Normal TSH and T4, pituitary problems excluded but apparently hypo

June 11, 2011

We're looking for a publication which supports the view that it is perfectly

possible for someone (our daughter) to be hypothyroid in the following

circumstances:

1. a TSH well within range, i.e. 2.8 (range 0.5 to 5) and a T4 of about 15

(range 9 to 22); and

2. no evidence of a pituitary problem (serum prolactin, gonadatrophins, random

oestradiol and IGF-1 all " normal " ).

She has been consulting Dr S who has no doubt that she is hypothyroid and has

progressively increased her thyroid medication to 150mcg T4 and 1 grain of

Armour, resulting in a vast improvement in her well-being. Her goitre has also

shrunk somewhat in the course of this treatment.

She has also seen two endos who say she cannot be hypothyroid in view of the

biochemical results. They are implying her improved well-being is a placebo

effect or the result of verging on being hyperactive (her current TSH is

suppressed). They are recommending that alternative avenues should be

investigated. One such avenue has already been checked out, namely chronic

fatigue syndrome, but that has been discounted. The GP is in agreement with the

endos and will not prescribe the medication recommended by Dr S.

Can anyone (Sheila?) point us to a suitable up-to-date medical journal

publication please?

TC

June 11, 2011

Hi,

Miraculously she would be hypothyroid if she crossed the channel and went to

France, or Belgium, or if she went to Norway or America... Most countried

class you as hypothyroid with a tsh of 2.5 - 3. Only for some reason the

British are a different race to the rest of the world and we can tollerate a tsh

of up to 5 or 10 without being hypo...

A normal TSH is 1.

The endos are being a bit silly.... maybe they are relying on'Our holy miracle

of the infallible TSH test'.....

No doubt Sheila will know instantly where to find the information, but today

she isn't around because of the TPA meeting in Skipton. Dr S is there too, along

with Dr P.

Have you approached Dr S for published evidence?

x

>

> We're looking for a publication which supports the view that it is perfectly

possible for someone (our daughter) to be hypothyroid in the following

circumstances:

>

June 12, 2011

Hi TC,

...and Dr Hotze MD from the USA is quite explicit:~

http://www.youtube.com/watch?v=eSwgUndHcqU & NR=1

about your question.

best wishes

Bob

>

> We're looking for a publication which supports the view that it is perfectly

possible for someone (our daughter) to be hypothyroid in the following

circumstances:

>

June 12, 2011

Hi Bob

What I'm really looking for is a disclosure, preferably a publication in a

respected medical journal, which categorically states that you can be in range

and without pituitary problems but still be hypo. The YouTube video is

interesting but it doesn't really hit the nail on the head.

Thanks all the same.

TonyC

> >

> > We're looking for a publication which supports the view that it is perfectly

possible for someone (our daughter) to be hypothyroid in the following

circumstances:

> >

>

June 12, 2011

Thanks

I'll get my daughter to ask Dr S. But if anyone else can give me an unequivocal

medical reference, it would be very much appreciated. I have a suspicion that

there's nothing out there. I've tried Googling but haven't found what I'm

looking for, namely a literature reference which categorically states that

someone with a TSH in range and without pituitary problems can be hypothryoid.

My best

TonyC

June 12, 2011

Tony,

I've just been looking up what I can find in the Mark Starr book n

(hypothyroidism type 11)...... he says that there was a prominent new textbook

published in 2000 (Warner and Ingbar - The thyroid .....) and the chapter

devoted to TSH and other measurements..... The first paragraph says " the

single best test for assessment of thyyroid function is measurement of serum

thyrotropin (TSH). That is because assays for serum TSH are highly sensitive in

detecting either thyrotoxicosis or primary hypothyroidisn " Dr Starr then

says that that absolutely NO REFERENECES are given to prove the validity of this

statement. - this is the medical dogma of our time.

A similar situation arose when the BTA published it's silly piece of work a

couple of years ago citing no references.... Sheila and various other doctors

challenged the dubious 'facts' and never recieved any replies......

I'll keep searching through the Mark Starr book.... you never know.... I

think you need something that explains about Hypothyroidism type II.

>

> Thanks

>

> I'll get my daughter to ask Dr S. But if anyone else can give me an

unequivocal medical reference, it would be very much appreciated. I have a

suspicion that there's nothing out there.

June 12, 2011

I

would point out that a TSH of 2.8 is far from 'normal'. In Germany, Belgium,

Sweden, the top of the TSH reference range is 2.5 with a recommendation by

Belgium practitioners that this be lowered even further to 1.5. Here in the UK,

the BTA and RCP would try to tell us that patients should not be given a

diagnosis of hypothyroidism if their TSh is anywhere within the reference range

of 0.5 to 10.00 - the highest in world. These doctors need to test her level of

free T3 and has she been tested to see whether she is suffering from antibodies

to her thyroid?

Check

out the following link.

http://www.bioscilibrary.com/resource/summerschool/2006/ss06/ss06_gur.htm

http://jcem.endojournals.org/content/84/5/1759.full

http://f1.grp.fs.com/v1/cNT0TTkK9zTblNfmA6Q796vSGEEWyNeLNbGZ4wwh-OmonQfgblNWSKIsIs2py2Qt_AJ3iJRjVRnSpZlvHUZxMw/TESTS/Defying%20the%20Reference%20Ranges.doc

http://f1.grp.fs.com/v1/cNT0TQABNqrblNfm_FXsibE8wsIN8G0Hfx4jaGzOi5B82n_pu7otfWLlswY7D0ussKzTIAFMYZl7BrEtxuR5vA/TESTS/UUNDERSTANDING%20THYROID%20FUNCTION%20LABORATORY%20TESTS.doc

thyroid treatment/files/TSH%20~%20What%20affects%20the%20level%20of%20TSH/

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1341585 & blobtype=pdf

The

TSH Story

What's the deal about TSH?

TSH. Try Something Harder. It

can feel like you always have to do that when your thyroid isn't working right,

but TSH stands for Thyroid Stimulating Hormone. The TSH test is the main one

that doctors use to diagnose hypothyroidism or hyperthyroidism, so it's an

important test to understand.

TSH is a

pituitary hormone, not a thyroid hormone. Its job is to stimulate the thyroid

to produce more thyroid hormone, so a high TSH level usually indicates that

your body isn't getting enough thyroid hormone. This condition is

hypothyroidism. A too-low TSH level usually indicates the opposite, or

hyperthyroidism.

The main

problem with the TSH test is that the reference range for it is too wide at most

labs. The upper end of the range at some labs goes as high as 6, but according

to the hundreds of references that we've compiled, symptoms of hypothyroidism

accompanied by a TSH level over 2, sometimes lower, are suspect. Whenever you

get lab tests, ask for a copy of the results. Don't just let someone tell you

that your TSH level is " normal. "

Another

problem with going by TSH levels is that because TSH is a pituitary hormone,

sometimes it doesn't tell the thyroid story. If there's a problem with the

pituitary gland, or the hypothalamus (which controls the pituitary), TSH could

be at an optimal level, but your actual thyroid hormones (T4 and T3) could be

too low, or too high. Using the TSH test to check for thyroid problems in this

situation is like looking at the thermostat to check the temperature of a house

when the thermostat itself is broken.

What now?

If you have

a " normal " TSH level but you still think you have hypothyroidism, ask

for more thyroid testing, such as free T4 and free T3

tests, and tests for thyroid antibodies. A TRH stimulation test might produce more

conclusive test results. Note that hypERthyroidism can also be missed by

relying too much on the TSH test; some people get symptoms of hyperthyroidism

when their TSH level is within the lab reference range, but at the low end of

the range. You can also print our files of references about TSH to bring to

your doctor. If you think you are undertreated, you can use these compilations

to ask your doctor about a dose increase.

Keep in mind

that some other health conditions have symptoms that are similar to those of a

malfunctioning thyroid. For more on this, see Maybe It Isn't Your Thyroid in our Archives

section.

What about low or suppressed

TSH levels?

A lot of

hypothyroid patients need to have a very low TSH level to be symptom-free.

Some doctors

believe that too little thyroid medication is preferable to the possibility of

temporarily overdosing, and won't increase the dose once the TSH level is

within the wide reference range. While it's commonly taught that too much

thyroid hormone causes health and functioning problems, it's not as well known

that so does even a slight deficiency of thyroid hormone. Undermedicating a

patient is like stopping a diet too soon, or driving a car too slowly for

traffic conditions. Doctors generally don't advise patients on diets to lose

only some of their excess weight so that they don't lose too much. Neither do

they drive under the speed limit so that they don't risk driving over it by

accident.

If you take

a little too much thyroid medication, you can reduce your dose and still reach

your target. You'll never get there, however, if you don't have enough thyroid

hormone. Cars have speedometers, which are usually reliable, but the TSH test

has been proven to be an unreliable indicator of adequate thyroid hormone

levels.

Medical

journal articles have shown that treatment started with a TSH level in range accompanied

by hypothyroidism symptoms resulted in health improvements. In addition, a TSH

level at the higher end of the range (but within many reference ranges) may

correlate with other health conditions — depression,

heart disease, and high cholesterol, for example.

Where are those TSH

references?

The TSH References page provides an overview of the references

and why we need them. The compilations of references are divided into medical

journal references and references from other sources, and each has a

printer-friendly version so that you can take these references to your doctor

if they're relevant to your situation. On the " TSH: Patients'

Experiences " pages, you can read how getting the TSH level at the optimal

level greatly improved the lives of many thyroid patients.

On our Suppressed TSH Levels: Medical Journals page,

we have medical references to counter doctors' concern about a suppressed TSH

level with some of their patients.

T3 levels

may be another piece of the puzzle to feeling well. See also our T3

Supplementation article and links.

Purpose

of this compilation

To show that a

suppressed TSH (thyroid stimulating hormone) level in patients on treatment for

hypothyroidism or hyperthyroidism doesn't necessarily indicate a non-euthyroid

state.

A related compilation at

this site is TSH Levels in Treated Versus Untreated People.

See also the links in

the right column as well as in our T3

References and Desiccated

Thyroid References sections.

A. Suppressed TSH, thyroid hormone levels, and

euthyroidism

B. Suppressed TSH and bone metabolism

C. Suppressed TSH and cardiac effects

A. Suppressed TSH, thyroid hormone levels, and euthyroidism

1. " Thyroid

function tests and hypothyroidism " (UK, 2003)

We have long taken the

view that most hypothyroid patients are content with a dose of thyroxine that

restores serum concentrations of thyroid stimulating hormone to the low normal

range. However, some achieve a sense of wellbeing only when serum thyroid

stimulating hormone is suppressed, when we take care to ensure that serum

tri-iodothyronine is unequivocally normal.

Until valid evidence

shows that such a policy is detrimental we will continue to treat patients

holistically rather than insist on adherence to a biochemical definition of

adequacy of thyroxine replacement.

Toft

AD, Beckett, GJ. Thyroid function tests and hypothyroidism. Brit Med J

2003;326:1087 (17 May) Letters.

Full Text

2. " Suppression of

Serum TSH by Graves' Ig: Evidence for a Functional Pituitary TSH Receptor "

(Netherlands, 2001)

Antithyroid treatment

for Graves' hyperthyroidism restores euthyroidism clinically within 1–2

months, but it is well known that TSH levels can remain suppressed for many

months despite normal free T4 and T3 levels....We conclude that TSH receptor

autoantibodies can directly suppress TSH levels independently of circulating thyroid

hormone levels, suggesting a functioning pituitary TSH receptor....

....Such a mechanism may

very well be responsible for the low TSH levels observed in otherwise euthyroid

Graves' patients receiving antithyroid drug treatment.

Brokken

LSJ, Scheenhart JWC, Wiersinga WM, Prummel MF. Suppression of Serum TSH by

Graves' Ig: Evidence for a Functional Pituitary TSH Receptor. J Clin

Endocrinol Metab 2001 Oct;86(10):4814-7.

Full Text

3. " TSH as an index

of L-thyroxine replacement and suppression therapy " (Ireland, 1992)

Suppressed TSH levels

were associated with...normal FT4 levels in 62.5% [of the 90 clinically euthyroid

patients receiving treatment with L-thyroxine].

Igoe

D, Duffy MJ, McKenna TJ. TSH as an index of L-thyroxine replacement and

suppression therapy. Ir J Med Sci 1992 Dec;161(12):684-6.

Abstract

4. " Thyroid

stimulating hormone measurement by an ultrasensitive assay during thyroxine

replacement: comparison with other tests of thyroid function " (UK, 1987)

Serum thyroid

stimulating hormone (TSH) was measured using a highly sensitive

enzyme-amplified immunoassay in 37 clinically euthyroid patients receiving

thyroxine replacement therapy and compared with other biochemical tests of

thyroid function....A suppressed serum TSH was found in 65% of patients with a

normal serum total thyroxine.

Wheatley

T, PM, JD, Raggatt PR, OM. Thyroid stimulating hormone

measurement by an ultrasensitive assay during thyroxine replacement: comparison

with other tests of thyroid function. Ann Clin Biochem 1987 Nov;24 (Pt

6):614-9.

Abstract

5. " Clinical value

of a sensitive immunoradiometric assay for TSH " (1985)

....our extended study

here has revealed that a significant number of euthyroid patients with

undetectable TSH (1.5% in our study) are likely to be found if TSH becomes the

initial test for thyroid function. Thirty [out of 111] of the hypothyroid

patients on thyroxine were found to have undetectable TSH, but only one showed

clinical signs of thyrotoxicosis. Most of the patients, although having raised

serum free T4, had serum free T3 levels within the euthyroid range or just

slightly elevated.

KR, RD, Hewitt JV, D. Clinical value of a sensitive

immunoradiometric assay for TSH. Ann Clin Biochem 1985 Sep;22 (Pt

5):506-8.

Abstract

6. " Therapy of

primary hypothyroidism with L-triiodothyronine: discordant cardiac and

pituitary responses " (1980)

....higher doses of L-T3

or substituting L-T4 therapy could suppress TSH secretion further without

altering the other peripheral responses to thyroid hormone.

Ridgway

EC, DS, H, et al. Therapy of primary hypothyroidism with

L-triiodothyronine: discordant cardiac and pituitary responses. Clin

Endocrinol (Oxf) 1980 Nov;13(5):479-88.

Abstract

B. Suppressed TSH and bone metabolism

1. " Thyroid

function tests and hypothyroidism " (UK, 2003)

The weakness of the

meta-analysis, showing that thyroxine induced suppression of thyroid

stimulating hormone led to reduced bone mineral density, was recognised by the

authors themselves, who said that their design (cross sectional studies) was

not appropriate because the many risk factors for bone loss do not allow

correct matching of controls with cases.[footnote 4] This realistic assessment accords

with the earlier views of lyn et al that thyroxine treatment alone does

not represent a significant risk factor for loss of bone mineral density.[footnote 5]

Toft

AD, Beckett, GJ. Thyroid function tests and hypothyroidism. Brit Med J

2003;326:1087 (17 May) Letters.

Full Text

2. " [Prolonged

suppressive L-thyroxine therapy. Longitudinal study of the effect of LT4 on

bone mineral density and bone metabolism markers in 71 patients] " [Article

in French; abstract in English] (France, 1999)

Seventy-one patients

(including 28 menopaused women) taking long-term L-T4 for thyroid carcinoma

were divided into 3 groups according to their TSH level: low (TSH < 0.04

mlU/l), moderate (0.04 TSH < or = 0.10 mlU/l) and high (TSH > 0.10

mlU/l)....No lumbar or femoral osteopenia was observed in these patients taking

L-thyroxin, even for those with complete TSH blockade.

Rachedi

F. [Prolonged suppressive L-thyroxine therapy. Longitudinal study of the effect

of LT4 on bone mineral density and bone metabolism markers in 71 patients]. Presse

Med 1999 Feb 20;28(7):323-9.

Abstract

3. " Suppressive

doses of thyroxine do not accelerate age-related bone loss in late

postmenopausal women " (Japan, 1995)

One group of patients

was given suppressive doses of L-T4 (TSH <0.1 mU/L, n = 12) and the other

group was given nonsuppressive doses of L-T4 (TSH > 0.1 mU/L, n = 12). There

was no difference in bone metabolic markers and incidence of vertebral deformity

between the groups....These prospective and cross-sectional data suggest that

long-term levothyroxine therapy using suppressive doses has no significant

adverse effects on bone.

Fujiyama

K, Kiriyama T, Ito M, et al. Suppressive doses of thyroxine do not accelerate

age-related bone loss in late postmenopausal women. Thyroid 1995

Feb;5(1):13-7.

Abstract

4. " Suppressed TSH

levels secondary to thyroxine replacement therapy are not associated with

osteoporosis " (UK, 1993)

We set out to measure

bone mineral densities in two groups of post-menopausal women receiving

thyroxine replacement therapy (those with serum TSH levels persistently

suppressed or non-suppressed) and to compare the results in both groups with

those of the local control population....CONCLUSION: In this patient

population, the reduction in bone mineral density due to thyroxine is small. It

is unlikely to be of clinical significance and should not on its own be an

indication for reduction of thyroxine dose in patients who are clinically

euthyroid.

Grant

DJ, McMurdo ME, Mole PA, Paterson CR, Davies RR. Suppressed TSH levels

secondary to thyroxine replacement therapy are not associated with

osteoporosis. Clin Endocrinol (Oxf) 1993 Nov;39(5):529-33.

Abstract

C. Suppressed TSH and cardiac effects

1. " Minimal Cardiac

Effects in Asymptomatic Athyreotic Patients Chronically Treated with

Thyrotropin-Suppressive Doses of L-Thyroxine " (US, 1997)

....in the absence of

symptoms of thyrotoxicosis, patients treated with TSH-suppressive doses of L-T4

may be followed clinically without specific cardiac laboratory studies.

Shapiro

LE. Minimal Cardiac Effects in Asymptomatic Athyreotic Patients Chronically

Treated with Thyrotropin-Suppressive Doses of L-Thyroxine. J Clin

Endocrinol Metab 1997 Aug;82(8):2592-5.

Full Text

We're looking for a publication which supports

the view that it is perfectly possible for someone (our daughter) to be

hypothyroid in the following circumstances: