues are only part of a proper diagnosis. Often, just as important are the patient's symptoms, basal temperature, family history, associated illnesses, and physical exam. For instance, researcher-clinician Ernest Mazzaferri, MD, said it well in the Journal of Postgraduate Medicine: "Thyroid tests do not replace good clinical judgment, and should not be used alone to confirm or refute a diagnosis, or to dictate therapy." Indeed, supporting this view are numerous scientific articles by respected researchers (such as those by W. Fraser in the highly-regarded British Medical Journal), which for years have severely questioned the debated value of thyroid lab tests.
My medical colleagues' current over-reliance on blood tests alone is largely what is driving the interest in thyroid advice websites. Health care consumers are literally sick and tired of having their very real thyroid conditions being under-diagnosed and inadequately treated. They know the truth when they see it. And this time they did not find it in Good Housekeeping magazine.
Datis Kharrazian, DHSc, DC, MNeuroSci is an educator, nutritionally-oriented chiropractor, and author of the book Why Do I Still Have Thyroid Symptoms /When My Lab Tests Are Normal?.
In a sense these doctors have a point -- medication often doesn't help hypothyroidism when it's within a certain range. That's because for most people in this country hypothyroidism is caused by an autoimmune disease called Hashimoto's, in which the immune system slowly attacks and destroys the thyroid gland. In these cases it's important is to address the immune imbalance. Luckily the scientific literature gives us ample evidence on how to do that clinically. Only then can we truly address the cause of hypothyroidism, regardless of whether thyroid hormone medication is necessary.
It's unfortunate this author is using coffee to sustain her energy and relying on crossword puzzles to maintain her cognition when she knows she has an autoimmune thyroid condition. The research shows that by ignoring an autoimmune thyroid condition one raises the risk of developing future autoimmune issues. Also, the brain is highly dependent on sufficient thyroid hormones to function normally and she is accelerating her own brain degeneration, memory loss, and autonomic dysfunction by ignoring her declining thyroid health. It is best to address an autoimmune thyroid condition sooner rather than later to avoid increasing health problems.
Mark Starr, MD is an integrative physician in Arizona, with expertise in hormone balance and thyroid treatment. He is also author of the book Hypothyroidism Type 2: The Epidemic.
The thyroid gland controls our metabolism. For decades, the Basal Metabolic Rate (BMR) was used to help physicians diagnose hypothyroidism. Despite normal BMR test results, astute physicians would often give patients suspected of being hypothyroid a trial of thyroid hormones. Doctors knew the BMR test was not infallible. The research in my book 'Hypothyroidism Type 2: The Epidemic' shows there is no correlation whatsoever between the TSH and patients' BMR. The fact that the TSH levels required to diagnose hypothyroidism varies from 10.0 in the UK to 2.5 in Sweden proves there is no science to justify using the TSH to diagnose hypothyroidism. It is the medical dogma of our time and an abomination that results in the suffering of tens of millions.
Kenneth Woliner, MD is an integrative and functional medicine practitioner who works extensively with thyroid and hormone imbalance patients. His private practice, Holistic Family Medicine, is located in Boca Raton, Florida.
Dr. Daniels, as someone who mainly specializes in treating cancers of the thyroid, parathyroid, and adrenal glands, seems oblivious to the overwhelming medical literature regarding hypothyroidism and the need for early diagnosis and treatment. Untreated hypothyroidism not only leads to troublesome symptoms of fatigue, constipation, depression, and obesity, but also causes kidney disease, elevated lipid levels and fatal coronary heart disease.(5, 6, 7, 8).
Dr. Garber flippantly dismisses his patients who have attempted to get treatment for their troubling symptoms. It is true that thyroid hormone is not indicated for the treatment of obesity and giving thyroid hormones to a person without a thyroid condition, in an attempt to speed up the metabolism, will not lead to weight loss. Hypothyroidism, however, is associated with a low basal metabolic rate (BMR), and when untreated, makes it extremely difficult for a patient to maintain a normal weight, despite eating a very low calorie diet.(9,10). Instead of listening to his patients, it appears that Dr. Garber is more interested in giving placating remarks.
Hypothyroidism is increasingly common, with many patients still yet undiagnosed (11, 12). Patients are unsatisfied with condescending physicians such as Dr. Garber and the care they provide (13, 14)Rather than being verbally abusive toward his patients, perhaps Dr. Garber should listen to his patients and give them the medicine they desperately need (15, 16).
Writer, researcher, former professor, and longtime practitioner in the field of cardiology, Richard N. Fogoros, MD is also About.com's guide to heart disease.
Whether to treat subclinical hypothyroidism when the TSH level is less than 10 mU/L is, as Ms. Carlton points out, controversial. Many endocrinologists (such as those the author consulted for this article) generally recommend no therapy for these patients. However, other expert endocrinologists are inclined to treat subclinical hypothyroidism in patients who have symptoms suggestive of hypothyroidism, or who have goiters, or who have significant risk factors for heart disease (since subclinical hypothyroidism has been associated with an increased risk of coronary artery disease, heart failure, and cardiac mortality).
Each patient is a unique biochemical individual and needs to be treated as such. My experience has clearly shown that a drifting TSH, even in the normal range, is a precursor to bigger problems down the road. Most patients are optimized with a TSH around 1.0 mIu/ml. A study showed that higher rates of thyroid cancer found in subjects with a higher mean TSH (1-5 mIU/L) as compared to those with benign disease with a mean TSH 1.01miu/ml.
Richard Podell, MD, MPH, is in practice in New Jersey, and is also Clinical Professor in the Department of Family Medicine at the UMDNJ-Robert Wood Johnson Medical School.
Double-blind studies have shown that thyroid is an effective treatment for depression--even when thyroid hormone blood test levels are normal. Psychiatry textbooks now include thyroid hormone as a standard treatment option for persons with difficult to treat depression. For example, a recent study found that thyroid was more effective than placebo for improving depression among persons who had not responded well to initial treatment with Zoloft. (4)
Mainstream endocrinology relies on the TSH test, which is not a direct measure of thyroid function, and can, in fact, be unreliable....In spite of the obvious need for a better approach to the low thyroid condition, there has been very little movement to rehabilitate mainstream endocrinology, which dogmatically clings to the TSH test.
Do you think Good Housekeeping has done a disservice to thyroid patients? Share your comments here on my blog, or at the Thyroid Support community on Facebook.
And to reach out to Good Housekeeping, start by telling your thyroid story.
I also encourage you to write to Good Housekeeping's Editor, Rosemary Ellis, at firstname.lastname@example.org, and by regular mail at:
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(1) Bjorn O. Asvold; Trine Bjoro; Tom Ivar L. Nilsen; David Gunnell; Lars J. Vatten Thyrotropin Levels and Risk of Fatal Coronary Heart Disease: The HUNT Study Arch Intern Med. 2008;168(8):855-860. Online
(4) Cooper-Kazaz, R. et. Al. Combined Treatment with Sertraline and Liothyronine in Major Depression, A Randomized , Double-blind, Placebo-Controlled Trial, Archives of General Psychiatry 2007; 64-679-88 Online
(6) Asvold BO, Bjøro T, Vatten LJ. Association of thyroid function with estimated glomerular filtration rate in a population-based study: the HUNT study. Eur J Endocrinol. 2011 Jan;164(1):101-5. Online
(7) Asvold BO, Vatten LJ, Nilsen TI, Bjøro T. The association between TSH within the reference range and serum lipid concentrations in a population-based study. The HUNT Study. Eur J Endocrinol. 2007 Feb;156(2):181-6. Online
(9) Svare A, Nilsen TI, Bjøro T, Asvold BO, Langhammer A. Serum TSH related to measures of body mass: longitudinal data from the HUNT Study, Norway. Clin Endocrinol (Oxf). 2011 Jun;74(6):769-75. Online
(11) McMillan C, Bradley C, Razvi S, Weaver J. Psychometric evaluation of a new questionnaire measuring treatment satisfaction in hypothyroidism: the ThyTSQ. Value Health. 2006 Mar-Apr;9(2):132-9. Online
(13) Bjoro T, Holmen J, Krüger O, Midthjell K, Hunstad K, Schreiner T, Sandnes L, Brochmann H. Prevalence of thyroid disease, thyroid dysfunction and thyroid peroxidase antibodies in a large, unselected population. The Health Study of Nord-Trondelag (HUNT). Eur J Endocrinol. 2000 Nov;143(5):639-47. Online