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HYPOTHYROIDISM - The Unsuspected Illness



I and many other physicians find that:
1. A person can have an underactive or hypothyroid condition which is many times not diagnosed by regular blood tests.


2. Normal blood test levels (according to lab range) may not mean they are optimal for you. If you have symptoms which can be attributed to "low thyroid," and even if your lab tests are in "normal range," I sometimes put my patients on thyroid medications to see if this treatment can alleviate their symptoms.

3. Some of my patients require thyroid hormone in the "higher than normal range" to feel better.

4. Most doctors order only a TSH (Thyroid-Stimulating Hormone) test and rely on it to diagnose hypothyroidism and monitor treatment progress. A TSH test is a fraction of the overall thyroid picture. TSH is NOT a thyroid hormone. It is a pituitary hormone from which doctors have to guess the quality of your thyroid hormones. In addition, it can only diagnose "primary" hypothyroidism, NOT other types of hypothyroidism.

Many times, the hypothalamus-pituitary axis does not function efficiently, and the TSH level does not change exactly as T3 and T4 levels change. Dysfunction of this hypothalamus-pituitary axis can cause "secondary or pituitary" and "tertiary or hypothalamic" hypothyroidism.

Just because your TSH level is "normal" does not mean that you do not have an underactive or hypothyroid condition. A good doctor will not rule out a thyroid condition solely on the basis of a TSH, but will order a complete thyroid panel before ruling out a thyroid condition. A full thyroid panel—which includes TSH, Free T3 (FT3), Free T4 (FT4), Reverse T3 (rT3), Thyroglobulin level and thyroid antibody tests (thyroglobulin antibody and microsomal TPO or Peroxidase antibodies)—is important not only for diagnosis but to decide what type of thyroid treatment to utilize for each individual. A full screening is also important because thyroid antibodies diagnose an autoimmune (Hashimoto's Thyroiditis and Grave's disease) condition that can only be found by a full thyroid panel long before other blood values become abnormal. Treatment for people with antibodies can actually help forestall full-scale development of thyroid disease in some people.

5. Proper interpretation of any lab result is very important, and thyroid results are no exception. A "normal" blood test does not mean "optimum. " Many mainstream doctors think that, "You don't have hypothyroidism, because your blood tests are normal," even if you have all the symptoms of hypothyroidism. I and many other doctors think differently. If you have "low" or "mid-range normal" blood levels, and still experience symptoms of low thyroid function, then that level is not optimum for you. Your body is asking for a "high-normal" level. The normal range for T4 is 4.5 to 11.5 (it varies for each lab), and if your T4 level is 5.0 or 6.0, it may 'normal' but not be 'optimal' for you. There is no medical regulation that states you feel the hypothyroid symptoms only at 4.4 or below and not, for instance, at 4.6 or above. Newborns have highest T4 levels in the range of 12.0 and 13.0. As you get older, your thyroid level starts to decline, and you develop subtle symptoms of hypothyroidism, but you are not diagnosed properly or treated because your "blood test levels are normal". I describe this as a "not feeling well syndrome. "

6. Normal range for Free T3 is 2.30 to 4.20 (again, it varies for each lab). In my experience, most patients with Free T3 level of 3.0 or less will have symptoms of hypothyroidism. I have some patients who don't feel normal till their Free T3 level is 5.0 or even higher. Even with this high FT3 level, they do not have palpitation or tachycardia (when their adrenals are also balanced). I have not seen osteoporosis due to a high level of T3.

7. Very few doctors order Reverse or inactive T3 (RT3) and thyroid antibody levels. RT3, Free T3 (FT3) and Free T4 (FT4) should be checked at the same time. The body produces the RT3 naturally to rid itself of excess of T4, but in some cases, especially during stress or after delivery, and high or low cortisol (adrenal hormone) levels, it's made in excess. When RT3 is in excess it occupies the same cell receptors where active T3 (FT3) stimulates cellular activities and functions. Excess RT3 clogs cell receptors thus making then inactive or non functional. This can happen in any organ or any part of your body. If it occupies cell receptors in your adrenals, your adrenal will not function properly. If it occupies receptors in your ovarian cells, ovaries will not function efficiently. Same thing can happen in heart, brain, muscles or any other part or organ in body affecting function of that particular part.
If your RT3 level is high or if your FT3 and RT3 ratio is low, you will suffer from symptoms of underactive or hypothyroid condition.

8. Most doctors rely only on lab results. They exclude your symptoms and how you actually feel. They think that if your test results are "normal," you are not suffering from hypothyroidism. Many of these patients have been wrongly diagnosed as depressed or suffering from fibromyalgia, chronic fatigue syndrome, anxiety, stress, insomnia, etc. Some are even categorized as chronic complainers or even malingerers. They have been put on anti-depressants and a multitude of other medications without much benefit. I believe that test results are only part of the equation, and your symptoms—including fatigue, weight gain, cholesterol levels, hair loss, body temperature, and depression, among others—are also a good way to gauge whether you have enough—or not enough—thyroid hormone in your body.

I recommend to you and to all my patients to do their own reading and make their own decisions about their health care. A more-informed patient will get the best results. Don't let your doctor rely only on one test (TSH) to tell you whether your thyroid is functioning appropriately or not. Take into account the whole picture, from the blood tests to the physical exam, signs, symptoms and the basal body temperatures.

9. Many doctors who put their patients on thyroid medications will follow them up only with a TSH level test. Again, in my experience and opinion, TSH level will fluctuate wildly when somebody is on thyroid medication and may not reflect exactly if T3 and T4 levels are ideal or not. Because of this, many patients are inadequately treated with thyroid medications and have been told to reduce their medications because TSH has gone down. In my experience, many patients who are on thyroid medications will have low TSH even though they are not hyperthyroid. Reducing medication dose will bring upon their hypothyroid symptoms. The correct tests to follow in patients taking thyroid medication are TSH with Free T3 and Free T4 levels, and not just TSH alone. Low TSH levels do not necessarily indicate hyperthyroidism in everyone. Patients with low TSH levels can still have symptoms consistent with hypothyroidism.

10. A low body temperature plays a large role in diagnosing thyroid problems. Many doctors do not check or ignore your body temperature to correlate with your symptoms. Ideal body temperature is 98.6° F. Most doctors are concerned if your temperature goes above 99° F, but they are not concerned if it is below 98° or 97° F. I have seen patients with 95° and 96° F temperatures, and their doctors have failed to find out why. In our body, there are thousands of chemical reactions occurring every minute. As in cooking, where correct temperature will prepare food properly, these metabolic reactions also will perform efficiently at an ideal temperature of 98.6° F. Our body maintains this ideal temperature (98.6° F) because of internal metabolism and these chemical reactions. If our metabolism is slow, it will be reflected in low temperature, and the most common reason for a slow metabolism is an underactive or hypothyroid condition.

11. Most mainstream medical doctors will prescribe only T4-based medications, such as Synthroid®, Levothyroxine®, etc. Even if a patient's symptoms do not improve, they fail to change medications. I think a doctor should choose a thyroid medication based on your blood tests and symptoms; something that works safely and makes you feel well.

In my practice, I use nutritional supplements, Iodine, T4-based medications, T3-based medications or a combination of both T3 and T4 (such as Armor Thyroid® or Nature Thyroid®, etc. ) based on symptoms, blood tests results and how treatment is helping the patient. I even prescribe compounded T3 or a combination of T3 and T4 that is individualized for each patient. Some doctors feel that "Armor Thyroid® or Nature Thyroid® are not good medications or they are not standardized," etc. In my opinion, these natural thyroid medications not only contain T3 and T4, but also T1, T2, Calcitonin and probably many other chemicals that we have not even identified. Armour Thyroid® has been around for over 100 years and has proven to be extremely safe and effective.

I feel that if one brand of T4 drug (Synthroid®, Levothyroid®, Levoxyl® or Unithroid®) doesn't work, I should be willing to try another. If T4-based medication doesn't work, then I am willing to try T3 (Liothyronine or Cytomel®) or a combination of both (Armor Thyroid® or Nature Thyroid®, etc).

12. Thyroid hormone works in harmony with other hormones, especially adrenal. If you read the prescribing instruction for any thyroid medication, it clearly states that "… Synthroid® and other T4 based medications are not advisable in patients with uncorrected adrenal insufficiency…. " I have noticed the majority of hypothyroid patients also suffer from adrenal dysfunction. All hypothyroid patients should have at least their cortisol, DHEA and aldosterone levels checked to identify any adrenal dysfunction before starting thyroid medications. If underlying adrenal and other hormonal dysfunctions are not dealt with properly, many patients do not get full relief of their symptoms or even suffer from side effects of thyroid medications such as tachycardia, palpitations, etc. When you have associated dysfunction of other hormones, your thyroid medication may not work efficiently or as well as it could. The endocrine system is like a symphony. When all instruments are in harmony with each other, music is pleasant. Similarly, when all hormones are balanced, patients feel their best. Just balancing one hormone or another may not be sufficient.

13. Underactive or hypothyroid-related symptoms and conditions are frequently missed or misdiagnosed. It is very common for doctors to inadequately connect patient's symptoms and problems with their underactive or hypothyroid status, because they can affect any organ or system in the body from head to toe. Symptoms such as fatigue, fibromyalgia, chronic constipation, high cholesterol level, frequent sinus infections, fogginess, weight gain or difficulty losing weight, allergies, hives, bloating, menstrual irregularity, endometriosis, hair loss, depression and even miscarriage, etc. , are often not considered connected with a patient's underactive or hypothyroid condition, because their TSH levels are "normal. " I do recognize that there are other medical conditions aside from underactive or hypothyroidism that can cause these symptoms, and these symptoms can respond to other treatment modalities.

I do not feel that these debilitating symptoms are simply a "normal part of living. " I and many other like-minded doctors recognize these symptoms as needing treatment. Many of our patients have gone from doctor to doctor and have had the same symptoms treated in different ways, often without much benefit.

14. Other associated conditions: underactive or hypothyroid patients often suffer from other debilitating conditions such as: underactive adrenals or adrenal insufficiency, other hormonal imbalances (progesterone, estrogens, testosterone, etc. ), low blood pressure, hypoglycemia, chronic yeast (candida) problems, low immune function, etc. Many times, symptoms related to these conditions can be resolved with proper thyroid treatment. If not they need to be addressed separately. Unless you correct these conditions, you will not see full benefits and improvement from your thyroid treatment.

15. IRON, FERRITIN and Thyroid: Iron (and iodine, selenium, magnesium and zinc), are essential for normal thyroid hormone production and metabolism. Both too high or too low can cause or aggravate hypothyroid condition and symptoms.
Other then preventing anemia, iron is also an important facilitator of thyroid hormone at cellular level. The iron helps to push the T3 into the cells and then into the nuclei of the cells. We need both optimal levels of iron and optimal levels of adrenal hormone (cortisol) in order to tolerate thyroid replacement medications. Patients with low iron and ferritin (storage iron) find it more difficult to raise their thyroid medication dose to optimal level. Iron and ferritin are often chronically low in hypothyroid patients.

Iron deficiency anemia can also cause symptoms which are similar to hypothyroid symptoms, such as depression, achiness, fatigue, etc. In females I like ferritin level of 80-100 and above 110 in men.
If you have very high ferritin then also you will not be able to tolerate thyroid treatment. Too high a level of ferritin can be due to on-going inflammation (which thrusts iron into storage), and is often present in many thyroid patients.

16. Subclinical Hypothyroidism: Experts estimate that as many as 17 percent of the general population suffer from a form of underactive thyroid known as subclinical hypothyroidism. Typically, doctors have not treated subclinical hypothyroidism, claiming that there is no demonstrable benefit to patients. I and many other practitioners feel that the benefits of treatment outweigh any risks.

According to research published in the Annals of Internal Medicine and also in The Journal of Clinical Endocrinology & Metabolism, "Older women with subclinical hypothyroidism were almost twice as likely as women without this condition to have had heart attacks and blockages in the aorta. " The researchers concluded that treating subclinical hypothyroidism can improve a number of heart disease risk factors, as well as certain quality of life measurements such as:

  • reduced total cholesterol level
  • a drop in low-density lipoprotein (LDL), also known as "bad" cholesterol
  • improved endothelial function, a marker for hardening of the arteries
  • a reduced waist-to-hip ratio
  • a reduction in body weight, on average 1.1 pounds, and an improvement in feelings of tiredness

17. Most thyroid replacement therapies used in this office are generally well tolerated, but there is no therapy which is completely without risks. Any T3, T4 or combined therapy must be carefully managed and monitored. Some of the potential side effects of T3, T4 or combination therapies are: anxiety, palpitation, tachycardia, difficulty falling asleep, shakiness, menstrual irregularities, choking, difficulty swallowing, stomach discomfort or pain, diarrhea and fever, etc. However, in my experience, for most patients, the potential benefits greatly outweigh the risks.

If you have any questions or need more clarification, please do not hesitate to ask us.

Hitendra Shah, M.D.
Healthy Thyroid – Healthy Body

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