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Notes on Hypothyroidism

      A large part of my practice consists of the treatment of underactive thyroid hormones (hypothyroidism). I am not an endocrinologist, nor even an internist, but I have made an extensive study of the subject and now have 12 years of clinical experience in treating several hundreds, maybe 1,500, patients with this condition. I would probably never have become so fascinated by it if, after having all my patients' nutrient and hormone levels measured for a full 10 years, I had not finally measured the same levels in myself and discovered an elevated TSH (thyroid stimulating hormone) level, indicating hypothyroidism, among other deficiencies and imbalances! I was born with a thyroglossal cyst, which was removed when I was 12 years old; in retrospect, it seems that my hypothyroidism dates back to the surgery at age 12, which means that it went undiscovered for 36 years. The physical and mental effects during those 36 years, compared to the first 12, and the past 12, years of my life, are clear to me now. But their origin was hidden from me, my physician father, and every physician I ever saw, for all that time. I hope to not miss this condition, nor fail to treat it optimally, in any future patient.

      A concept I find strange is that of 'subclinical hypothyroidism'. This term used to refer to those cases which had TSH levels above its normal range but under 10 mIU. Nowadays, the physicians who treat patients with TSH levels at all above its normal range, still sometimes refer to this degree of hypothyroidism as either grade 2 (fair enough) or 'subclinical': I have never seen a case which exhibited a TSH level above its normal range (with low normal Free T4 and Free T3 levels) that did not have clear symptoms of hypothyroidism. I can only conclude that physicians are not eliciting all the symptoms of hypothyroidism when making this assessment. It can be debated that patients with a TSH level in the upper half of its normal range don't always have clear symptoms of hypothyroidism, yet, in my experience, they do.

      An axiom that I, generally speaking, agree with is that physicians should only prescribe good quality, brand name thyroid hormone replacement products but these should not be restricted to the brand name T4 hormone Synthroid, nor should they be restricted to only T4 products. The former manufacturers of Synthroid (Boots Pharmaceuticals) were recently reported by The Wall Street Journal to have commissioned an endocrinologist at a prominent SanFrancisco Bay area medical school to conduct clinical/ pharmaceutical research, which they hoped would show that Synthroid is the only stable and consistent brand of T4. They also put up $250,000 to fund the research. The article was accepted for publication by the Journal of the American Medical Association but was withdrawn when Boots pulled the article, as their legal contract with the medical school entitled them to do, when they discovered that all the T4 products tested, including Levoxyl (Jones Medical Industries) and Levothroid (Forest), had been found to be of at least equal, if not superior, quality!

      Armour Thyroid (by Forest Pharmaceuticals), Euthroid and Forest Pharmaceuticals' Thyrolar are perfectly good T4/ T3 combination products, in my opinion. The latter 2 are synthetic, the former natural desiccated hog thyroid. I believe the reason why all of them have been suspected, to a greater or lesser extent, of 'instability' is not because they are poor quality products but because they are prescribed incorrectly, both in the sense of the wrong patients being chosen for this therapy (whose Free T3 levels are no lower than their Free T4 levels); because the Free T3 level is not done as part of the diagnostic work up, nor in monitoring the treatment; and because the necessary after-meals and twice-daily prescribing are not done. The FDA even banned the use of Euthroid and, I believe, Thyrolar temporarily as well, a few years ago.

      In someone on T4 whose Free T3 level is lagging, it is not only acceptable but desirable to add small to large doses of Cytomel or, possibly, the sustained release T3 (5-25 mcg), after brkfst and supper daily, as long as the patient does not have an acute life threatening illness.

      For a much fuller explanation of my approach to hypothyroidism, see