My checkup

[JEPG]

I went to the endo and he said everything looked great that my TSH was normal. My antibodies were high and he said that I am just showing signs of being all around the hashimotos. I still feel so sluggish. Any feedback would be appreciated.

[Mark Lupo, M.D.]

Need a little more history to comment.....are you on meds yet?  What does "normal" TSH mean?  Patients with positive antibodies need close attention to make sure TSH is 0.5-2.0 (around 1 is typically my goal).

Here's some general info on treating based on TSH -

The treatment of hypothyroidism means striking a careful balance between a patient's symptoms and the lab (usually TSH) value.  TSH is the most relied upon lab by thyroid experts world-wide to determine appropriate levels of thyroid hormone replacement.  It does not directly reflect tissue activity of thyroid hormone but there is no test available that does that and TSH is the best approximate we have now.

That being said, the target TSH is 0.5-2.0 for a patient on replacement.  In general, patients who are older or have heart disease do better with a TSH that is not <0.5 as shown in several studies that these patients have increased risk of premature death.

Younger patients who are otherwise health may feel better with a TSH that is slightly lower than 0.5.  There are definite risks associated with TSH <0.1 even in patients who "feel fine" -- studies show that a TSH this low over time can significantly alter heart function.

[ancientmariner]

When you have antibodies, the TSH is worthless...the antibodies are destroying your thyroid, so of course you feel horrible. Are you on any meds? If they aren't making you feel well, you probably need more, regardless of what the TSH says. A free T3 and free T4 lab will tell you more - the free T3 is the amount of thyroid hormone in your blood ready for use, and the free T4 is the amount of storage hormone ready to be converted to T3. I've read that those should be at least above midrange, and the T3 closer to the top for feeling well..

[Mark Lupo, M.D.]

There is no randomized clinical trial that I am aware of that concluded that TSH is "useless" if you have antibodies.  That does seem to be a theory professed by some, but until a well designed trial proves this I would not assert it in the way it has been asserted here and on other internet sites.  Please see my previous comments today and how the TSH is used and while yes there has been too much dependence from the medical community of keeping the TSH "normal" it is still a useful test if interpreted in each individual clinical setting.

[PNWBabe]

I just read an email from a friend who had 1/2 of her thyroid removed a couple of days ago. This is what she said:

Apparently, even though it didn't show cancer, he is stuck on how
horrible the gland looked when he took it out. It took 4.5 hours just
to take out the right side. And he was telling me how horribly scarred
and tough it was.  Then today at my visit he started reading the
pathology report on it and it basically said that my thyroid gland
wasn't a gland at all but something similar to an island that had been
nuked, dried out and left to a horrible atmosphere for many years
lol.. so I guess it wasn't doing me any good in there anyway,.. He said
I have one of the worse cases of Hashimoto's thyroiditis he had ever
seen....  Now I definately know that I have a reason to feel like
****.. But my TSH tests never come back really bad.  In the last few
months it hasn't been over 2.7 something ..Since I started armour
though and gotten to 2 grains it has gone down to .811 (on a .35 to 5.5
range)-- with a slight improvement of my syptoms (symptoms)..yeahhhh  :)

I find it interesting that though her TSH was "normal" her gland had been destroyed and she felt awful. Had her doctor gone soley by TSH, can you imagine how long she would have felt crappy. If you haven't done any reading, there are a couple of good books that you might look in to reading. One is "Thyroid-Guardian of Health" by Phillip Young and the other is "Hormones, Health and Happiness" by Steven Holtze. Be your own best advocate!

[PNWBabe]

P Saravan, W-F Chau, N Roberts et al,
Psychological well-being of in patients on adequate doses of L-thyroxine: results of a large controlled community based questionnaire study
Clinical Endocrinology, 2002; 57:577

..some patients with TSH levels within the laboratory normal range might still be hypothyroid at the cellular level for several reasons. First, individuals with a TSH in the upper normal range might have previously had a set point for TSH in the low normal range prior to developing thyroid disease and hence had been used to higher circulating thyroxine levels.

In summary, this community-based study provides the first evidence that patients on thyroxine replacement therapy titrated [adjusted] to a normal TSH level display significant differences in their psychological well-being when compared to age- and sex-matched controls.

If confirmed in other studies, these findings indicate a need to re-examine our approach to thyroxine replacement therapy and develop improvements in therapy that can return the psychological status of patients to that of the control population.

[PNWBabe]

C Meier, P Trittibach et al,
Serum thyroid stimulating hormone in assessment of severity of tissue hypothyroidism in patients with overt primary thyroid failure: cross sectional survey
British Medical Journal, 2003 (8 February); 326:311-312

http://bmj.com/cgi/content/full/326/7384/311?ijkey=t0IcAVMIzqO8M

The measurement of pituitary thyroid stimulating hormone (TSH) is the most sensitive test for early diagnosis of primary hypothyroidism. The magnitude of elevation of TSH is commonly believed to correspond to the severity of tissue hypothyroidism. We aimed to evaluate the value of measuring serum TSH in assessing the severity of tissue hypothyroidism in patients with overt hypothyroidism.

TSH is a poor measure for estimating the clinical and metabolic severity of primary overt thyroid failure. This is in sharp contrast to the high diagnostic accuracy of TSH measurement for early diagnosis of hypothyroidism.

We found no correlations between the different parameters of target tissues and serum TSH. Our findings are in accordance with a cross sectional study showing only a modest correlation between TSH and the percentage of positive hypothyroid symptoms and data showing discordant responses between the pituitary and peripheral target tissues in patients treated with L-triiodothyronine. We assume that secretion of TSH is driven by maximal stimulation, with no further increase occurring with greater severity of hypothyroidism. Therefore, the biological effects of thyroid hormones at the peripheral tissues and not TSH concentrations reflect the clinical severity of hypothyroidism. A judicious initiation of thyroxine treatment should be guided by clinical and metabolic presentation and thyroid hormone concentrations (free thyroxine) and not by serum TSH concentrations.

[Mark Lupo, M.D.]

interesting abstract cut/pastes - but TSH is still useful until we have a better way to measure tissue activity - it is not perfect and we know this but it should not yet be ignored -- see my previous answers yesterday regarding TSH -- it is fairly consistent with the first cut/paste particularly.

[PNWBabe]

I don't believe I was stating that TSH doesn't have its place. However, I do think that it should be a doctor's objective to see his/her patients well and thriving rather than existing. As it is established, there can be tissue resistance when in fact labs appear "normal". I use the term "normal" in quotes since we all know that each patient is different and none should be treated as though this disease is a cookie cutter disease. I speak from experience when I tell you that I was on .175 synthroid, after being diagnosed with a TSH of 1.57 and antibodies of >1000, and felt crummy. My thyroid labs appeared normal, but, I was FAR from it. My hair continued to fall out, my weight and blood pressure increased, my skin looked like fish scales, yet, the doctor was blind to all those things because my labs were "normal". I think that most of the women on this forum aren't looking to survive..but to LIVE again. To feel great, and not just like they make it through the day. Now that I am on 4 grains of Armour, my dose being split throughout the day, with a small amount of adrenal support, my skin is smooth, I have lost weight, my hair has stopped falling out and my cholesterol has dropped 48 points in a year with no change of diet or exercise. My risk for coronary disease has gone from +5.4 to now -.01. Yes, labs..labs that show that Armour works when given to patients in doses that change their lives, that give them their lives back. That is what we want Dr. Mark, it is what we deserve!

[Mark Lupo, M.D.]

The TSH is not perfect - we both agree it's useful however, particularly for identifying patients at risk (just like bone density identifies patients at risk for fracture but is not great for following a patient on treatment) Population studies (esp in older patients) show that a low TSH is associated with cardiovascular disease - that is why I am cautious in general statements on a forum like this -- for young health patients the TSH may not be as important as current practice suggests.  Dosing thyroid hormone must be individualized to a patient's symptoms, labs, age and medical history.

[PNWBabe]

How many doctors dose by symptoms and labs, not just labs, since labs can be scued by other medications and antibodies? I think that is the root of the problem with treating thyroid patients. Most doctors don't know all of the symptoms of low thyroid and most won't dose until symptoms are gone, but dose by labs values only.

[Mark Lupo, M.D.]

hard to answer that question - but the numbers are easier to treat than the patient.......the trick it to take both into account.

[PNWBabe]

so, basically, doctors take the easy way out and treat by the numbers, rather than studying,reading and learning what ALL the symptoms of hypo are. Instead of treating their patients until symptoms resolve. This leaves millions of patients hanging, with lingering symptoms, on needless prescriptions and surviving.