As a General Practice physician who has
been providing thyroid care for over 30 years, I am
continually surprised by my patients' stories of their
experience with endocrinologists. Many times patients tells me
that they had just begun to feel slightly better on thyroid
medicine when their specialist said, "This is it. We can not
increase any further. Your tests tell me you're presently at
just the right dose." Evidently they had started working with
this doctor right around the time of the low thyroid
diagnosis. They had begun a low dose of maybe 75mcg. of
Synthroid, and were beginning to feel better than rock bottom,
but not great. Now, some years later, they are still feeling
only partially back to their original full self.
They keep telling this to their specialist, who then keeps
responding, "we can't increase the dose any further. Your
tests are fine now."
When confronted with what may be unfair tyranny of the test, I
generally tell my patients they have several options. Any one
of their choices might boost them up from their present
partial recovery to perhaps 90 or 100% of their prior full
function.
These options include:
- Controlled trial of more thyroxine
- Switching brands of thyroxine.
- Adding some T-3 (Cytomel) to the
thyroxine regime.
- Switching to Thyrolar (brand name
mix of T-3/ T-4).
- Trying animal thyroid (Armour or
Nature-throid).
- Boosting any medication with
natural therapies.
This present discussion will focus
only on option #1.
First of all, 75 or 100 mcg. of thyroxine are a modest dosage
for most adults. A well-known professor of endocrinology is
convinced that a good "rule of thumb" eventual dose for most
of his patients is one microgram per pound of body weight. For
instance, a woman who weighs 137 pounds might do well with 137
mcg. of thyroxine (a few brands other than Synthroid are
available in pills at this exact dose). A man who weighs 175
pounds might do well with the 175 mcg. pill. Before
acquiescing to your doctor's test-result edict of final dose,
you might want to ask for a short clinical trial of the
medical center professor's protocol of "one mcg per pound of
body weight". Keep in mind that the rule of thumb dosage is
only a general initial guide, and that it might not apply well
in cases of obesity.
If your doctor says "no, I realize you would like more
medicine, but I don't think that is wise considering your test
results," then you might want to look at your tests very
carefully. Most likely your doctor is talking about the level
of TSH (thyroid stimulating hormone). 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. Let us explain why.
The "normal" range of the TSH test generally runs from 0. 4 –
5.2. When I consult with people who call me from different
parts of the country, I suggest to them a therapeutic target
range of 0.3 – 0.5. This is at the low end of the test's
normal range, not the mid-normal. The reason I do this is that
most people who are suffering from low thyroid are ill because
of antibodies from the immune system wrongly attacking the
thyroid gland, and thereby compromising its function.
This immune attack 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. The gland thereby receives a well-deserved vacation, in
order to heal and repair the immune system damage that caused
the illness in the first place.
Sometimes, both patients and doctors are concerned about this
maneuver -- called "TSH suppression" -- where the TSH level is
suppressed to just at or just below the lower end of the
normal range. They evidently feel that giving the thyroid
gland a healing vacation will cause harm or result in the
gland being irreversibly turned off. After working in this way
for a great many years, consulting for with numerous
university specialists, and combing the relevant medical
literature, I am totally convinced that thyroid glands are not
at all injured by this maneuver.
If you haven't yet begun to feel as well as you would like,
then you get to look at this TSH issue very carefully. If the
dose of thyroxine you are currently taking (Synthroid, Levoxyl,
Unithroid, Levothroid, L-thyroxine, Levothyroxine) has not
resulted in a TSH that is down to the lower end of the normal
range, then you may not be taking enough medicine. Neither I -
nor any other doctor - can promise you that simply taking an
amount of thyroxine to reach a TSH of 0.3, or 0.4, or 0.5 will
give you full and lasting resolution of your thyroid
difficulties. But I can tell you this – it is the next thing
to try on your journey to full recovery. You may well be
getting short-changed due to an under-informed or overly
cautious medical provider.
Just last week I provided phone advice follow up appointments
for four or five people from different parts of the county
with this exact TSH issue. It is evidently quite common. I had
advised them each, in earlier telephone consultations, to tell
their practitioners that medical center endocrinologists
commonly aim for a TSH of 0.2 before saying "That's enough
thyroxine. More will not be a good idea". They know that
insisting on a TSH well within the normal range often condemns
patients to less than full recovery of function and enjoyment
of life. All of the patients I spoke with in follow-up were
pleased to report an improvement. The additional increase in
their thyroxine dose resulted in a lower TSH level and also
resulted in less symptoms.
One patient, who lives in St. Louis, had previously said his
general practitioner was concerned about the possible adverse
effect of thyroxine on the heart. When I asked the patient if
the doctor had now found anything about heart function that
was amiss, he said, "no, she did not." She had reported to the
patient that the pulse, blood pressure, heart sounds, and
cholesterol levels were actually all improved on the higher
level of thyroxine that resulted in the lowered level of TSH.
Nevertheless, she was still concerned about possible heart
side effects. I was able to put both the patient and his
doctor at ease with a quick call to the doctor. I reassured
her that without any symptoms on the part of the patient or
clinical signs able to be spotted by the doctor, the
likelihood of adverse cardiac problems due to a lowered TSH
was negligible. Only those people with a known history of
heart arrhythmia, mainly atrial fibrillation, need to be so
concerned.
Another phone consult patient was from Chicago. There, a
doctor had told her that he did not want her TSH to go below
1.0 because he was concerned about osteoporosis from too much
thyroxine.
First of all, as we detailed in our book Thyroid Power, this
possible adverse effect of thyroxine is not really an issue
unless the TSH is suppressed to a level that is below 0.1.
(The laboratory results of a TSH that is clearly too low are
often shown on lab reports as "less than 0.1", or 0.06, or
"less than 0.01"). There is a world of difference between a
TSH going below 1.0, which is quite okay to try, and going
below 0.1, which should be discouraged.
Secondly, this factor is more of an issue in people who have
osteoporosis in their family lineage, or who are already
showing signs of osteoporosis themselves. Keep in mind,
however, that many people who are being treated for low
thyroid have early signs of osteoporosis BECAUSE OF UNTREATED
OR LESS THAN FULLY-TREATED HYPOTHYROISISM. These two
conditions are known to cause osteoporosis, worldwide they
likely have in the past caused much more loss of bone density
than has over-treatment with thyroid hormone. Appropriate
doses of thyroid medication are not harmful to the bones of
hypothyroid individuals.
The benefits of a full dose of thyroxine are enormous. A full
dose could possibly lead to a full recovery. Many people are
being prescribed less than a full dose, and are told to be
satisfied with it. If you are going to take thyroxine, and
just thyroxine alone, at least take an optimal amount of it.
The actual proper amount of medicine varies tremendously from
patient to patient. Also, keep in mind that taking thyroxine
alone is not always your optimal choice.
You deserve to live the fullest life possible. Knowledge is
power. We wish you full recovery and empowerment on your
thyroid journey! Next article we will expand upon the topic of
how to obtain additional benefit in symptom relief by simply
switching brands (such as replacing Synthroid with Levoxyl).
NOTE: Also in the Thyroid Power
book, we have a special section that can help you enormously
in getting the dose you need from your health provider. It
is called "Show This To Your Doctor". In addition to this
support, we have another powerful suggestion for you. In
asking your practitioner to aim for a low-normal TSH, you
might have better luck in if you write up your own
disclaimer ahead of time. A simple statement, inserted into
your medical chart, could go as follows: "I understand that
Dr. _________ has advised me that the amount of thyroxine on
which I feel most comfortable results in a TSH level that is
considered less than optimal by the doctor. I hereby release
and hold harmless the doctor for allowing me a clinical
trial of this dose. The pro and con have been explained to
me."
Keep in mind that this high a dose of thyroxine, and this
low a TSH result may not be needed forever. Optimal thyroid
dosing is an ongoing process. The ideal level is always a
moving target, depending upon many factors. These may
include age, constitution, illness, stress, pregnancy,
menopause, other life crises, and – in addition - how long
you have been on thyroid medicine.
An article as it appears on
Mary Shomon's website
Thyroid-Info.
http://thyroid-info.com/articles/shamestsh.htm |
