disappointed with my conservative family doctor

I went to see my family doctor today, based on my annual lab exams which appointed a high TSH as I posted 3 weeks ago (below). I found a doctor on Mary Shomon's website that seems to work with integrative medicine, more open and also prescribes armour when he finds suitable - Dr. David Borenstein - but wanted to see what she had to say today. She wanted to order another TSH and "thryoid exams". I brought her a complete list based on advice I got here including FREE T3 and Reverse T3, she said what really matters is TSH and almost didn't want to order FREE T3 and just did because I insisted. She said I didn't need the Reverse T3 and did not order it. Btw, what is it for?

Besides, when I complained about feeling fatigued, she said it must be mostly because of depression. She said if TSH came high again, although it is subclinical hypo, she would recommend treatment. I almost knew the answer, but asked anyway: how would the treatment be. She goes: I would start you on Synthroid. I asked what she thought about the natural hormones with T3 and as expected she said what I read countlessly online: that she doesn't specially like them and that they are "hard to track" (not sure why they all say that? marketing from Synthroid labs?). Not sure how to tell her I prefer to treat this with another doctor without hurting her feelings, I wish to continue with her as my PCP.

I also told her I don't wish to continue with antidpressant zoloft she gave me 3 weeks ago (it takes away sexual desire and makes me anxious and feeling funny), I am hoping with hypo treatment I will feel better. Am I right to wait and not take it?

Well, Dr. Borenstein only has available slots in 3 weeks and I am almost crying cause I think I should see him instead of her for treatment, and I want to start it asap as I can hardly get up from bed lately.

Anyone treated with Dr. Borenstein? Please let me know if he's good and solves issues.

--

Tests: (3) TSH W/FREE T4 RFX (43562A)

TSH [H] 4.68 MIU/L  (0.40-4.50)

T4, FREE 1.2 NG/DL   (0.8-1.8)

- Tests: (4) Total T3 (30536R)

T3,TOTAL 79 NG/DL (76-181)

Also, my LDL colestherol came back high for the first time in my life:
- Tests: (1) Lipid Panel (CPT-80061)
CHOLESTEROL,TOTAL [H] 208 MG/DL (125-200)
LDL CHOL, CALCULATED [H] 130 MG/DL     (<130)

[gimel]

Can't provide any info on Dr. Borenstein.  Reviews written by his patient do sound promising that he is a good prospect.  So worth pursuing.

As for waiting 3 weeks, I understand just how long that is when you are feeling so bad.  Perhaps while waiting, you might pursue with your current doctor getting some thyroid medication.  If you would give a copy of this letter to your doctor, and then point out that even though TSH is a poor indicator of thyroid levels, your TSH is higher than the range currently recommended by the AACE, which is .3 - 3.0.   This letter was written by a good thyroid doctor for patients that he sometimes consults with from a distance.  The letter is then sent to the PCP of the patient to help guide treatment.  Note that he treats hypo patients clinically by testing and adjusting Free T3 and free T4 as necessary to relieve symptoms.

http://hormonerestoration.com/files/ThyroidPMD.pdf

In the letter also please note the following statement.  "the ultimate
criterion for dose adjustment must always be the clinical response of the patient. I have prescribed natural dessicated thyroid for your patient (Armour, Nature-Throid) because it contains both T4 and T3 (40mcg and 9mcg respectively per 60mg). This assures sufficient T3 levels and thyroid
effects in the body. Since NDT has more T3 than the human thyroid gland produces, the well- replaced patient’s FT4 will be below the middle of its range, and the FT3 will be high “normal”


Also you might give the doctor a copy of this list of typical hypothyroid symptoms, marked up to identify those which you have.  

http://endocrine-system.emedtv.com/hypothyroidism/hypothyroidism-symptoms-and-signs.html

Also, even though they did not test the more important Free T3, your Total T3 is very low in the range compared to your Free T4, indicative of poor conversion of T4 to T3.  Also,tell her that Free T3 has been shown in scientific studies to correlate best with hypo symptoms, while Free T4 and TSH did not correlate.

After laying all this on your doctor, then I suggest that you should ask for a trial prescription of Armour Thyroid, or Nature-Throid, to assure your Free T3 level is increased toward relieving your symptoms.  I don't see how this could hurt anything, just take a bit of your time.  It might wake up your doctor and help get you started toward feeling better much sooner that way.

[rach7612]

Hey, Your current doctor may not wish to treat you anymore if you end up following a plan prescribed by another doctor that goes against her philosophies. But don't feel guilty about seeking a second opinion for a lifelong disease. Just make the appointment. FYI - starting zoloft may be easy to do and prescribe, but ADs are notoriously hard to come off of once you've been taking them for even a couple months. Depression is not a disease - it is a syndrome, or symptom. And doctors have to guess at the cause (they usually say it's a "chemical imbalance" - a term invented by psychiatrists and drug companies) and prescibe a pill to see if they're right. If they're not, then you deal with withdrawal from that and try a new drug, and so on. If you have evidence of the cause (low thyroid levels), why would a doctor prescribe a pill for a different cause (I'm guessing she says you have "low seratonin"?) that she has no blood test or brain scan to demonstrate. You are right to be cautious here!!

I'm not saying depression isn't real, but many doctors diagnose you with depression and move on, instead of seeing that it's a symptom of a real biological disease or a human reaction to painful life situations. Just look at how many people have been treated for depression only to discover years later, it was hypothyroid all along!

[rach7612]

Also there's nothing wrong w/ starting synthroid under your current doctor. I'm pretty sure that's the starting point for almost all thyroid doctors and the sooner you start it, the sooner you will know if it's going to work for you or not.

[gimel]

The reason I recommended going with a NDT med is that thethinme already appears to have a T4 to T3 conversion problem.  Taking a T4 med only will likely exacerbate any conversion problem.  Plus she will see symptom improvement earlier.

[thethinme]

thanks gimel! yes I am also hopeful about Dr. Borenstein and he thinks to be super open minded at his interview at Mary Shomon's website, a good read I recommend for everyone.

I think my current doctor is a VERY smart woman but when I tried to argue today about the need of FREE T3 etc she looked at me in that way "how do you expect to know more about this than me"? so while I think it's a good idea to give her this great letter you posted (and I intend to do so, even if her next patients are to benefit from it, and not me), I am not really hopeful she will be open to change her way of working. now unfortunately I understand exactly what everyone here keeps complaining about re: doctors.

I totally agree that I might have issues with T4 to T3 conversion. I understand people who seem to have this might do better with Armour, correct? (was Armour formulated again after the 2009 fiasco, and if not, does it still work when people crush it before having it, etc.? could not find current info)

[thethinme]

thanks rach. yeah I totally thought about it, I think not only she'll get offended but also how will she trust what other doctor is doing that is not in accordance with her views... but as you said, although it seems to be a simple disease, it is lifelong and we know that the symptoms are really debilitating, so I must do what I thing is right for me. I have an appointment on the 20th and possibly sooner if someone cancels.

who knows though... she was totally against me going to Mexico to do Weight Loss Surgery which my insurance did not cover, (cheaper abroad - 8K vs. 20k) and now she's happy I did it as I am in my ideal weight etc.

she prescribed zoloft in my annual when I complained that I was still low and had difficulty getting up of bed. we did not have the results yet and did not know I was hypo. we found out a week later when labs came in. and today she seemed to be blind to the fact that my depression and fatigue can be from the hypo, she didn't seem to be able to relate the two and seemed convinced it's just because of my life situation now, etc. it can be... but honestly I prefer to be treated for hypo first, and see if it improves. I hate the way ADs make me feel anyway.

I am a little afraid of starting syntroid for a few weeks only and then have it changed by the other doctor and make my body crazy in general... if Dr. Borenstein recommends Synthroid I will take it, I am not against it, I just think I want MY case to be evaluated and have the best drug that's right for me recommended, which obviously a more conservative doctor can't evaluate without being biased.

oh my, wish this was simpler! =)

[thethinme]

wow even in Wikipedia it's written that people who have problems with conversion from T4 to T3 should not take Levothyroxine. my doctor seems to be right though, if what's written is correct, that the natural hormones are "inconsistent" and has "potential differences between drug lots".
hmm I wonder how much this affects the lab results. do people on natural thyroid complain a lot about number differences here?

https://en.wikipedia.org/wiki/Thyroid_hormone#Formulations

Formulations

Today most patients are treated with levothyroxine, or a similar synthetic thyroid hormone.[9][10][11] However, natural thyroid hormone supplements from the dried thyroids of animals are still available.[11] Natural thyroid hormones have become less popular, due to evidence that varying hormone concentrations in the thyroids of animals before they are slaughtered leads to inconsistent potency and stability.[12][13]

Levothyroxine contains T4 only and is therefore largely ineffective for patients unable to convert T4 to T3.[14] These patients may choose to take natural thyroid hormone as it contains a mixture of T4 and T3,[11][15][16][17][18] or alternatively supplement with a synthetic T3 treatment.[19] In these cases, synthetic liothyronine is preferred due to the potential differences between drug lots of natural thyroid products. Also it would be counterintuitive to supplement with a T4/T3 combination if the patient cannot convert T4 to T3.

[rach7612]

I understand! That's why I def recomend you get a second opinion even if you feel like you're risking the relationship with your current doctor.

My former PCP would sometimes refer to "my depression" as if it were a separate issue. He actually never diagnosed me with depression (he prescribed it for insomnia) but at later appointments when he saw the AD in my chart he would explain some thyroid symptoms (which DID begin to include depression) as possibly being from my "clinical depression".  sigh...  

I liked him overall - and he was great in evaluating and then referring to a colleague for my husband's running injury, but I'm hesitant to go back, for similar reasons you probably understand. He was firm that only TSH had any meaning and the doctor I see now relies on a number of other tests, plus symptom reports.

[gimel]

For whatever it is worth, I take 3 grains of Armour daily.  I have noticed no indications of any problems with it.  I just take it and swallow, two grains in a.m. and one in the early afternoon.

As for any supposed inconsistency, I'd be very surprised if there is any statistically valid study that proves significant inconsistency.  I am much more suspicious that such information comes from the makers of T4 meds (the large pharmaceutical companies).  They are also the ones that do everything they can to promote T4 as the only thyroid med to use.  For every scientific study that claims there is no benefit to taking meds with T3 versus, T4 only, upon reading and analyzing them carefully, I always find errors in the design of their study, or fault with their conclusions.  And guess who supports most of the research done, and also supports the professional thyroid organizations that also promote T4?  You guessed it.  

Let me close by giving you a quote from a good thyroid doctor.  

"The thyroid gland produces both T4 and T3, so it makes sense to supply both hormones in adequate amounts to produce all the benefits of thyroid sufficiency. Providing a substantial amount of T3 assures that the patient will get some benefit, even from low doses. Armour® thyroid is dessicated porcine thyroid gland and it contains the prohormone, T4, and the active
hormone, T3. Fortunately, the pig's thyroid hormones are identical to ours. Dessicated porcine thyroid has a safety and efficacy track record spanning many decades. It is produced using the latest technologies to assure consistent T3 and T4 content in every tablet--it is held to the same
standards as synthetic T4 products. In addition, it provides other hormones and nutrients from the thyroid gland (calcitonin, T2, iodine, etc.). When we decide to take over the function of the thyroid gland by supplying thyroid hormone orally, it makes sense to replace everything that our
thyroid glands make. Dessicated thyroid is much higher in T3 than is our normal thyroidal production. This is advantageous as T4 to T3 conversion is poor with oral thyroid replacement and especially when the TSH is suppressed with therapy, as it often is. Every symptomatic person deserves a trial of gradually increasing doses of dessicated thyroid hormone to see if this will eliminate the symptoms without causing any signs or symptom of excess dosing."

[flyingfool]

I've also read that they synthetic T4 medications have had more recall's due to variation in potency of their pills than natural Dissected Thyroid. NDT has been used for almost 100 years without much recorded history.  Any variation must be basically insignificant.

NDT producers I would imagine out of simple fear of getting sued would monitor their potency levels with frequent testing. I would suspect that the amount of fillers (cellulose etc) they put into the lots are adjusted to help minimize dosage or potency variations.  It only makes sense.

You NEED a new Dr.  It doesn't matter how much you like your current Dr is she will keep you feeling ill.  You need T3.  NDT seems like a potentially excellent choice in your particular situation.

Alternatively you could slightly lower your T4 and add a pure T3 medication (cytomel).  You absolutely NEED to be tested for FT3 in general but is absolutely critical in my opinion if you start on any medication containing T3 whether NDT or adding Cytomel.

[thethinme]

thanks flyingfool (& also gimel and rach ;)

totally true - I can't continue with her if she keeps me feeling ill. that's the main point here. and although I don't know much yet, (new to all this) and am waiting for the labs I did with her yesterday (with FT3 but she said I didn't need RT3), my instinct is telling me that if I start on any medication without T3 in it or accompanying it, my symptoms won't improve.

I will post the lab results here as soon as I have it. really want to hear what you guys think. hope the lack of RT3 in my labs won't make it too hard for you guys to give an opinion.

I've been reading a lot on adrenal fatigue, yeast, Wilson's syndrome, etc... is it a general consensus on this board that these things are real or a "scam"?

[flyingfool]

RT3 is controversial and I'm trying to learn more about this.  There definately is some relation with the adrenals and fatigue. As long time Hypo the adrenals try to make up for this and at some point they are taxed and problems may occur.  Also the enzymes that do the work of the conversion of T4 into T3 and RT3 are also affected by the adrenals (cortisol) so they are all interconnected.

The two theory's are I believe Wilson believed that the RT3 plugs up the T3 receptors leaving no room for the FT3 to do the work. However the opposing thought on this is that people who are Hyper can also have very high RT3 levels.  So if this "plugging" theory was real, why wouldn't the people who are Hypo not have plugged receptors and not show Hyper signs?

This is why it is controversial.

It may really have to do with each individual's response or amount of the various enzymes that cause the conversion process.  If one person has an enzyme that causes an over production of RT3 OR an UNDER production of FT3 or some combination, the "cure" would be different and their symptoms would be different.

Bottom line I think is that if you get your FT4 to the middle f the range AND FT3 levels in the upper 1/3 of the range, AND then you still have symptoms that are unexplained, you have to start looking elsewhere.  And RT3 is one of those places.  But since your FT3 levels are unknown it is hard to determine just yet.

[thethinme]

yes I've been trying to read a lot on this as well. the problem is, the more you read, the less you're certain about just how low T3 levels originate. there seems to be a complete lack of research on this, perhaps because the drugs to treat thyroid issues are cheap and people don't really care to invest money on research. today I was reading that malnutrition or low-carb diets interfere with T3 conversion / production.

who knows what the real cause is. and I don't buy it that whenever you read about causes for Hypo they are all unrelated to nutrition etc. I bet it plays a good part on how things develop. I wish people were researching it more seriously.