Aa
"Normal values"
I feel that one of the reasons that many patients do not get the proper treatment for Hashimoto's thyroiditis, is too wide limits for TSH. As a non-American - what is the accepted present range of normal TSH-values in untreated patients? And - what is accepted as a non-pathological level for anti-TPO?
You are very welcome. I just wondered where you are located, that you are seeing improved results in treating patients. And are you speaking of hypothyroid patients specifically, or patients in general?
My ears have been fluttering! Thank you very much for taking the time to make this issue clearer - much clearer.
I work as a histopathologist and just wonder some times what the clinicians have been up to. Now during the last years however they are much stricter in taking the whole picture, as you describe it, into consideration and the flock of pleased patients is becoming larger.
Again thank you so much!
Eivind Carlsen
I work as a histopathologist and just wonder some times what the clinicians have been up to. Now during the last years however they are much stricter in taking the whole picture, as you describe it, into consideration and the flock of pleased patients is becoming larger.
Again thank you so much!
Eivind Carlsen
Almost 10 years ago the American Association of Endocrinology recommended that the reference range for TSH should be revised from .5 - 5.0 down to .3 - 3.0. After all this time the new range is still largely ignored by most labs and doctors. The range was initially established from the entire data base of test results. Then they made an assumption that about 2.5% of patients were hypo and 2.5% hyper. The upper and lower limits of the reference range were set based on those assumptions.
Finally in 2002 the AACE finally acknowledged that there were lots more patients that were hypo, beyond their 2.5% assumption. So they went back and purged from the data base, test data from patients who were suspect as having thyroid problems. Then they recalculated and published their new reference range.
Unfortunately, this was somewhat of an academic exercise anyway, because TSH is a pituitary hormone that is supposed to reflect the levels of the actual thyroid hormones, but cannot be shown to correlate well with either Free T3 or Free T4, much less with symptoms, which should be the most important concern. In reality TSH is affected by so many variables, that it is inadequate as a diagnostic by which to treat a thyroid patient. At best TSH is an indicator to be considered along with more important indicators such as symptoms, and also levels of the biologically active thyroid hormones, Free T3 and Free T4. Due to the effect of thyroid meds on TSH, it becomes even less useful as an indicator after starting on thyroid meds.
A good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels. Symptom relief should be all important, not just test results. You can get some good insight into clinical treatment from this letter written by a good thyroid doctor for patients that he sometimes consults with from a distance.
http://hormonerestoration.com/files/ThyroidPMD.pdf
In the letter note the statement, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."
Since I mentioned the importance of Free T3 and Free T4, I should also point out that when doctors are willing to test beyond TSH, they then frequently use "Reference Range Endocrinology", by which they will tell you that any thyroid test that falls within the range is adequate for you. This is incorrect. The ranges for Free T3 and Free T4 were established in the same way as for TSH. These ranges have not been corrected, like done for TSH. Having some training in statistical analysis, I have previously said that if the data bases for these two tests were similarly purged of suspect patient data, the new ranges would be more like the upper half of the current ranges.
That is why we hear from so many members with hypo symptoms, but their doctors tell them that their Free T3 and Free T4 are within the range, so it could not be a thyroid problem. Wrong. Many of our members, myself included, report that symptom relief for them required that Free T3 was adjusted into the upper third of the range and free t4 adjusted to around the middle of its range.
The ranges for FT3 and FT4 would not be such a big issue if doctors would use them as a guideline within which to adjust levels as necessary to relieve symptoms. Unfortunately again, this is not the case. In support of this, there are studies that show that Free T3 correlated best with hypo symptoms, while Free T4 and TSH did not correlate. Here is a link to one study.
http://www.ingentaconnect.com/content/routledg/cjne/2000/00000010/00000002/art00002
As for the TPO ab test, I know of no reason to question the range used for that test. Usually if a patient has Hashimoto's, it shows up in either the TPO ab or TG ab tests, compared to their reference ranges. Although this primary hypothyroidism is diagnosed most frequently, there are also many patients with undiagnosed secondary hypothyroidism, mainly because of over reliance on the TSH test and "Reference Range Endocrinology".
Sorry if I bent your ear too much, but those are good questions and deserved more than just a short response.
Finally in 2002 the AACE finally acknowledged that there were lots more patients that were hypo, beyond their 2.5% assumption. So they went back and purged from the data base, test data from patients who were suspect as having thyroid problems. Then they recalculated and published their new reference range.
Unfortunately, this was somewhat of an academic exercise anyway, because TSH is a pituitary hormone that is supposed to reflect the levels of the actual thyroid hormones, but cannot be shown to correlate well with either Free T3 or Free T4, much less with symptoms, which should be the most important concern. In reality TSH is affected by so many variables, that it is inadequate as a diagnostic by which to treat a thyroid patient. At best TSH is an indicator to be considered along with more important indicators such as symptoms, and also levels of the biologically active thyroid hormones, Free T3 and Free T4. Due to the effect of thyroid meds on TSH, it becomes even less useful as an indicator after starting on thyroid meds.
A good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels. Symptom relief should be all important, not just test results. You can get some good insight into clinical treatment from this letter written by a good thyroid doctor for patients that he sometimes consults with from a distance.
http://hormonerestoration.com/files/ThyroidPMD.pdf
In the letter note the statement, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."
Since I mentioned the importance of Free T3 and Free T4, I should also point out that when doctors are willing to test beyond TSH, they then frequently use "Reference Range Endocrinology", by which they will tell you that any thyroid test that falls within the range is adequate for you. This is incorrect. The ranges for Free T3 and Free T4 were established in the same way as for TSH. These ranges have not been corrected, like done for TSH. Having some training in statistical analysis, I have previously said that if the data bases for these two tests were similarly purged of suspect patient data, the new ranges would be more like the upper half of the current ranges.
That is why we hear from so many members with hypo symptoms, but their doctors tell them that their Free T3 and Free T4 are within the range, so it could not be a thyroid problem. Wrong. Many of our members, myself included, report that symptom relief for them required that Free T3 was adjusted into the upper third of the range and free t4 adjusted to around the middle of its range.
The ranges for FT3 and FT4 would not be such a big issue if doctors would use them as a guideline within which to adjust levels as necessary to relieve symptoms. Unfortunately again, this is not the case. In support of this, there are studies that show that Free T3 correlated best with hypo symptoms, while Free T4 and TSH did not correlate. Here is a link to one study.
http://www.ingentaconnect.com/content/routledg/cjne/2000/00000010/00000002/art00002
As for the TPO ab test, I know of no reason to question the range used for that test. Usually if a patient has Hashimoto's, it shows up in either the TPO ab or TG ab tests, compared to their reference ranges. Although this primary hypothyroidism is diagnosed most frequently, there are also many patients with undiagnosed secondary hypothyroidism, mainly because of over reliance on the TSH test and "Reference Range Endocrinology".
Sorry if I bent your ear too much, but those are good questions and deserved more than just a short response.
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