The Two Thyroid Camps: An Editorial

Some thyroid patients complain about fatigue or weight gain, the doctor runs a TSH test, they come up hypothyroid, get their prescription for levothyroxine, and a few weeks later, report that they're feeling great, and back to normal. These patients and their practitioners can't imagine that people struggle to even get tested, much less diagnosed, and they can't imagine that every patient doesn't flourish on a synthetic T4 medication. These patients -- and their doctors -- are avid supporters of the "Easy to Diagnose, Easy to Treat" wing of thyroid disease.

Many of the medical professionals in the "Easy to Diagnose, Easy to Treat" camp cling to old dogma like a life raft, believing such ideas as:

• All you need is a Thyroid Stimulating Hormone (TSH) test to diagnose and manage thyroid problems
• A TSH that falls in the laboratory normal range (usually around .50 to 4.50) means the thyroid is normal.
• There is no need to run thyroid antibodies tests if TSH is normal.
• There is never a need to run Free Thyroxine (Free T4) or Free Triiodothyronine (Free T3) tests, and their results are almost always meaningless to diagnosis and management of thyroid disease.
• There is never a need to run a Reverse T3 test, as the results have no bearing on symptoms or treatment.
• Levothyroxine (synthetic T4) is the only treatment ever needed for hypothyroidism.
• Radioactive iodine (RAI) ablation is the recommended treatment for most cases of Graves' disease and hyperthyroidism.
• There is no treatment for Hashimoto's disease.
• Indeterminate or inconclusive results on fine needle aspiration (FNA) biopsies of thyroid nodules mean a patient should have the entire thyroid surgically removed.
• Diet, lifestyle, and nutritional status have no impact on the development of or resolution of thyroid disease and its symptoms.

These medical professionals sit in their offices, amidst swag from the drug companies...they go to society meetings (usually funded by the levothyroxine drug companies), where they report on the results of research -- often funded by those same drug companies -- that tell them what they already know, and reinforce the dogma. They laugh at patients and call us "drug-seeking" hypochondriacs or say we have "fork in mouth disease," they deride the integrative and holistic practitioners who treat thyroid patients and call those practitioners quacks, they declare that natural thyroid drugs are obsolete, and they condemn natural and alternative medicine approaches as snake oil. They demand peer-reviewed, double-blind, journal-published studies, and when those studies are published, and they demonstrate findings that challenge their dogma -- for example, the 2009 Danish study published in the European Journal of Endocrinologythat showed T4/T3 combination therapy to be superior to T4 only -- they call it a "bad study" and simply ignore the findings.

Then there are the integrative and holistic practitioners -- and the occasional forward-thinking endocrinologists -- who are working with thyroid patients. Let's call them the "One Size Doesn't Fit All" camp. These practitioners are the ones who approach thyroid diagnosis and treatment with a more open mind. Most of these practitioners have a very different dogma, so to speak, with most believing that:

• The Thyroid Stimulating Hormone (TSH) test is just one of many tests that can be used to diagnose and manage thyroid problems -- along with careful medical history, and evaluation of symptoms.
• The TSH normal range is too broad, and the narrower range, at minimum, should be used as a starting point. That said, the TSH test can be flawed, and can miss thyroid problems that warrant treatment, such as subclinical hypothyroidism, and Hashimoto's disease.
• Establishing whether a thyroid problem is due to autoimmunity -- i.e., Hashimoto's disease or Graves' disease -- is always important information that warrants this testing.
• A complete thyroid panel should include Free T4 and Free T3, both to diagnose thyroid abnormalities, and to manage treatment. There are "optimal" levels for Free T4 and Free T3, and these should be used as guidance, rather than the broader "normal range."
• Reverse T3 is a valuable test that can help identify thyroid transport and cellular issues that have a role in diagnosis and treatment.
• Levothyroxine (synthetic T4) is just one treatment for hypothyroidism. Studies have shown that some patients do better, safely, with the addition of synthetic T3 for combination T4/T3 therapy. And years of practice have shown that some patients do better, safely, with natural desiccated thyroid drugs. The best thyroid hormone replacement drug is the one that safely works best for each patient.
• Radioactive iodine (RAI) ablation and surgery are treatments for Graves' disease and hyperthyroidism, however, before any permanent, irreversible actions are taken, most patients should be offered the opportunity to take antithyroid drugs, and potentially achieve a disease remission. Patients should also be carefully evaluated to ensure that the hyperthyroidism is not a transient phase of Hashimoto's disease.
• Hashimoto's disease, even when TSH, Free T4 and Free T3 levels are within normal, is a disease process that can sometimes be halted or put into remission with thyroid hormone replacement medication. Thyroid hormone replacement medication can also help prevent progression to overt hypothyroidism in some patients, and therefore, Thyroid Peroxidase Antibodies (TPOAb) should be tested, and the potential value of treatment carefully considered in patients who test positive and have thyroid symptoms.
• Indeterminate or inconclusive fine needle aspiration biopsies of thyroid nodules should undergo additional specialized analyses that can determine if a nodule is cancerous, and help patients avoid unnecessary surgery.
• Diet, lifestyle, and nutritional status have an impact on the development of or resolution of thyroid disease and its symptoms, and identifying dietary, lifestyle and environmental toxins, chronic infections, nutritional deficiencies, and other hormonal imbalances are all important parts of thyroid treatment.

As you can see, each camp is approaching things in very different ways. And for almost two decades, efforts to bring the two camps together, to improve the situation for thyroid patients, has to a large degree failed. Sadly, conventional endocrinology and the medical establishment are hidebound, fiercely determined to cling to their outdated dogma, ignore patient experience, and dismiss new research findings. This leaves thyroid patients frustrated, undiagnosed, untreated, sometimes poorly treated, and often forced to go outside their HMO and insurance coverage, and pay out of pocket, to see the doctors who are willing to think outside the box to diagnose and treat thyroid disease.

As a patient advocate, I think it's time for the two camps to come together. And to make that happen, the first step is for the various players in the world of endocrinology to take a long, hard look at their motivations, their biases, and their shortsighted dedication to outdated diagnostic and treatment practices that are not meeting the needs of today's thyroid patients.