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Mary Shomon

Failure to Diagnose and Treat Subclinical Thyroid Disease is the Real Bad Medicine: A Response to the British Medical Journal Article by Dr. Des Spence

By December 10, 2012

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In an article at the British Medical Journal titled Bad medicine: thyroid disease, Des Spence, a general practitioner in Glasgow, suggests that he believes that thyroid disease is being overdiagnosed.

He states that:

...in recent years UK specialists have suggested the treatment of subclinical hypothyroidism in patients only with clear symptoms. In the United States they go further: the endocrinologists' and thyroidologists' consensus statement "favors routine screening" and "early detection and early treatment," with some even suggested lowering the current threshold for diagnosis."
He claims that because thyroid symptoms are not specific, that patients "hang a lot of life's problems" on a thyroid condition, and therefore pressure doctors to be treated.

He then goes on to claim that while the epidemiology has not been well studied, "subclinical hypothyroidism spontaneously corrects in 80% of patients in two years." He backs this up by citing one study of a very small population, published in the Journal of Clinical Endocrinology and Metabolism. That study found that among 40 patients who had subclinical hypothyroidism -- defined as a TSH above 5, with "normal" Free T4 -- all of them "reverted" to "normal" TSH levels...within four to five years.

Dr. Spence then goes on to state that "thyroxine prescribing has doubled in the past decade, which cannot reflect a true rise in incidence of hypothyroidism." The only conclusion is that we are overdiagnosing and overtreating thyroid disease. Again, through overdiagnosis, doctors are systematically failing in our duty to protect the well, which is the worst medicine of all."

How can Dr. Spence conclude that there is no rise in the incidence of hypothyroidism? With increasing amounts of endocrine-disrupting chemicals in our water and food supplies, a population that now has decades of cumulative radiation exposure, and unexplained increases in the rates of autoimmune diseases, to dismiss the rise in prescriptions as solely due to overdiagnosing and overtreating is unscientific.

And going back to his contention that hypothyroidism is overdiagnosed because of 40 study participants who "reverted" to normal levels within five years...first, he ignores the controversy over what TSH range is considered to be "normal." Only four of the patients reverted to TSH values less than 2.0, while 65% reverted to levels above 3.0, and 30% "normalized" at levels above 4.12. That means that most of the patients had TSH levels above 3.0 -- a level that many physicians -- at least in the U.S. believe warrants treatment. Many endocrinologists in the United States believe that a TSH level above 3.0 is not "normal" and that controversy has been going on for more than a decade.

Next, Dr. Spence fails to mention, that in that study he cited, among the 40 people studied, three had a goiter, and 24 were positive for thyroid peroxidase autoantibodies (TPOAbs), which is suggestive of Hashimoto's disease. Five patients had diabetes, 11 had high blood pressure, and 13 had hyperlipidemia (elevated blood fats/cholesterol.)

How many of those patients with a goiter saw that goiter grow during the years they went without treatment, waiting for their TSH to "normalize?" How many of them experienced neck discomfort, interference with swallowing or breathing, or developed a cosmetically unsightly goiter, when thyroid treatment may have slowed or halted growth of the goiter, or even reduced the size of the goiter?

How many of those 24 patients who have elevated TPO antibodies and Hashimoto's disease continued to experience symptoms of a failing thyroid, despite fluctuations in their TSH? And how many of those patients will eventually go on to develop overt hypothyroidism? Studies have shown that treatment of patients with "euthyroid" (normal thyroid levels) in Hashimoto's patients may prevent elevation of TSH levels to overt hypothyroidism (TSH above 10), alleviate symptoms, and even reduce thyroid antibodies. (Duygu Yazgan Aksoy, et. al. "Effects of Prophylactic Thyroid Hormone Replacement in Euthyroid Hashimoto's Thyroiditis" Endocr J (Japan) Vol. 52: 337-343, (2005).)

How many of those 24 patients who have elevated TPO antibodies and Hashimoto's disease will go on to develop thyroid cancer? Subclinically hypothyroid TSH levels in Hashimoto's patients increases the risk of developing thyroid cancer. (The association between serum TSH concentration and thyroid cancer).

How many of those who had elevated cholesterol would have seen their cholesterol levels normalize if they had been treated for hypothyroidism? According to the American Association of Clinical Endocrinologists, after diet, thyroid disease is the most common secondary cause of high cholesterol. Prescribing instructions for all cholesterol-lowering medications such as statin drugs, recommend testing for hypothyroidism prior to a physician prescribing them. (You'll find all of these drugs have prescribing information that states: "Prior to initiating therapy with ____, secondary causes for hypercholesterolemia (e.g., poorly controlled diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemias, obstructive liver disease, other drug therapy, alcoholism) should be excluded...")

How many of the diabetics might have had better control of their diabetes and lower Hemoglobin A1C levels with appropriate thyroid treatment? According to endocrinologist, Patricia Wu, MD, FACE, FRCP, writing in the journal, Clinical Diabetes, "The presence of thyroid dysfunction may affect diabetes control."

Given that we know that even subclinical thyroid disease is a risk for heart disease, how many of the patients with high blood pressure might have protected their heart health with thyroid treatment? Just recently, a study in the Journal of the American Medical Association pointed out that "subclinical hypothyroidism is associated with an increased risk of coronary heart disease events and coronary heart disease."

As a patient advocate, I think the real "bad medicine" is Dr. Spence's effort to extrapolate life- and health-changing thyroid diagnosis and treatment advice out of one study of 40 people, while ignoring all the peripheral issues -- heart health, cholesterol, blood pressure, diabetic control, thyroid cancer risk, and progression to overt hypothyroidism -- that can result from the failure to treat subclinical hypothyroidism.

Note on 12/10/12: The British Medical Journal has published my response to Dr. Spence's article at their site. Please "like" the post there, and if you feel inclined, I urge patients and practitioners to write your own responses as well! You can submit them here.

About Mary Shomon | Thyroid Forum | Twitter | Facebook

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Comments
December 10, 2012 at 5:14 pm
(1) Rod says:

Glad you posted that Mary!

As an earlier “Rapid Responder” on that British Medical Journal, I felt it was good to see your comments as well. Seeing the responses make this one of the Most Commented articles over much of the past month was also pleasing.

May I encourage those who go to view the original to consider using the “Like” feature on both Mary’s and any of the other 12 responses with which they agree?

December 10, 2012 at 7:20 pm
(2) Terri says:

Excellent article!!

December 11, 2012 at 7:33 am
(3) vimal says:

I agree with Mary. I feel it is deliberate attempt to keep people untreated. It helps medicine field in general.

December 11, 2012 at 8:00 am
(4) catinthehat3 says:

To add to your “how many’s”
How many of Dr Spence’s close relatives would he allow to suffer and go untreated like this for 5 years?
Answer? None.

December 11, 2012 at 8:31 am
(5) Mary R says:

My doctor told me that untreated hypothyroid can lead to high cholesterol, and maybe that is why so many older women develop heart disease. Just because a doctor says it is so, like this published doctor, does not mean it is so.

December 11, 2012 at 8:57 am
(6) Jelena says:

My doctor advises me not to take thyroid treatment untill my TSH level reaches 10. Five years ago I have been diagnosed with Hashimoto with TSH level 3,6 with normal values of free T3 and T4. I have a little goiter that I get checked every half a year with ultra sound and that proved to be not cancer. TSH values are stable.. The doctor is pleased with my blood work and ultra sound check.
What do you think?
Thank you.

December 11, 2012 at 11:16 am
(7) Pamala says:

In my case case it was diagnosed correctly. My TSH was below normal and my anti-bodies were too high. Same with my sisters and Mother.
What I don’t understand about this doctor’s thinking is that if the doctors do the full panel (as mine did) – the evidence is obvious (aside from constantly tired, sore throat, thinning hair, dry skin…I shan’t go on and preach to the choir!). The numbers are right there in black and white – or red – something in one of the panels is off.
Another thing I do not understand is WHY they want to under treat people. What purpose is there aside from them admitting that patients are correct and they are not? How egotistical! This is not what they vowed when they vowed to do no harm.

December 11, 2012 at 11:33 am
(8) Terry R. L. says:

Most definitely! Subclinical Hypothyroid is vastly underdiagnosed and not treated effectively or correctly. The Key is to find an MD who knows how to diagnose and treat effectively. Thyroid is one of the most important hormones, and like all hormones production decreases as age increases, and this affects all other hormones. I love the fable on how the TSH levels were established originally, as told by Jonathan Wright MD. Look it up, quite a disastrous but funny tale on how medicine can be in error.

December 11, 2012 at 12:56 pm
(9) Joyce says:

Having a thryoid issue and then prescribing to his theory is the same thing as NEVER receiving medical care. The absense of medical care makes things alright? So, if he were dxed with cancer, he should have medical care withheld, as in time, that too shall pass?

How did some of these people ever get to the point of having the MD behind their name? Obviously, unable to remove himself from and double open ended grocery bag has made him turn his anger onto people who have and will still find GOOD DOCTORS who will put patients first.

For a ‘doctor’ to put things like this in writing, it is obvious it is for publicity only.

He is one piece of work.

I have been treated for thyroid issues since 1992. I take medication, alternating doses qod. This is to keep my levels WHERE I AM HEALTHIER.

December 11, 2012 at 1:22 pm
(10) Tar says:

I bet the doctor would have a different view if he suffered from hypothyroidism and was under treated!

December 11, 2012 at 1:54 pm
(11) Toni Silva says:

Very good points made by Mary, I thank you!

December 11, 2012 at 4:30 pm
(12) Caroline says:

Thanks for highlighting this Mary. I have only been diagnosed and treated with Thyroxine for 6 months. I keep going back to the doctor with symptoms but my blood tests now say I am ok. So, despite the fact that I tell them I am not ok … they say I am. I wish there was a way that medical students could be given a pill to slow their metabolism down temporarily just so that they could know how this feels. Unless you have experienced it, I don’t think you would believe what an underactive thyroid feels like.

December 11, 2012 at 5:42 pm
(13) Ali says:

I have a friend who was recently diagnosed with hypothyroidism. When sent to an endocronologist, he told her she did not require medication so she continues to suffer. It is disgraceful that these ‘doctors’ allow their patients to live in ill-health with the strong possibility of heart disease and other life-threatening illnesses.

Why is this allowed?

December 11, 2012 at 8:16 pm
(14) Kara says:

WOW Dr Spence you got your 15 min of fame for running your mouth at the expense of many women severely suffering. You may want to read Dr Starr’s book about Hypothyroidism so you have more knowledge prior to not helping suffering women BEFORE it spirils to the EXTREME BAD DAMAGE like so many ignorant Drs do. It’s like you don’t want to help someone with a broken leg until they come back with a broken arm too. Why is that? Well. The drug company controls a lot of doctoring. And they want women so damaged that you rely heavily on drugs for ever. Thanks Dr Spence! Modern medicine has some brilliant leaders empowering women to seek help earlier and your shhoshing them away until they “have 2 broken arms”.

December 11, 2012 at 10:03 pm
(15) Amanda says:

It is terrible how Doctors sometimes use their professional standing to offer misleading information. I developed hypothyroidism after the birth of my first child and later discovered that I have Hashimoto’s. My levels constantly change and my symptoms along with them. I just had mine tested again and my TSH was 3.6. According to my medical providers laboratory that is considered within normal range. I am lucky to have a provider who understands that I don’t feel well when it is that high and will adjust my medication to get it lower. With it a that level I am actually sitting my my home with my thermostat at 72 degrees in a fleece shirt, robe and covered with a blanket. If I remove any of these items I will be violently shivering in less than half and hour because of hypothyroidism. I have many times noticed the symptoms of hypothryoidism start bothering me and after getting my labs done they find I am subclinical hypothyroid (if you can techincally be considered so when already being treated for hypothyroidism) and with a medication adjustment I feel so much better. I can only imagine how people with subclinical hypothroidism must feel if they do not recieve treatment. Unless the person feels poorly with treatment or becomes hyperthyroid with it I cannot see the harm in treating hypothyroidism in any form. Plus, if you consider all the other medical and health issues that hypothyroidism can contribute to it would seem irresponsible of a doctor to choose not to treat a patient.

December 12, 2012 at 1:56 am
(16) Itay says:

Thank you for the great article. You are right about the misleading way ofusing the medical literature. Sad, but this is how medicine works these days. It is well known that medicine is not accurate science as doctors wants us to think. Any way, as a fellow patient/advocate from Israel (and after a huge omission with Eltroxin – a levo-thyroxin drug in israel) i can tell you that the paternalism that doctors use against thyrois patients is very sad and bad. During this omission in Israel doctors tagged the patients as “hysterical” in order to manage the omission in a easy way. That happened in spite of the fact that many of us had a TSH change and a lot of Adverse effects. They just used the known method of “dont let the facts confuse you…”. it is very sad how drug companies and doctors is helping each otger instead of taking real care of the patients….

December 12, 2012 at 9:10 am
(17) Clare Jenkins says:

I would have thought the increase in thyroxine prescription could be more likely to be due to ) an increased population per se. b) a disproportionately increased elderly population, c) enlightened diagnosis of hypothyroidism after years of under diagnosis and under treatment. 40 patients is in any case a ridiculously small number on which to make such a massive extrapolation, even if we disregard (which we cannot) the pathologies of these particular patients – hardly a representative cross section.

December 21, 2012 at 7:13 am
(18) Cara says:

Follow the money folks. In the UK., thyroid disease is a listed condition – just like diabetes and other long terms conditions here in Ireland and all over most of the western world – which means treatment is covered on the NHS (Bristish National Health service) – so – lower the number of people being treated and you lower the cost. . . only in the short term – until the complications of un/under-treatment arise and cost far more in the short term.

March 10, 2013 at 5:01 pm
(19) consulta medico online says:

I really liked its publication, congratulations

April 5, 2013 at 8:30 am
(20) Tracy says:

Dr. Spence’s response speaks volumes about his regard for women’s opinions on their own health status.

August 26, 2013 at 12:17 am
(21) Dee says:

I was treated for subclinical hypothyroidism (TSH 4.8) with the goal of getting my TSH to 1.0.–Supposedly the ideal level for one with hypothyroidism. I never really felt better; in fact , over a period of three years, i felt worse. I believe I was treated too much . . . to where I was pushed into subclinical HYPERthyroidism, as, in the end, I had such muscle weakness in my thighs that I could not pedal a bike up hill, shaky hands, palpitations, fatigue, and my menstrual period went form heavy as always ot non-existance. etc. Finally asked doctor to test for Hasimotos-(original doc never did–just assumed, I guess!!) I am negative for that disease. So, she took me off medication altogether. I feel better overall, but have gained weight, seem more fatigued, have scant periods. I’m thinking my ideal would be to be at TSH 3.0 or so, as now it is around 5.4.

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