Hypothyroidism and TSH Levels: Articles by Doctors

Reasons for "normal" test results with hypothyroidism symptoms

Purpose of this compilation

To show that using only the TSH (thyroid stimulating hormone) level as a diagnostic tool can miss many cases of hypothyroidism or result in undertreatment, and that if it is used, the current acceptable range is to be questioned.

1. Kenneth Blanchard, MD, PhD: "Hypothyroidism at Midlife"

Of the many standard teachings in this area [thyroid disorders], I believe the most common mistake physicians make in everyday practice is to "rule out" hypothyroidism on the basis of laboratory tests alone.

...In my practice, if the medical history and physical findings are highly suggestive of hypothyroidism, patients are treated with a therapeutic trial of thyroid 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, so that more individuals are being included in this diagnosis.

Accessed 2003/09/09 at <www.menopause-consultant.com/MDs/kennethblanchard.html>, but no longer online as of 2003/10/12.

2. Ward Dean, MD: "The Underdiagnosed Epidemic"

Although many people exhibit symptoms of hypothyroidism, they usually don't receive treatment for this condition if they have normal blood test readings. Their physicians often tell them that their symptoms are due to other causes or that their problem is "all in their head." I have known many patients who were referred to psychiatrists to treat their so-called "psychosomatic" problems. However, when they were later given thyroid replacement therapy, they improved dramatically.

Online at <http://freespace.virgin.net/smokey.quartz/underdiagnosed.html> (accessed 2003/09/09).

3. Barry J. Durrant-Peatfield, MB, BS, LRCP, MRCS: "Suggestions for an Approach to the Management of Thyroid Deficiency"

That the diagnosis is all too frequently missed...is commonly the result of an incomplete clinical appraisal in favour of the standard thyroid function tests. These tests are the real problem in diagnostic failure since there are inherent problems in interpreting blood levels of thyroxine and/or thyroid stimulating hormone (TSH) when blood levels may differ widely from tissue blood levels. Since the diagnosis may very properly, and easily, be made clinically, unreliable blood levels should NOT take precedence over clinical judgment.

Online at <http://personal.atl.bellsouth.net/w/u/wurmstei/Peatfield_Suggest.htm> (accessed 2003/09/09).

4. Michael Lam, MD: "Hypothyroidism"

The myth that an elevated TSH level...is required, as prerequisite for diagnosis of hypothyroidism must be dispelled. There is little doubt that an elevated TSH signifies [an] under active thyroid as the pituitary gland secretes TSH in response to a low thyroid hormone level. The real question is: how high a TSH is considered high?...

Many patients with TSH level of 2.0 (not 4.5) or more have classic symptoms and signs of hypothyroidism.

Online at <www.lammd.com/A3R_brief_in_doc_format/hypothyroidism.cfm> (accessed 2003/10/12).

5. Edward M. Lichten, MD: "Natural Treatment of Thyroid Deficiency Syndrome: Are You Thyroid Deficient?"

Doctors have been taught to look for elevated levels of TSH....

But, those of us researching thyroid disease have learned that these thyroid tests are just 'tests at best.' If the patient complains of a low body temperature on awakening (basal body temperature) then there is inadequate thyroid hormone no matter what the blood tests show. If there is fatigue, dry skin, brittle hair and weight gain on a low calorie diet, then there is insufficient thyroid hormone.

Online at <www.usdoctor.com/thyroid.htm> (accessed 2003/10/12).

6. Patrick Magovern, MB, BCh, BAO, LMCC, DObst (RCPI), MICGP, DipMedAcp, CAFCI, PGCertNut Medicine: "Hypothyroidism and Underactive Thyroid"

My view is that there is a sub-group of patients who despite having 'normal' T4 and TSH may well have a thyroid problem....If I am seriously considering a diagnosis of hypothyroidism in the presence of 'normal' T4 and TSH (both of which investigations will usually have been carried out long before the patient arrives at my door) the first thing I do is to look at free T3 and free T4 levels along with another TSH and usually at thyroid antibody levels.

Online at <www.integrativemedonline.com/pages/thyroid.html> (accessed 2003/09/09).

7. Joseph Mercola, DO: "Optimum Diagnosis and Treatment of Hypothyroidism With Free T3 and Free T4 Levels"

Most patients continue to have classic hypothyroid symptoms because excessive reliance is placed on the TSH. This test is a highly accurate measure of TSH but not of the height of thyroid hormone levels.

The basic problem that traditional medicine has with diagnosing hypothyroidism is the so called "normal range" of TSH is far too high: Many patients with [TSH levels] of greater than 1.5 (not 4.5) have classic symptoms and signs of hypothyroidism.

Online at <www.mercola.com/article/hypothyroid/diagnosis_comp.htm> (accessed 2003/09/09).

8. Joseph Mercola, DO: "Thyroid Disease Far More Widespread Than Originally Thought, 13 Million May Be At Risk"

...many people whose test results are dismissed as normal could continue to have symptoms of an underactive thyroid. Their moods, emotions, and overall well-being are affected by this imbalance, yet they are not receiving the care they need to get to the root of their problems....Even if the TSH level is in the lower segment of the normal range, a person may still be suffering from low-grade hypothyroidism.

Online at <www.mercola.com/2000/mar/5/thyroid%5Fupdate.htm> (accessed 2003/09/09).

9. Kenneth N. Woliner, MD, ABP: "Combined T4/T3 Therapy: Placebo or Tomato?"

...tailoring thyroid hormone therapy to normalize laboratory tests such as the TSH may not be the best approach to normalizing patient symptoms. Treating the wrong thing (the TSH versus the actual patient) can mislead the most well-intentioned of investigators. What if T4 is better at normalizing the TSH, but combination T4/T3 therapy is better at normalizing symptoms? What if the process of keeping the TSH "within normal limits" makes combination T4/T3 therapy less effective? It will be difficult to answer these as long as physicians hold onto the paradigm that the TSH test is infallible.

Online at <www.thyroid-info.com/articles/t4t3studies.htm> (accessed 2003/11/06).

B. Reasons for "normal" test results with hypothyroidism

1. John C. Lowe, MA, DC: "drlowe.com Most Recent Q&As"

[May 25, 2003] Patients may be suffering from hypothyroid symptoms due to autoimmune thyroid disease, and while thyroid function test results may be "normal," high antibody levels will reveal the disease. In fact, thyroid function test results may be "normal" for years despite patients having autoimmune thyroiditis the whole time.

[November 20, 2002] [Supplemental] T4 is highly effective at one thing: suppressing TSH secretion by the pituitary gland. T4 can suppress pituitary TSH secretion while leaving the metabolism of other tissues so slow that the patient continues to suffer from hypothyroid symptoms. Consequently, the doctor concludes (from the lowered TSH) that the patient is well; in the mean time, the patient suffers from continuing hypothyroid symptoms. Even worse, if the T4 dose is too low, the patient's symptoms may actually worsen.

Online at <www.drlowe.com/QandA/askdrlowe/mostrecent.htm> (accessed 2003/10/12).

2. John C. Lowe, MA, DC: "What Your Hypothyroid Patients Should Know about Synthroid"

The pituitary is highly sensitive to T4, and small dosages of T4 decrease the pituitary release of TSH, lowering it into the reference range. Tissues other than the pituitary are comparatively insensitive to small dosages of T4. Much higher dosages are required to normalize the metabolism of these other tissues....when T4 therapy normalizes TSH blood levels of many patients, it leaves their metabolism subnormal. These patients remain symptomatic despite their normal TSH levels.

Online at <www.chiroweb.com/archives/19/22/16.html> (accessed 2003/09/09).

3. Ralph J. Luciani, DO, MS, PhD, MD: "Hypothyroidism: An Undertreated Illness"

Most physicians rely solely on the TSH level to determine whether the thyroid gland is producing enough T3 and T4. This test can be exceedingly misleading if someone is taking thyroid hormone as therapy for low thyroid function, or if the quality of the T3 produced by the thyroid gland is not normal.

Online at <www.abqclinic.com/index.htm> (accessed 2003/09/09).

4. Richard Shames, MD, with Karilee Halo Shames, PhD, RN, HNC: "Avoiding the 'Tyranny of the Test': Finding Your Optimal Dose of Thyroid Medicine"

Many physicians are wrongly seeking to have their patients arrive at a TSH level that is in the mid-normal range. In actuality, the mid-normal range is a great target goal for most blood test results. However, it is not generally the most sensible goal of therapy for thyroid patients taking thyroid pills. Instead, for most thyroid sufferers, the goal of therapy should be to achieve a TSH near the low end of the normal range....

This immune attack [from thyroid antibodies] is often lessened when the thyroid gland is stimulated as little as possible by TSH. Recall that TSH means "thyroid STIMULATING hormone". Rather, the person generally does better when her body runs on thyroid hormone pills, allowing the gland to be in a mostly unstimulated, resting state.

Online at <www.thyroid-info.com/articles/shamestsh.htm> (accessed 2003/09/09).

5. Jacob Teitelbaum, MD: "Highly Effective Treatment of Fibromyalgia and Chronic Fatigue Syndrome: Results of a Placebo Controlled Study and How to Apply the Protocol"

As physicians, we are trained to interpret a low-normal TSH — that is, 0.5 to 0.95 as a confirmation of euthyroidism. The rules, however, are different with CFIDS/FMS [Chronic Fatigue and Immune Dysfunction Syndrome / Fibromyalgia Syndrome]. In this setting, hypothalamic hypothyroidism is common and the patient's TSH can be low, normal, or high.⁵ This is why I recommend an empiric therapeutic trial of thyroid-hormone treatment if the TSH and T4 are both low normal. Also, if sub-clinical hypothyroidism is missed, the patient's fibromyalgia simply will not resolve.

Online at <www.townsendletter.com/Oct_2002/fibromyalgia1002.htm> (accessed 2003/09/09).

6. Kenneth N. Woliner, MD, ABP: "Combined T4/T3 Therapy: Placebo or Tomato?"

There are many possible reasons for why patients may have resistance to thyroid hormone and exhibit symptoms despite having a normal TSH. Thyroid Peroxidase and Thyroglobulin Antibodies can interfere with the thyroid hormone function in the peripheral tissues while not affecting the suppressive effect of thyroid hormone on the TSH.¹⁴ The T3 receptor has 4 different gene variants with different types of receptors expressed in the brain than in the peripheral tissues.¹⁵ Lastly, there are some patients who have difficulty converting T4 to the active T3 hormone because of selenium deficiency or other conditions that interfere with human iodothyronine selenodeiodinases.¹⁶ In any of these cases, the TSH might appear normal despite clearly abnormal thyroid hormone function.

Online at <www.thyroid-info.com/articles/t4t3studies.htm> (accessed 2003/11/06).

7. Kenneth N. Woliner, MD, ABP: "Understanding Thyroid Lab Tests"

Despite being called 'ultra-sensitive,' the 'TSH' blood test has its limitations....It isn't accurate for everyone.

To prevent too many 'false positives,' too many people from being called 'Hypothyroid' when they are indeed normal, the lab makes a cutoff at some point. Unfortunately, their cutoff point cuts off many patients from getting proper treatment. We call them 'false negatives.'

There is no way to know how much of a negative effect those thyroid antibodies are having, we just know that they are there. The presence of thyroid antibodies throws off every thyroid test, including the TSH.

Online at <www.thyroid-info.com/articles/woliner.htm> (accessed 2003/09/09).