According to Dr. Ron Manzanero, the key to the answer is the word "optimal." Says Dr. Manzanero: "I want my patients to feel optimally well. In order for this to happen there is a dance between the physician and the patient that must take place."
Dr. Manzanero feels that the doctor must have a thorough knowledge of the symptoms of hypothyroidism, knowledge of the physical manifestations of hypothyroidism in the body, a thorough knowledge of the optimal tests to run, and a thorough knowledge of all the various therapeutic options available. He also feels that it's important that the doctor remove all bias in his or her mind, and not evaluate patients with preconceived notions.
According to Dr. Manzanero:
Such preconceived notions can include things like:So, what is optimal wellness? For Dr. Manzanero, when we're talking about hypothyroidism, it means the complete absence of low thyroid symptoms. Says Dr. Manzanero: "The patients will feel they have high energy instead of fatigue, maximal cognitive functioning instead of memory and focus problems, a sense of happiness instead of depression/ anxiety, et cetera. As simple as this sounds, it is amazing how many physicians have forgotten this. Instead, they focus on a single thyroid test, the TSH test and let that become their sole determining guidepost in managing low thyroid. (Again, this is a dance, a partnership, not a condition that a doctor should have to "manage" and order for a patient.)"
The patient's role in the "dance" is that he or she must learn what the many symptoms of hypothyroidism are and to know in particular what their unique signs and symptoms of low thyroid are. They should be able to report this information to the doctor.
- Depression needs treatment with an antidepressant drug. (Mood disorders can be a symptom of low thyroid!)
- Synthroid is all that a hypothyroid patient needs. (Many people only feel optimal when they have some additional T3 added to their prescription. A Greek study confirmed this.)
- All the doctor needs to evaluate a hypothyroid patient's status is the TSH test. (See below.)
- Patients will do better on Armour Thyroid. (Sometimes people wrongly assume that "natural' thyroid is better in all cases.)
- Armour thyroid is not standardized. (There are many unsubstantiated dogmas that are propagated in medical training.)
For Dr. Manzanero, another part of the equation is the exclusion of physical exam findings and the overreliance of the TSH test. "Many times patients can have a 'normal" TSH test and yet sit there in front of the doctor with physical signs such as, dry parchment-like skin, thinning of the outer third of the eyebrows, dry straw-like hair or thinning of the hair on the scalp and extremities, edema in the tissues, thick callous formation on the soles of the feet, or brittle splitting nails that may have longitudinal ridges present. Also, too often doctors forget to have patients monitor their body temperatures, which can reflect thyroid functioning."
According to Dr. Manzanero, a whole chapter could be written on the laboratory tests. He believes the optimal set of labs should at the very least contain the TSH, Free T4, Free T3, and thyroid antibodies. Other tests could include iodine testing, immune cytokine tests (TH1/TH2) pathways, gluten gliadin antibodies, and heavy metal allergy testing. The latter three tests are important in the autoimmune hypothyroidism condition known as Hashimoto's, because certain heavy metals and gluten food consumption have been linked to this autoimmune condition.
Dr. Manzanero has more to say about the TSH, Free T4, and Free T3 thyroid tests.
I find it absurd that my medical training taught me to solely rely on the TSH. Back in the mid-1990's I learned from my patients - much to my embarrassment - about the importance of the Free T3 levels. A few of my better-educated patients would ask me to include the T3 level in my assessments, and I frankly didn't know why. "That wasn't what they taught us in med school!" If T3 is the active thyroid hormone in the body, doesn't it make sense to see how much the body is converting from the inactive T4? The reason many of my patients on synthetic T4 replacement are still symptomatically hypothyroid is because they do not optimally convert the T4 into T3. Not checking the T3 level is like the President asking how many barrels of emergency gasoline the National Guard has, and getting an answer in the amount of crude oil. T4 is the "crude oil" while T3 is like the "gasoline." Certain parts of the body will convert the T4 made in the thyroid gland, into the active form, which is T3.
One other important thing to consider in regards to lab testing, is considering the optimal range. This concept not only applies to just thyroid testing, but to most labs tests. Many physicians simply do not realize that the standard "normal" ranges are often determined from samplings of sick people. I've done my own "in-house" observations of optimally fit people and found their TSH levels to be around 1.0 to 2.2. (The Free T4 around 1.10 to 1.35, and the Free T3 around 3.1 to 3.8.) All of these ranges are well within the so-called 'normal' ranges. Many of the progressive thyroid doctors may have some variations, but we all understand that the current test ranges are substandard.