Normal Labs And Still Having Thyroid Symptoms?
Therefore: Current best method to diagnosis
With increasing knowledge of the complexities of thyroid function at the cellular level, it is becoming increasingly clear that TSH and T4 levels are not the reliable markers of tissue thyroid levels as once thought, especially with chronic physiologic or emotional stress, illness, inflammation, depression and aging. It is common for an individual to complain of symptoms consistent with hypothyroidism but have normal TSH and T4 levels. While there are limitations to all testing and there is no perfect test, obtaining free triiodothyronine, reverse triiodothyronine, and triiodothyronine/reverse-triiodothyronine ratios can be helpful to obtain a more accurate evaluation of tissue thyroid status and may be useful to predict those who may respond favorably to thyroid supplementation . Many symptomatic patients with low tissue levels of active thyroid hormone but normal TSH and T4 levels significantly benefit from thyroid replacement, often with significant improvement in fatigue, depression, diabetes, weight gain, PMS, fibromyalgia and numerous other chronic conditions .
With an understanding of thyroid physiology, it becomes clear why a large percentage of patients treated with T4 only preparations continue to be symptomatic. Thyroxine (T4) only preparations should not be considered the treatment of choice and are often not effective in conditions associated with reduced T4 to T3 conversion, reduced uptake of T4 or increased T4 to reverse T3 conversion. As discussed above, with any physiologic stress (emotional or physical), inflammation, depression, inflammation, aging or dieting, T4 to T3 conversion is reduced and T4 will be preferentially converted to reverse T3 ( which acts a competitive inhibitor of T3 (blocks T3 at the receptor) ), reduces metabolism , suppresses T4 to T3 conversion ) and blocks T4 and T3 uptake into the cell.
While a normal TSH cannot be used as a reliable indicator of global tissue thyroid effect, even a minimally elevated TSH (above 2) demonstrates that there is diminished intra-pituitary T3 level and is a clear indication (except in unique situations such as a TSH secreting tumor) that the rest of the body is suffering from inadequate thyroid activity because the pituitary T3 level is always significantly higher than the rest of the body and the most rigorously screened individuals for absence of thyroid disease have a TSH below 2 to 2.5 . Thus, treatment should likely be initiated in any symptomatic person with a TSH greater than 2. Additionally, many individuals will secrete a less bioactive TSH so for the same TSH level, a large percentage of individuals will have reduced stimulation of thyroid activity, further limiting the accuracy of TSH as a measure of overall thyroid status. Reduced bioactivity of TSH is not detected by current TSH assays used in clinical practice.
So WHAT DOES ALL OF THIS MEAN? Continue reading...
You politely avoid stating the obvious that “endo-crine-ology” is an anachronism. They live in a soundproof room and fashion themselves as experts of a small set of signaling molecules.
Fish do not have thyroid glands. When oceanic creatures crawled up on land, they had to fashion an iodine storage pouch for themselves because of its paucity on land. You give it a fancier name that belies its nature. Most iodine is stored in the mitochondria.
Iodine, along with iron and sulfur work on the electron transfer chain in the only place where oxygen is burned and energy (ATP) is created, the mitochondria. They have regulation pathways of which medical science knows nothing. Medical students are taught that Iron is just a cushioned seat for oxygen molecules hidden inside hemoglobin. Its most important job is inside the mitochondrial furnaces quenching the embers of the ox-phos fire.
The symptoms of hypothyroidism that you describe are far more complex than thyroid deficiency and speak more of chronic immune up-regulation. The hard job with the patients you describe are detecting how and why the immune system is drifting toward some bad ending. There is a strong association between Hashimoto’s thyroiditis and gluten intolerance. Fish, frogs and gerbils (almost) never eat donuts or pasta.
Essentially, our ontogeny has out run our phylogeny and we are exceeding our design specs.
Study the evolutionary biology of iodine and energy metabolism. It contains secrets that your mind will greatly appreciate. Our lives (ontogeny) are evolution writ small and caught on the wing of chance.
F.A.Munasifi
brittle nails, dry skin, depression, night sweats with rapid heart beat and depressed libido. Is there something I should do to identify the cause of these symptoms or am I on too low a dose despite my good blood levels?
Thanks for the article, its food for thought.
As any good general practitioner would do, he referred me to a really good endocrinologist for treatment. I've been lucky b/c my 100 mcg of Levothyroxine have brought my numbers within normal range and I haven't had any issues since diagnosis. But I've read horror stories about people who still don't feel right even after diagnosis and treatment. I've read that, like you state here, the problem is often doctors who don't try hard enough to really help the patient. Not to mention the millions of people out there who have a thyroid condition and do not even know it and are walking around with symptoms thinking they are attributable to some other condition.
I've had to self-educate myself on the condition since even my "good" endocrinologist did not advise me about how best to take my medication (for example, make sure you don't take your thyroid pill in the morning and then have coffee with milk or cereal with milk as the calcium can negatively affect your body's ability to absorb the thyroid medication). I learned a TON about this condition and how best to live my life by SELF-EDUCATION.
Thanks for the very detailed physiological info here Dr. Shapiro. Patients can print this out and visit their doctor with the info; I'd love to be a fly on the wall during that visit!
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