RE: Re: CASE STUDY - WANTED URGENTLY Sheila

[Guest guest]

I don't have to sign up - it just opens up for me to read.

However, if you are having difficulties, I have copied it and pasted it below -

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Whose Thyroid Hormone Replacement is it Anyway?

A.

P. Weetman

Authors

and Disclosures

Posted: 03/13/2006; Clin

Endocrinol. 2006;64(3):231-233. © 2006 Blackwell

Publishing

As an adult she had

her organs removed one by one. Now she is a mere shell with symptoms where her

organs used to be. - O. Abbot (1902-43)

Nothing seems more

straightforward than treatment of hypothyroidism. We have robust assays to

diagnose the condition and an effective replacement in the form of synthetic

thyroxine. However, the field appears to be in some turmoil and clinical

endocrinologists are under increasing pressure from disaffected patients who

believe their symptoms indicate hypothyroidism despite normal thyroid function

tests. Consider the following. A group of patients has just lodged a petition

with a Member of Parliament and the UK General Medical Council, as 'a formal

complaint against the clinical practice of the majority of the medical profession

with regard to the diagnosis and management of hypothyroidism on four counts:

1.

Over-reliance

on thyroid blood tests and a total lack of reliance on signs, symptoms, history

of the patient and a clinical appraisal.

2.

The

emotional abuse and blatant disregard by the majority of general practitioners

and endocrinologists over the suffering experienced by untreated/incorrectly

treated thyroid patients and their lack of compassion over the fate of these

patients.

3.

Stubbornness

of general practitioners and endocrinologists to treat patients suffering from

hypothyroidism with a level of medication that returns the patient to optimum

health. In addition the unwillingness to prescribe alternate thyroid treatment

for patients on individual grounds... such as Armour thyroid.

4.

The

ongoing reluctance to encourage debate or further research on hypothyroidism.'

This has led the

Member of Parliament to take the matter up with the Royal College of Physicians

of London.

Another patient

group, Thyroid Patient Advocacy (www.tpa-uk.org.uk), currently lists on its

website the campaigns it is mounting, which include pressing another Member of

Parliament to table an early day motion calling on the Government 'to raise

awareness of hypothyroidism and the dangers of misdiagnosing an under-active

thyroid and to promote the use of a range of treatments including thyroxine to

address the current inadequacy of testing, diagnosis and treatment of the

condition.' The same web-site makes the startling assertion that approximately

25% of the total population of the UK suffers from hypothyroidism and also

supports the wider use of Armour thyroid extract, as well as claiming that

diagnosis of hypothyroidism by blood tests alone is insufficient. This is far

from a UK phenomenon, and much of the impetus for the views of such patient

organizations derives originally from Broda in the USA (see www.brodabarnes.org).

Fundamental to the

diagnosis of hypothyroidism according to the 's approach is the basal

body temperature, and treatment is recommended with 'natural desiccated thyroid

hormone', rather than 'synthetic thyroid hormones'. Readers' reviews of

and Galton's still widely read 1976 book Hypothyroidism: The Unsuspected

Illness include the following quotations: 'Get the book there has never

been anything printed that will help you more' and 'The only reason the medical

profession won't use this theory is money' (www.amazon.co.uk).

Moreover, such views

on the futility of laboratory testing and the need for empirical, natural

hormone replacement are not confined to the thyroid field. Some medical

practitioners advocate the use of a variety of natural and synthetic steroids

for the treatment of mild to moderate adrenal insufficiency which is alleged to

coexist frequently with clinically diagnosed hypothyroidism: 'It is...

perfectly practical and reasonable, to establish the diagnosis (of

hypoadrenalism) on clinical grounds, and because the therapy given is of very

low - physiological - doses, there is no possible risk to the patient, however

long it is needed' (Durrant-Peatfield, quoted from www.tpa-uk.org.uk).

Why do some patients

feel so dissatisfied with and so mistrustful of standard medical advice? There

are two broad reasons. The first is experienced in virtually all specialities and

stems from the fact that we are practicing in the age of postmodern medicine.[1] A cardinal feature

of postmodernism is the derogation of objective facts which are the defining

characteristic of science and the replacement of scientific certainty with the

view that reality can have multiple meanings. Access to information by patients

has increased vastly due to the Internet, whilst changes in health care have

shifted the emphasis away from healing and towards rapid diagnosis and

treatment. Patients perceive symptoms and want an explanation for them, but in

the rush to satisfy targets most doctors have little time to understand both

the patient and their experiences which have led, in a more complex fashion

than we generally acknowledge, to the consultation in the first place.[2]

The majority of

patients who demand thyroid hormone treatment for multiple symptoms, despite

normal thyroid function tests, have functional somatoform disorders, which in

the postmodern world can understandably be misdiagnosed as hypothyroidism. Yet

we inside medicine are not even sure how best to classify somatoform disorders,

let alone explain them to patients, and this broad diagnostic label has many

shortcomings. In particular (i) the terminology is unacceptable to patients;

(ii) the classification supports the Cartesian dualism that somatic symptoms

can be either 'organic' or 'psychogenic'; (iii) these disorders do not form a

single category, although some have argued that there is a significant overlap

which may well have therapeutic if not aetiological relevance; (iv) such a

diagnosis is socially and culturally dependent and (v) there is considerable

unreliability and ambiguity in defining the diagnosis.[3] A paradigm shift in

our categorization of somatoform disorders has been proposed recently, with a

recommendation to return to a far less dualistic approach.[4] This shift is based

on evidence that functional neurological changes can be identified in some

patients with somatoform disorders, and there is therefore a compelling case

for a different approach using a 'psychologically augmented medical

consultation'.

Whilst such analyses

are undoubtedly changing our perception of patients' symptoms and ways of

tackling them, progress is slow and not helped by the rise of 'healthism',

which has been characterized by the following features: 'high health awareness

and expectations, information seeking, self-reflection, distrust of doctors and

scientists, healthy and often alternative lifestyle choices, and a tendency to

explain illness in terms of folk models of invisible germ-like agents and

malevolent science.'[5] Although this has

been most frequently described in healthy and well-informed middle-class

individuals who present with a variety of inexplicable symptoms, it is clear

that healthism is affecting the whole spectrum of patients. The advance of

healthism has its roots in postmodernism and accounts for the increasing number

of bilaterally unsatisfactory consultations with patients who have an

unshakeable self-diagnosis or a demand for a 'natural' rather than 'synthetic'

treatment.

Many high-profile,

alleged health hazards such as the MMR vaccine have engendered considerable

fear and an ever-increasing distrust of science as a result of the healthism

phenomenon. The scale of the problem has been eloquently described by Marcia

Angell in her 1996 Shattuck Lecture on the purported health risks of silicone

breast implants.[6] There is also a

striking parallel between that saga and the present one of thyroid hormone

replacement in euthyroid individuals. Women with implants who claimed a

connection with connective tissue disease sought to prove their case by stating

'we are the evidence'. As Angell observed, this argument seemed 'reasonable to

many people although... logically meaningless', and it distils what the Broda

school of thought really is: if you have the symptoms of hypothyroidism,

you must, reasonably, have that disease.

The second, more

specific reason for the unhappiness of these patients is that any innate sense

of disbelief in science has been heightened by the lack of consensus amongst

endocrinologists, particularly with regard to the diagnosis of subclinical

hypothyroidism, its importance, and the need for treatment. A healthy debate on

whether subclinical hypothyroidism is mild thyroid failure and should be treated[7,8] appears welcome but

can readily be understood to create anxiety or confusion in some patients with

a TSH of, say, 8 mU/l who access these papers from the Web. Recent attempts to

produce a comprehensive scientific review and guidelines for the diagnosis and

management of subclinical thyroid disease[9] provoked a

dissenting set of comments from members of the same organizations that had

sponsored the original guidelines.[10] In turn, this

spawned an editorial wondering whether we could achieve a consensus about the

consensus![11] The difficulty we

face as clinicians in formulating guidelines, or more commonly in judging how

to apply them to our own practice, stems from our individual perceptions of

benefit and risk. For instance, in the guidelines just mentioned, treatment of

subclinial hypothyroidism with a TSH level below 10 mU/l was not recommended,

largely based on the concern that more patients than we might suspect would end

up with a suppressed TSH as a result of over-treatment, and this risk was

deemed unacceptable in the face of so little evidence of benefit.[12] If one's own

practice is such that the rates of over-treatment are very low, thus minimizing

any risk, then the balance would shift, in my view at least, towards treatment

in a symptomatic patient with a TSH that is elevated but below 10 mU/l.

Another concern for

patients has been the recent debate over narrowing the TSH reference range.[13,14] As with the

treatment of subclinical hypothyroidism, this is a complex area, demanding a

sophisticated knowledge of laboratory medicine and clinical endocrinology to

interpret and translate the current state of play into everyday clinical

practice. In assessing these arguments, however, we should not be surprised

that patients question our reliance on TSH levels when they have read such

publications themselves.

What can be done?

Obviously the scientific debate must continue and will undoubtedly lead to more

definitive research that will answer these questions, although such studies

will be hugely demanding and difficult to fund. Two papers published in

November last year are examples of the further information we are now accruing

on the risks of subclinical hypothyroidism and provide reassurance that

subjects with TSH levels in the range of 2-7 mU/l show no increased incidence

of cardiovascular disease over a 4- to 20-year follow-up period, in turn

indicating that mild subclinical hypothyroidism does not require treatment, at

least with regard to any concern over cardiovascular risk.[15,16] In addition, we

must communicate areas of uncertainty in an open manner which allows for the

range of educational, social and cultural differences that can exist between

doctor and patient.

Dealing with someone

who has many hypothyroid symptoms yet clearly normal thyroid function tests may

be challenging, but physicians can do more than at present. Most patients with

functional somatoform disorders are given explanations which are experienced as

either a rejection of the reality of the symptoms or a simple collusion and

acquiescence to the patient's own biomedical theory.[17] Both types of

explanation are, not surprisingly, perceived to be unsatisfactory, whereas

empowering explanations can improve patients' well-being directly and can

reduce the demands they make on health services. Communication lies at the

heart of managing patients whose health problems cannot be explained and the

focus should be on the patient's concerns, the relief of symptoms and the

avoidance of alienation.[18] Finally, we should

retain our own sense of perspective, scepticism and humility. As functional

somatoform disorders are dissected further, new ways of managing these common

and troublesome disorders will undoubtedly become established. In the meantime

we must avoid endocrinological collusion as a strategy, which in turn requires

the avoidance of thyroid hormone treatment of euthyroid individuals, a robust

defence of the biochemical basis for the diagnosis of hypothyroidism and

institution of replacement with synthetic thyroxine as the standard, rather

than Armour thyroid extract.

CLICK HERE for subscription information about this journal.

References

http://www.medscape.com/viewarticle/524955

Is ther any other way of seeing this without signing up? i know its free.

Luv Ali

[Guest guest]

>>>That is awful! So basically what that says is anyone who has symptoms and signs of hypothyroidism, but whose blood results fall within the range designated 'normal' is making it up. <<<

In my case they didn't do sufficient tests. The TSH was within normal range and the T4 was in range albeit right at the bottom. So as far as they were concerned I was having sufficient thyroxine and all my devastating symptoms and SIGNS (how do you make your hair fall out, eyes go puffy, etc. etc. by imagination), must all be due to depression or all in my mind.

However, my samataform disorder has been cured, by having T3 added to the thyroxine. So I say OK my thyroid is fine so don't treat that, but treat my samataform disorder with what has been proven to cure it - T3 lol.

Lilian

[Guest guest]

This is what we are up against unfortunately, and the two big

words that stands out are ARROGANCE and IGNORANCE. Doctors did fine reaching a

diagnosis of hypothyroidism long before the invention of blood tests. They knew

what to look for in their patients, gave them a thorough clinical examination,

tested their cholesterol, took their temperature, tested their Achilles tendon

reflex etc.

Luv - Sheila

I don't think I've ever read anything so disgustingly arrogant in all my life!

I really hope that the press take this up and there is some real pressure on

the medical establishment to start listening to patients. The way we are

treated at the moment makes me so angry. We deserve so much better.

Georgie

---

_

[Guest guest]

Hi Sheila,

Unless I'm mistaken, there's no positive guidance at all, it just trashes other peoples work without offering anything himself - apart from be kind and humour the poor dear souls. What are his qualifications? This offers nothing to patient or GP - senile old f..t.

Love

Jane

Subject: RE: Re: CASE STUDY - WANTED URGENTLY Sheila

I don't have to sign up - it just opens up for me to read. However, if you are having difficulties, I have copied it and pasted it below - enjoy!

Whose Thyroid Hormone Replacement is it Anyway?

A. P. Weetman

Authors and Disclosures

Posted: 03/13/2006; Clin Endocrinol. 2006;64(3):231-233. © 2006 Blackwell Publishing

As an adult she had her organs removed one by one. Now she is a mere shell with symptoms where her organs used to be. - O. Abbot (1902-id.

4. The ongoing reluctance to encourage debate or further research on hypothyroidism.'

rather than Armour thyroid extract.

CLICK HERE for subscription information about this journal.

References

http://www.medscape.com/viewarticle/524955Is ther any other way of seeing this without signing up? i know its free.Luv Ali

[Guest guest]

I think he is particularly mad at TPA for campaigning against

'his' guidelines/guidance/statements because he knows we are after him and others

who seem hell bent on stopping the majority of us from getting a proper

diagnosis and being given a choice of thyroid hormone replacement. He tries to

waffle us with science. You should have seen Shomon's web site at the time

this article was written - you could almost smell the smoke coming from it.

Wait until our article comes out in the paper very shortly - I

guess that will be a cause of a further article written by him.

Luv - Sheila

Hi

Sheila,

Unless

I'm mistaken, there's no positive guidance at all, it just trashes other

peoples work without offering anything himself - apart from be kind and humour

the poor dear souls. What are his qualifications? This offers

nothing to patient or GP - senile old f..t.

Love

Jane

Subject: RE: Re: CASE STUDY

- WANTED URGENTLY Sheila

I don't have to sign up - it just opens

up for me to read. However, if you are having difficulties, I have copied it

and pasted it below - enjoy!

Whose

Thyroid Hormone Replacement is it Anyway?

A. P.

Weetman

Authors

and Disclosures

Posted:

03/13/2006; Clin

Endocrinol. 2006;64(3):231-233. © 2006 Blackwell

Publishing

As an adult she had her organs

removed one by one. Now she is a mere shell with symptoms where her organs used

to be. - O. Abbot (1902-id.

4. The

ongoing reluctance to encourage debate or further research on hypothyroidism.'

rather than Armour thyroid

extract.

CLICK HERE for subscription information about this journal.

References

http://www.medscape.com/viewarticle/524955

Is ther any other way of seeing this without signing up? i know its free.

Luv Ali