According to Dr. Richard Shames, M.D, thyroid problems may go undetected. It is estimated that low thyroid may affect up to 10% of the population in the United States and appears to be increasing. Some have even placed the numbers of Americans affected by thyroid disease as high as 20%.   Perhaps even more alarming is that Dr. Shames says Thyroid Disease sufferers may experience these three main challenges.

1) “Even when Thyroid Disease is suspected, it is frequently undiagnosed”

2) “When Thyroid Disease is diagnosed, it often goes untreated”

3) “When Thyroid Disease is treated, it is seldom treated optimally”

If you have been diagnosed or suspect a thyroid disorder one of the first things you must realize is that in most cases, your doctor may not have the knowledge to treat you effectively. In fact, your physician’s lack of knowledge could be harmful to your health. One of the most important things you can do if you suspect a thyroid disorder or if you have been diagnosed with a thyroid disorder and don’t feel as if you are being adequately treated is to arm yourself with knowledge so that you can do one of two things:

1) Provide information to your physician so that they can learn how to better treat thyroid disorders

or

2) Find another doctor who either is up to speed with the subtleties of thyroid disorder treatments or who is willing to learn

One of the most helpful books that I read after being diagnosed with a thyroid disorder is the book which we’re discussing today by Dr. Shames.
There are certainly other materials available on thyroid disorders and if you are a thyroid patient I would suggest you read and study as much as possible, but one of the best things about Dr. Shames’ book is that he explains some things like the “Tyranny of the Laboratory Tests” for thyroid patients so that you are more able to understand why your doctor may not be interpreting your tests correctly and what you can do about this.

Now, a disclaimer, while I don’t agree with everything  in Dr. Shames’ book, I think it provides a very good starting point for understanding why it is so difficult for thyroid patients to be properly identified within the current medical environment, and how treatment of thyroid patients once they have been diagnosed, is a combination of complete lab testing, along with physical exam, the patient’s symptoms, and taking into account the individuality of each particular person’s case. Unlike other illnesses like a broken leg, treatment of the flu, or even some cardiac conditions, thyroid disorder treatment is clearly not a “one size fits all.”

What you will find in Dr. Shames’  book also, are some quotes from other physicians who recognize how thyroid diagnosis and treatment is more involved than a simply lab test.

Thyroid tests do not replace good clinical judgment, and should not be used alone to confirm or refute a diagnostic impression, or to dictate therapy.

— Ernest Mazzaferri M.D. , Journal of Postgraduate Medicine

Let’s focus on just one element of thyroid testing for the purposes of this article, just because this one test is probably the most misunderstood even by medical practitioners. When patients go to their doctors and say that they would like to be evaluated for a thyroid condition, most physicians will mistakenly order only one test, the TSH test, otherwise known as the Thyroid Stimulating Hormone. And because most patients don’t ask for a copy of their lab results, if the physician’s office calls and says the TSH was “normal” then the patient thinks that the doctor has checked their thyroid and there is “nothing wrong”.

I hear this almost on a daily basis. Either via email or in person I may be approached by an individual who says that they have certain symptoms and one of the first questions that I find myself asking if their symptoms could be indicative of a thyroid disorder is “Has your doctor checked your thyroid properly?”  And inevitably the person says “Yes, my doctor checked my thyroid and he/she says it’s “OK.”

The next thing I ask is exactly what thyroid tests did your doctor order? And did you get a copy of your lab results? I usually get a blank stare back in return because there are so many people who think that their doctor would automatically do all the right tests and any possible thyroid problem would be picked up through their doctor’s testing.

Well, I hope your sitting down because I’m here to tell you, that simply isn’t the case for most patients. Most physicians will routinely only use one method of thyroid testing which can be inadequate for many and leave many patients undiagnosed, some for YEARS.

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There’s several reasons why this leaves many thyroid patients undiagnosed.

1) The TSH Test many times may be the only test that is ordered, and it can recognized thyroid disorders in some patients, but it is definitely not the only test needed and many patients go undiagnosed for years because their physicians did not order a complete thyroid panel

2) Confusion and Misinterpretation of Actual Lab Ranges: As we’ve discussed in previous articles, thyroid lab ranges may vary from laboratory to laboratory and have been adjusted over the years. Unfortunately, some labs have not changed their reference ranges for what constitutes “normal” and if your doctor has not educated themselves as to what the new standards of normal for thyroid lab testing is, you may be left untreated or undertreated if you have a thyroid disorder.

3) General Treatment Subtleties: Because most physicians haven’t learned much more than how to order a TSH test and then they may only look at the outdated reference ranges for their own testing laboratory and/or not understand that there are certain conditions with thyroid disorders that may make patients need differing doses of medications.

For example, in Dr. Shames’ book he explains that some physicians prefer that the lower limit of TSH be 1.0, while other doctors may use a TSH level of 0.5 as a marker for successful treatment. Some physicians at the University of California Medical Center in San Francisco, according to Shames prefer that the lower limit of 0.2 TSH is used as the cutoff, while Dr. Shames says he has patients that do not feel well until their TSH level is 0.1.

There are certain patients, namely thyroid cancer patients in which the general medical practitioner will find it common practice to aim for a TSH that is so low it is almost undetectable. In these cases research has shown that if you suppress the TSH totally, it can prevent any thyroid tissue that may remain after cancer treatment from becoming active—thus theoretically helping to prevent the return of cancer in these patients.

4) Auto-Immune Thyroid Disease and the TSH: There are other instances where a lower than normal TSH may also be helpful. And this is in the case of patients who have auto-immune thyroid disease. But, unfortunately for some patients, their doctors never test them for auto-immune conditions of the thyroid, and so their thyroid condition could also remain undiagnosed, if the clinician is simply going by the TSH test to determine if the patient has thyroid disease.

If you think of the theory regarding cancer patients and suppression of the TSH level, this can also apply to patients with auto-immune disorders. The thought is that when the TSH is higher, it can stimulate the antibody reaction, which can make both symptoms worse, and hasten the progression of auto-immune thyroid disease. Although the medical profession is still divided on this point, there are many practitioners who have found value in the TSH suppression for auto-immune thyroid disease patients and it may explain why some patients feel better when their TSH is lower.
So, if you have auto-immune thyroid disease, having a TSH within range may not necessarily be the best thing for you. You may need to have your TSH suppressed similar to thyroid cancer patients in order to feel well.

Suggested Tests for Evaluation of Your Thyroid

In order to adequately evaluate the thyroid testing should initially include:
TSH
FREE T3
Free T4
Reverse T3
TPO (Thyroid Peroxidase Antibodies)
TG (Thyroglobulin Antibodies)

Rather than rely solely on the TSH, it is important that thyroid patients work with a medical practitioner who will monitor and treat based upon the Free T3 and the Free T4 which are more reliable indicators, along with the family history, medical exam, and patient’s symptoms than using any one lab test to dictate treatment decisions.  Knowing whether or not you have auto-immune thyroid disease is also an important indicator as this may also influence treatment.  Getting a copy of Dr. Richard Shames’ book and educating yourself about thyroid disease will also serve you well for making informed decisions about your future medical care. And as always, make sure and get copies of all of your own laboratory results. Never rely on a physician’s office to call and tell you everything’s “normal” when your body is telling you it’s ‘not’.