THE MANY MYTHS OF hypothyroidism
By Kenneth Blanchard, M.D.
Read the transcript of Dr. Kenneth Blanchard (coming soon!)
Thyroid disorders are extremely common and, in my opinion, are often undiagnosed or poorly treated due to a total reliance on laboratory testing and some-long standing but fundamentally flawed principles of treatment. Of the many standard teachings in this area, I believe the most common mistake physicians make in every day practice is to “rule out” hypothyroidism on the basis of laboratory tests .alone, especially use of the TSH (thyroid-stimulating hormone) test. There are few teachings in medicine more sacrosanct than an elevated TSH test as the “gold standard” for a diagnosis of hypothyroidism. I believe that there are millions of patients (mostly women) who would benefit from thyroid hormone but who are not treated because of results from this test.
A common story in popular magazines is “The Diagnosis your Doctor Will Probably Miss”. The story is that many individuals (mostly women) with symptoms like fatigue, depression, muscle aching, constipation, etc., see a physician who orders a T4 test and, on the basis of this, are told that hypothyroidism has been “ruled out”. The “smarter physician” also orders a TSH test because this is more sensitive and often reveals an abnormality even when T4 results are normal. While this scenario can happen, I believe it is far more common to find both T4 and TSH tests registering normal in the face of significant clinical hypothyroidism. In my practice, if the medical history and physical findings are highly suggestive of hypothyroidism, patients are treated with a therapeutic trial of the hormone and the results are overwhelmingly positive. As of early 2001, opinion in this field is still that the TSH test is absolute, although the upper limit of normal has been questioned, which is starting to include more individuals in this diagnosis.
Another common teaching that I believe to be fundamentally wrong is that all treatment should be done with 1OO% T4 hormone L-thyroxine (Synthroid, Levoxyl, etc.). The normal secretion of the thyroid gland contains small amounts of the T3 hormone (triiodothyronine) and I believe that giving some T3 is an important part of effective treatment for most individuals. The standard medical view is the T3 is unnecessary because T4 is converted to T3 in the body. But many patients taking the standard 100% T4 hormone report chronic fatigue, depression, menstrual abnormalities, fibromyalgia, irritable bowel syndrome (IBS), restless legs and other complaints, and these complaints are almost always better when some T3 is added. This particular teaching in medicine has been breached by a paper appearing in the New England Journal of Medicine in 1999 in which patients on standard 100% T4 were given some T3 and all patients felt better mentally and physically. The use of T3 has been standard in my practice since 1990 and I am quite sure it will be routine in the near future, although many physicians at this point still do not use T3 in addition to T4.
Thyroid hormone activity has a variety of complicated interactions with other hormones. For instance, I believe that thyroid hormone treatment is effective in PMS (premenstrual syndrome) despite the fact .that there are major studies in the literature which say this is not true. It is most likely that PMS fundamentally represents a deficiency of progesterone production prior to menstrual flow, but I believe that normalization of thyroid deficiency enables the woman to make more progesterone, thus relieving the symptoms. The woman in her mid-forties who is just starting to have irregular periods and notices some hot flashes, sweats and sleep disturbance at night can often be treated simply by optimal thyroid replacement, specifically including some T3. While such symptoms are commonly regarded as estrogen deficiency and will respond to the use of estrogen, I find that many such women have normalization of symptoms on proper thyroid therapy alone. The fundamental reason for this may well be that normalization of thyroid function enhances estrogen production by the ovaries themselves and by, the increased production of estrogen in fat tissue from adrenal hormone precursors.
If a woman at this age has frequent migraine headaches that are clearly related to the menstrual cycle (essentially premenstrual), these will often respond to balanced T4- T3 treatment, again possibly because of raising and/or stabilizing levels of estradiol. While clinical depression is not an integral part of menopause, there are many issues at this time of life that can cause emotional upset or depressed feelings. Again, use the T3 hormone in a physiologic way can be very helpful. Indeed, much of the current use ofT3 is in the hands of psychiatrists, who. use it as an adjunctive treatment for depression that is not responding well to standard antidepressants. Although this can be extremely effective, psychiatrists tend to use pharmacologic doses rather then physiologic doses. In other words, they exceed the amount needed to reproduce normal hormone balance. For virtually every purpose, a physiologic dose is desirable since excessive doses yield no additional benefits. I also disagree with the use of Armour thyroid by itself for the same reason, that it does not contain a physiologic balance of T4 to T3. The human thyroid produces roughly 95% T4 and 5% T3. Armour thyroid is an animal thyroid that contains 80% T4/20% T3. People who take Armour thyroid usually feel better for a short period of time because they were deficient in T3 but, after a period of time, the Armour thyroid will cause a T4-T3 imbalance at tissue level and a variety of undesired symptoms can then develop over time. One can get a better balance by giving some T4 with the Armour.
Some doctors are reluctant to prescribe (and some women reluctant to take) thyroid hormones in the belief that this will somehow increase the risk of osteoporosis. . I personally do not believe that there is good evidence for this, although my guess would be that excessive thyroid hormone does contribute to bone loss. Since there is no benefit in going above the normal physiologic levels of thyroid hormone, following the TSH result and clinically monitoring the patient will prevent overdose and resultant adverse effects.
Every organ system in the body is affected to some degree by treatment with thyroid hormone. I believe that the proper treatment of hypothyroidism with physiologic amount ofT4 and TI is critical in managing many complex medical problems at mid-life. If treatment is carefully monitored, there are no adverse effects. Management of hypothyroidism with T4 and TI is significantly more complicated than the standard 100% T4 therapy that has been used for the past 30 years or so. TI dosage must be monitored and altered precisely for optimum effect and this must be done by the use of compounded T3 time-release capsules. These are almost always made in units of 1OO capsules for practical reasons. Patients are initially seen every three months in order to adjust the dosage for the next prescription of T3. Another practice that will eventually become standard in this field is the adjustment of thyroid dosage for seasonal change, i.e., higher dosage in the colder weather and reduced dosage in the warmer weather.
Once dosage has been adjusted over 3 to 5 3-month visits and everything appears stable, visits are done at 6-7 month intervals. Patients must be ready to keep their appointments and take the medication exactly as directed. At the present time, there are many patients on a waiting list so that patients who drop out of the treatment plan fall back to the end of the list. Patients who have difficulty with the practices outlined above should stay with their current therapy.
By Power-Surge guest:
Kenneth Blanchard, M.D
Read the transcript of Dr. Kenneth Blanchard (coming soon!)
Read the Power Surge disclaimer
“I repeat over and over on the site that any complaints a woman has during menopause should not automatically be attributed to the process of menopause. That’s an important disclaimer. In short, before assuming, not that you are, that any of the things you’ve mentioned in your message are associated with peri or postmenopause, you should be checked by a doctor you respect, trust and admire — one who listens to you and doesn’t just hand you a prescription to resolve your problems.
That having been said, let me tell you that during those “worst” years of perimenopause, I experienced SO MANY strange, inexplicable and, oftentimes, bizarre feelings in my body, I conjured up notions of having a brain tumor, Parkinson’s Disease, Lupus, Fibromyalgia, Chronic Fatigue Syndrome, Menniere’s Disease, a heart condition, paralysis, a potential stroke, glaucoma — have I left anything out? And I say none of this with humor.
Perimenopause is the singularly most uncomfortable time of a woman’s life. I’ve posted many times about the internal shaking. It’s been my nemesis and continues this day to plague me.
I had the facial tremors and buzzing sensations on a daily basis. The feelings were so strange, they almost defy description. No one could see it, but it felt as though I were having a stroke. I’d often experience numbness in my face and on my left side at the same time — a red flag would go up because I thought I was definitely having a coronary situation or stroke. Facial ticks, facial tremors, an electrical buzzing in the back of my neck and various parts of my body drove me to distraction.
The good part about this story is that most of those symptoms DO go away once you’ve been without a period for about a year or two. Those feelings, in the majority of cases, are due to the hormonal fluctuations your body is experiencing. Imagine turning the thermostat in your house up and down a dozen or more times a day. Your house wouldn’t know whether to turn on the heat or air conditioning.
Our bodies become very sensitized during this process. Feelings are frightening — we can walk around for days feeling vertigo/dizziness and/or a ringing in the ears (tinnitus). There were days I had to grab onto a bannister or railing for fear that I was going to fall over. My legs still pose a problem — becoming weak and feeling as if they’re not going to support me any longer. Pain in the feet, calves, shoulders, joints aching and paining often to the point of bringing tears to your eyes.
My suggestion to you would be to get yourself a thorough examination by your doctor. Have a blood workup, sugar test, thyroid, hormone levels, total lipid / cholesterol profile. Insist on an Echo cardiogram, not just a cardiogram.
Our bodies are composed of so many different types of hormones — not just estrogen, progesterone and testosterone. Our bodies react to the constant ebb and flow of these hormone levels. Our central nervous system, nerve endings produce electrical impulses. Those electrical impulses are felt differently by every woman. Some women never feel them, while others are fraught with all sorts of strange sensations.
Once you’ve been given a clean bill of health by your doctor, the singularly most important thing you need to do during perimenopause is do relaxation techniques. Learn breathing exercises. Use the paper bag method (I call it “brown bagging it) I have described in many areas of the Web site and on these boards. I’ll provide a link to that at the end of this message.
Feed yourself affirmations every day that this, too, shall pass — that you are not dying — that although you feel as if your body is going to hell in a handbasket and you’re never going to survive this transition, you will. That, most importantly, there is nothing to be afraid of even though it feels at times like someone is holding a gun to your head and ready to pull the trigger.
Oh, Lord, would it were so that they’d find a way for women NOT to have to go through menopause. And, further, I am sick of hearing *some* people say that it’s all in our minds, or it’s our nerves, or if we had better things to do with our time, we wouldn’t think about it. I’ve never stopped being busy during this transition, but that didn’t ease the symptoms.
To those people, I say … until you’ve walked a mile in another person’s shoes, you can’t know what they are going through. Women in menopause aren’t hypochondriacs. I have to be dragged and feeling as if I’m not long for the world before I go to the doctor. Why? Because during perimenopause, I have learned… doctors don’t have answers to most of our questions other than to prescribe tranquilizers or anti-depressants or hormones…. and although some of these medications may help in the short term and to get you over the “hump” of perimenopause, most of them don’t work in the long term — or through the duration of perimenopause and it concerns me that there are no real long-term studies on these SSRI’s (anti-depressants).
If you feel you need to take something to get through this process, absolutely take it. Don’t make a martyr or yourself. However, remember, these medications only temporarily mask the symptoms. Learning ways to relax and cope with the changes you’re undergoing works far better over the long haul than anything else.
I have provided various relaxation and breathing techniques on this, the anxiety and the panic boards that can be tremendously helpful. The one I’d recommend is something I refer to as “brown bagging it.” It’s in various places of the site, but I’ll give you a link to my article after I’ve finished this message.
It has been my experience and I believe that of many other women who’ve passed through Power Surge over the seven years it’s been online that once you are in the throes of perimenopause, for about one or two years — perhaps a third (but not often), you will experience every conceivable symptom on the list of 34+ symptoms (* see below). I went through severe migraines and was *never* a headache person in my life. They lasted about a year or two – on and off, not every day, but they eventually stopped. I went through the facial tremors, buzzing experience as though I’d had my finger in an electrical socket. The migraines and severe palpitations, hot flashes, night sweats, crying and severe mood swings, horrific depression so much so that at times I would put my head on the pillow at night and whisper to God, “Please, if I have to feel this way tomorrow, let me not wake up.”
Those feelings — horrible as they are — don’t generally last for the full transitional period. They usually occur during the worst phase of perimenopause and only last about a year or two. That doesn’t mean you won’t ever experience them again in some milder form, but the severity and frequency will certainly decrease — and hormone therapy isn’t the magical answer. Many women using hormones still experience many of these symptoms.
Just remember that as long as you’ve been given the okay regarding your health by your health care provider, these are symptoms of menopause and, yes, I say symptoms. People have said to me, “Why do you call them symptoms? Menopause isn’t an illness.”
I tell them that I know menopause isn’t technically an illness, but seeing as how I have never felt worse in my life, I will not say that I am well.
I get very passionate about this subject and one of the reasons I’ve kept Power Surge an independent entity is because it allows me the opportunity to express myself without wondering who’s going to pay the bills if I tell the truth about the medical profession and some of the techniques of the pharmaceutical companies.
I will never get rich from Power Surge, but knowing that this community has helped so many women understand what they’re going through without just dumping medical abstracts at them and pushing pills on them has been the most gratifying and “freeing” experience of my life.
Finally, let me add my favorite words — THIS, TOO, SHALL PASS. Believe me, I thought in my heart I would never, ever survive perimenopause, but the internal shaking eases up even though it’s hell while you’re going through it. The palps will stop as well. It just takes time and a LOT of patience!
Be good to your body and it will return the favor in spades.
For the “brown bagging it” reference and many other helpful suggestions, check out the Power Surge Menopause Survival Tips article.
…and the ever useful…
* The 34+ Signs of Menopause
Dearest”
Thyroid disorders are extremely common and, in my opinion, are often undiagnosed or poorly treated due to a total reliance on laboratory testing and some-long standing but fundamentally flawed principles of treatment. Of the many standard teachings in this area, I believe the most common mistake physicians make in every day practice is to “rule out” hypothyroidism on the basis of laboratory tests .alone, especially use of the TSH (thyroid-stimulating hormone) test. There are few teachings in medicine more sacrosanct than an elevated TSH test as the “gold standard” for a diagnosis of hypothyroidism. I believe that there are millions of patients (mostly women) who would benefit from thyroid hormone but who are not treated because of results from this test.
Power Surge 