Treating T3 Deficiency, the Evidence You Need
Written by Neal Rouzier, MD
Your 45 y/o female patient that is now optimized on your HRT program returns for evaluation after her PMD voiced concerns about your treatment with thyroid hormone.
She states that she stopped her desiccated thyroid hormone based on advice from her PMD that she did not need thyroid hormone as her thyroid function tests were normal and taking thyroid could be harmful. Her doctor wants to know why you prescribed thyroid hormone for her when her TSH test was perfectly normal indicating that she did not need thyroid hormone to begin with.
Upon being questioned, she admits that she is feeling tremendously better on thyroid whereas nothing else has helped.
If you are interested in learning more about treating T3 deficiency, please consider taking our thyroid series.
Answer and Discussion
You advise the patient that her PMD’s response is classic and expected. You agree with the patient and advise her to stop the thyroid treatment as you do not want the patient and her doctor to be confused.
However, you advise the patient that she will experience a return of all her symptoms of metabolic syndrome, weight gain, and fatigue.
You provide the patient all of the literature presented in Treating T3 Deficiency, the Evidence You Need in hopes that both she and her doctor may come to understand that you were just trying to improve her signs and symptoms as well as quality of life that no other therapy provided.
Explaining all of the foregoing before the patient left the office may have circumvented the problem.
Here, read this!
I do not believe that there is any one subject in medicine that is as misunderstood, politicized, debated, denigrated, and contentious as thyroid hormone. The pharmaceutical thyroid industry has spent millions on brain-washing physicians and convincing them that thyroxine is the best and only thyroid medicine that should be utilized. So many patients have relayed to me that their PMD will no longer treat them if they continue to take Armour Thyroid.
Doctors actually say this?
Yes, and do so emphatically – which proves the power of a pharmaceutical company and marketing.
The disdain for desiccated thyroid as demonstrated by AACE guidelines and thyroid societies is not seen anywhere else in medicine. Yet, most recent medical literature proves better patient satisfaction and symptom improvement with DTE than with thyroxine, much to the chagrin of the endocrine world. As a result, I feel that everyone should be well versed in all the thyroid literature and able to be conversant with both patients and colleagues.
Most importantly, I believe, is to have at your fingertips all the necessary literature if you ever have the opportunity to say to your peers and endos, “Here, read this!”
Having command of the literature and the confidence with which to convey it, will speak volumes to support why we do what we do. Each and every paper presented and reviewed in the webinars will be available for you to download. Last year, the webinar series What You Need to Master Before Prescribing Testosterone was intended to provide the top 100 most important articles on every aspect you should know about testosterone. I plan to do the same for thyroid.
So, when your patient states that their doctor wants to know why you prescribed thyroid hormone when the lab tests were normal, you can say, “Here, read this!”
TSH and Thyroid
For the seasoned veteran that is already an expert, these new articles demonstrate why we should not be using TSH to diagnose hypothyroidism nor use it to monitor therapy.
TSH level has nothing to do with improvement of clinical signs and symptoms, despite normalizing TSH levels. Multiple papers published in thyroid journals call for elimination of the TSH to diagnose hypothyroidism, rather than use Free T4 and Free T3 tests and clinical symptoms instead. This flies in the face of AACE guidelines, which many authors state should be discarded and revamped.
The other reason to not use TSH to diagnose hypothyroidism is the lack of correlation of TSH normalization and clinical improvement. Multiple studies prove correlation of Free T4 and Free T3 to clinical improvement and not TSH normalization, which we have observed for years but they are now finally publishing it in thyroid journals.
Lastly, clinical improvement in signs and symptoms, or where the patient feels the best and experiences improvement in carbohydrate markers and lipid parameters, occurs when the TSH is suppressed, which is verboten by endocrinologists and PMDs. Recent literature explains appropriate thyroid monitoring via Free T4 & FreeT3 levels combined with improvement in clinical parameters and not reliance on just TSH.
Association does not Prove Causation
I realize that this is counterintuitive as to what we have been taught for 50 years, but it is the latest EBM. Later we will review all the literature demonstrating that endogenous hyperthyroidism (Graves’ disease) causes atrial fib, sudden cardiac death, cancer, osteoporosis, and an 20% increased mortality, even when the thyroid gland is removed and the TSH is normalized. However, exogenous thyroid replacement does not, which is confusing and unsettling to most practitioners. Graves’ hyperthyroidism, with the associated pathologies, should not be extrapolated to exogenous replacement, as suggested by lack of harm in any study where TSH is suppressed to treat thyroid cancer. The autoimmune element of Graves’ is what drives the disease and not the thyroid hormone as is evidenced when the thyroid level and TSH are normalized but the disease complications progress. Not so with exogenous thyroid replacement, which most clinicians fail to comprehend. Another example of “association does not prove causation.”
Treating T3 Deficiency
Finally, treatment with thyroxine to simply restore TSH to normal is so out of vogue and counter to so much literature. However, most physicians remain unaware of the plethora of recent data demonstrating that the concepts taught to us for the last 50 years are incorrect. There is no venue for clinicians to gain this knowledge and understanding of all the available literature, and certainly not from any endocrine courses. My goal for Treating T3 Deficiency, the Evidence You Need is to present all the EBM demonstrating current research that results in a change in concepts to what has been etched in stone for over 50 years and that probably will not be changed any time soon. As is so often quoted, medical guidelines and textbooks are 20 years behind current science and literature.