Overlooked, Underdiagnosed?

by Mary J. Shomon

An upcoming article in the American Medical News discusses how conflicting screening guidelines are confusing the whole thyroid issue. On the whole, writer Susan Landers has written a sensible article, and features the open-minded and smart perspectives of Terry Davies, MD, professor of medicine at Mount Sinai School of Medicine in New York and director of the division of endocrinology, who declares that "there is chaos in the medical community."

In contradiction, Paul Ladenson, MD, professor and director of endocrinology and metabolism at Johns Hopkins, shows his stripes as an endocrinology conservative by pronouncing that "even if it isn't easy to decide who to screen, at least the TSH test provides a straightforward way to make the determination to treat. 'The only hard part about making the diagnosis of an underactive or overactive thyroid gland is thinking about the possibility,' Dr. Ladenson says. 'Once that occurs, it's very easy in the laboratory to rule these disorders in or out.'"

I would ask Ladenson why it is so hard to decide who to screen? The vast majority of thyroid patients are women. Women should be tested. Women who are trying to get pregnant and can't should be tested. Women having menstrual disruptions should be tested. Women complaining of fatigue should be tested. Women with high cholesterol levels should be tested. Women having a particularly difficult menopause should be tested. Women complaining of hair loss should be tested. Women complaining of unexplained weight changes should be tested. Women complaining of anxiety or depression should be tested. All diabetics should be tested. Everyone over 60 should be tested regularly any time other bloodwork is done as part of a regular physical exam. How complicated IS this, Dr. Ladenson? Sounds pretty basic to me.

What IS complicated is diagnosis, despite Ladenson's protests to the contrary. His slavish over-reliance on the TSH test, along with the same from many of his colleagues, means that diagnosis is actually quite difficult. There are still endocrinologists out there who will tell a patient who has every single clinical sign of hypothyroidism -- including a big goiter, plus a family history of thyroid conditions -- that their TSH of 5.49 means that they do not have a thyroid problem. And this may be while Free T4 and Free T3 levels are out of control and antibody levels are soaring (indicating autoimmune disease heading for full development) -- all signs that a patient has thyroid disease, despite a so-called "normal TSH."

Easy, huh?

It may be easy "in the laboratory" to rule these disorders in or out, but people are not petri dishes, and doctors are not lab technicians. If diagnosing thyroid conditions does not require any actual doctoring or clinical observation of symptoms or interpretation, if it does not involve knowledge of autoimmunity and antibodies, or the meanings of elevated T4 and low T3 in the face of high normal TSH levels -- if diagnosing thyroid problems is merely reading a number off a piece of paper as determined by a laboratory, then exactly why would anyone need an endocrinologist for thyroid diagnosis? Who would pay the hundreds of dollars an hour most endocrinologists like Ladenson charge for someone who reads a number off a piece of paper?

Does reading a single number off a lab report -- when the lab report even flags something as "high" or "low" -- requires specialization and years of medical school? I don't have a medical degree, and I can do this, so I guess, according to Ladenson's particular way of looking at it, I can diagnose thyroid problems as well as he or any other endocrinologist can?

The article also discusses how in November 2002, AACE published revised guidelines that narrowed the range for normal thyroid function from the old TSH of 0.5 mIU/L to 5.0 mIU/L, to 0.3 mIU/L to 3.0 mIU/L. Here it is, folks. Documentation. In a publication produced by the American Medical Association itself. I dare your doctor to read this, and tell you that the "normal range" is still .5 to 5.5!!!

This one is a keeper. Print it out and bring it in to your doctor who thinks that keeping you at a TSH of 5.49 is a good standard of care.