Published Articles

3 February 2011 - 4:25pm

3 February 2011 - 4:25pm

 

By Richard Shames, M.D. & Karilee Shames, Ph.D, R.N.

Here is the first and introductory installment for a series of art icles on the thyroid - female hormone connection.

In recent weeks, it has come to my attention that a great many women are still confused about the interactions between their thyroid hormone and their female hormone balance. The good news is that the estrogen panacea is winding down. The bad news is that a great many women don't know how to proceed with female hormone balance. 

The more progressive gynecologists are using bio-identical hormones instead of Premarin & Provera. Nevertheless, estriol and micronized progesterone may still not be yielding the results you would like, unless potential thyroid situations are taken into account. This can be difficult if your gynecologist - like many - is still not using the new TSH guidelines (remember that a TSH level over 2.0 is suspicious for low thyroid, and above 3.0 is diagnostic for it). 

When we first wrote our book THYROID POWER, we took the position (for simplicity) that an additional thyroid balance would be available by adjusting female hormones, if needed, then adjusting adrenal hormones, if needed. The reverse of this posture is also quite valid. Further adjustments of thyroid (whether you are being treated for a diagnosed thyroid problem or not) can be of great benefit in your reproductive hormone balance. The interaction between these two hormonal systems is extremely significant. Anyone who has taken birth control pills, or estrogen, needs to keep in mind that one additional effect of that maneuver is to increase thyroid-binding proteins in the blood. 

This means that almost any thyroid blood test result is quite suspect, because the regular tests will show plenty of thyroid hormone in the bloodstream, but you may still not have sufficient thyroid hormone in the tissues. In other words, estrogens will make thyroid blood tests even more unreliable than they already are. 

What this means is that you can be told you don't have a thyroid problem when you really do. In addition, if you are taking thyroid medicine, you could be told that you're taking plenty, when in the reality of your tissue levels (not measured on blood tests) you need more. 

This is not a minor subtlety. It is of critical importance to you. A lack of proper thyroid hormone levels has been implicated in everything from bad PMS to irregular cycles, low libido, infertility, miscarriage, endometriosis, polycystic ovary, uterine fibroids, dysfunctional bleeding, severe menopause, and osteoporosis. With a long list of possible gynecological problems such as this, you are well advised to optimize your thyroid function as much as possible.

So once again I return to a recurrent theme in my office & coaching practice: if there has been any thyroid, diabetes, migraine, colitis, rheumatoid or other autoimmune problems in your family, then you are likely to have some degree of thyroid involvement yourself. This is especially true approaching and during menopause years. The Journal of Epidemiology in 2001 had a compelling art icle revealing that as much as 26% of menopausal women were hypothyroid, making their menopause years worse.

Therefore, you owe it to yourself to do extra diagnostic maneuvers for revealing low thyroid, such as obtaining thyroid antibody testing in addition the routine T3, T4, and TSH. In addition, make sure the T4 determination is the Free T4, and your T3 testing is for both Free T3 and Total T3. Consider asking for a clinical trial of thyroid medicine if you are in the low normal area on these results.

Perhaps even more important is for the person who is already diagnosed and being treated for low thyroid to make sure that your treatment protocol is optimal. In my coaching practice, where I speak with women from all over the country, I frequently find someone who is experiencing uncomfortable symptoms of female hormone imbalance due to an inadequate dose of thyroid medicine. Often these symptoms completely disappear without further female hormone intervention simply through the proper thyroid care alone. 

Keep in mind there are at least five (5) different kinds of synthetic thyroid, and five (5) different kinds of natural thyroid, in addition to Armour. Sometimes it's not just the dose of your medicine, it's the type or brand - and don't forget that many women need a mix of thyroids rather than just one type. 

We'll share more on each of these topics in our next installments! Stay tuned...

This art icle  appears on the Mary Shomon 's website About Thyroid
http://www.thyroid.about.com

 

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3 February 2011 - 4:24pm

3 February 2011 - 4:24pm

 

By Richard Shames, M.D. & Karilee Shames, Ph.D, R.N

With researchers discovering that the benefits of estrogen are overrated and dangers underreported, it may be time to focus on your thyroid.

The news is in from the National Institutes of Health: the benefits of estrogen have been overplayed, and its risks have been minimized. Not only have valid studies found that estrogen replacement therapy has less protective value for heart disease, Alzheimer's, depression, urinary incontinence, and especially osteoporosis, but in addition, the latest studies are confirming its increased cancer potential.

In other words, the preventive powers of estrogen replacement therapy are much less than the drug companies have been saying, and its risks are greater. This is especially important information for any woman concerned about her thyroid health. Perhaps the biggest potential for mischief in the whole thyroid field is in the arena of women's health and menopause. Everything from minor vaginal irritations to repeated miscarriages have been shown to be thyroid-related in a certain percentage of sufferers. Menopause is not an illness, but it can begin to feel that way if your thyroid is low or borderline at the time of your change.

Women in this frustrating circumstance are often told "It's just your menopause," as if they should expect to feel awful for years because of a natural reduction in estrogen. Without an accurate diagnosis of low thyroid, these women are simply given estrogen and their symptoms linger. The ovaries and uterus need proper amounts of thyroid hormone as much as any other organ or system.

Despite increased awareness in the medical community about the issues and interventions surrounding menopause, tremendous numbers of women still suffer from menopausal difficulties. They expend a great deal of time, money, and heartache on hormone replacement therapies. Frequently, neither the synthetic nor the natural hormones provides complete relief. This is often because the underlying problem is undiagnosed low thyroid. By age 50, one every twelve women has a significant degree of hypothyroidism. By age 60, it is one woman out of every six.

This runaway thyroid epidemic seems to be striking menopausal women harder than any other group of patients. Fortunately, much can be done to help them. The standard maneuver for perimenopausal patients who consult gynecologists is to provide a handful of estrogen samples. We have heard too many stories of women in their late 40's and early 50's who were given these hormones to take without any blood testing at all. The compliant patient will follow the doctor's advice. But, in those cases where women have been put on estrogen, and the symptoms of hot flashes, insomnia, irritability, palpitations, and "fuzzy thinking" are still quite annoying, the addition of thyroid hormone can be a godsend.

For those symptomatic menopausal women not wanting or benefiting from estrogen, we advocate thyroid blood testing first, perhaps followed by a clinical trial of thyroid hormone, even if their blood tests are in the normal range. Frequently, the underlying hypothyroidism is such a controlling factor that simply correcting it returns the whole system to fairly normal functioning. Menopause continues, but it is a more mild, gradual, and comfortable process. If your thyroid is low, your hot flashes will be much more pronounced, much more frequent, and more disconcerting. This is because thyroid is your energy throttle, and you need energy to go through the change gracefully.

How much energy people have, how well they get up in the morning, how well they sleep, and how much stamina they have for the day is directly related to their levels of thyroid hormone. When your level is too low, you don't have the energy to cope adequately with anything, much less the additional stress and emotional liability associated with the menopausal years.

Consider the following case: a 51-year-old schoolteacher from the Midwest named Sarah. Both she and her mother started menopause at the early age of 46. Sarah knew that her mother had low thyroid, as well as severe menopause problems. Neither the mother, nor Sarah, nor their doctors connected these two situations. When Sarah herself began to have the same severe menopause problems as her mother, she accepted it as her genetic predisposition. She was sometimes so hot and sweaty during a school day that she would need to keep a change of clothes in the teachers' lounge. Needless to say, the kids got on her nerves easily, and she was not enjoying her previously satisfying job.

Faced with these difficulties, Sarah did what her mother had not done: she began taking Premarin and Provera immediately. The hoped-for relief, however, was only minimal, even when the gynecologist increased her dosage.

Fortunately, Sarah was referred to our office, and we discovered that her previously normal TSH was now, with advancing menopause, 6.2, clearly in the abnormal range. This indicated that her thyroid hormone levels were not keeping up with the extra demands of her changing metabolism. Once on thyroid medication, Sarah began to feel like her old self in a matter of weeks. Her menopause symptoms faded into the background, and her life became more balanced and enjoyable. Best of all, she no longer needed the Premarin and Provera to maintain this more graceful version of menopause. Thyroid hormone alone resolved the problems.

Other menopausal symptoms are equally amenable to treatment with thyroid hormone alone. Atrophic vaginitis, or thinning of the vaginal wall as the result of falling estrogen levels, can lead to itching, discharge, and painful intercourse. All of these symptoms are much more severe when your thyroid is low. Women who have had unremitting vaginal dryness that was unresolved with vaginal creams or estrogen pills are often found to be low thyroid, if checked carefully. In addition to getting an important part of their intimate life back, once treated with thyroid medicine, these women are pleased to find that their problems with dry hair, dry skin, and cracking nails are often resolved as well.

We don't intend to belittle the persistent difficulty that some women have at this time in their life. Not everyone will be helped as quickly or as completely as was Sarah. The dance of the hormones is very complex, so the idea that you can take just one hormone, or even two, and experience total relief, is not always borne out successfully. You need to look at the whole picture. That's what we mean by holistic health.

Contrary to what the pharmaceutical industry and your doctors may be telling you presently, a blue ribbon panel of specialists from around the world have confirmed that estrogen's benefits have been over-rated and its risks minimized. Optimizing your thyroid can be a far better way to achieve the smoother menopause and the preventive health care you may desire.

This articles appears in Share Guide-A Holistic Health Magazine-Issue #71 Jan/Feb 2004www.shareguide.com

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3 February 2011 - 4:23pm

3 February 2011 - 4:23pm

 

A Look at the Relationship, with Drs. Richard and Karilee Shames

An interview by Mary Shomon as it appears on her website Thyroid-Info
http://www.thyroid-info.com/articles/shamesadrenal.htm

Mary Shomon
Is there an important adrenal component to thyroid optimization?

Drs. Shames
If you have been prescribed the proper amounts of thyroid hormone -- perhaps with additional substances to balance your reproductive system -- and all is working well, you do not need to pay much attention to your adrenal glands. If, on the other hand, you are not doing as well as you'd like, and especially if your symptoms have been somewhat atypical all along, then other factors need to be considered. One of the most important additional factors to take into account is your adrenal hormone level.

Mary Shomon
What do the adrenal glands actually do?

Drs. Shames
Your adrenal glands are two tiny pyramid-shaped pieces of tissue situated right above each kidney. Their job is to produce and release, when appropriate, certain regulatory hormones and chemical messengers.

Adrenaline is manufactured in the interior of the adrenal gland, in an area called the adrenal medulla. The adrenal medulla is stimulated directly by nerves from the sympathetic portion of the autonomic nervous system, which regulates fight or flight.

The human body is organized so as to be able to respond immediately to threatening situations by generating a tremendous amount of energy in a hurry, which enables the person to run away quickly, or face the threat and fight it with a massive influx of chemical support. These chemicals increase blood pressure, he art rate, and blood flow to muscles, while mobilizing sugar to burn. Nerve impulses from the brain cause the release of adrenaline from the adrenal gland, which helps you react appropriately in immediate short-term stress situations (the "fight or flight" response).

Cortisol, the another chemical from the adrenal gland, is made in the exterior portion of the gland, called the adrenal cortex. Cortisol, commonly called hydrocortisone, is the most abundant -- and one of the most important -- of many adrenal cortex hormones. Cortisol helps you handle longer-term stress situations.

In addition to helping you handle stress, these two primary adrenal hormones, adrenaline and cortisol, along with others similarly produced, help control body fluid balance, blood pressure, blood sugar, and other central metabolic functions.

Mary Shomon
How is proper adrenal function related to a thyroid problem?

Drs. Shames
A major connection exists between low thyroid and low adrenal. Low adrenal, also called adrenal insufficiency, can actually cause someone's thyroid problem to be much worse than it would be otherwise. Correction of low adrenal is similar to correction of low thyroid. You merely take a pill that contains some of the hormone you are lacking. In the case of low thyroid, you obviously take thyroid hormone. In the case of low adrenal, you simply take some adrenal hormone. Chapter 7 in Thyroid Power assures you that doing so, when appropriate, is not only safe and effective, but it can change your life for the better.

Cortisol is in the category of medicines called steroids, a class of body substances that derive their name from the fact that they are built upon the structure of the common cholesterol molecule. Both health practitioners and the lay public have great concern about the safety of taking oral steroids. We would like to address this issue directly by making a distinction between high-dose steroid therapy and low-dose adrenal supplementation.

What we are talking about is the use of small amounts of natural adrenal hormone (hydrocortisone) to bring slightly low adrenal function up to its proper normal daily range. This is in stark contrast to the high doses of powerful synthetic adrenal hormones commonly used to treat severe health problems, or to assist in building muscles.

Mary Shomon
Why is it important for low thyroid people to know the levels of their adrenal hormones?

Drs. Shames
Adrenal insufficiency symptoms include: weakness, lack of libido, allergies, dark circles under the eyes, muscle and joint pain, dizziness, low blood pressure, low blood sugar, food and salt cravings, poor sleep, dry skin, cystic breasts, lines of dark pigment in nails, difficulty recuperating from stresses like colds or jet lag, no stamina for confrontation, tendency to st art le easily, lowered immune function, anxiety, depression, and premature aging. Some of these symptoms are similar to those of low thyroid.

If low-thyroid people with these symptoms are put on thyroid hormone alone, they sometimes respond negatively. These people may have coexistent, but hidden, low adrenal. If they take thyroid hormone by itself, the resultant increased metabolism may accelerate the low adrenal problem.

The addition of thyroid hormone in this situation unmasks the also disturbing low adrenal situation. The proper approach in this case is to treat the patient with thyroid and adrenal support simultaneously.

Adrenal insufficiency, especially when unmasked by the addition of thyroid hormone, is unpleasant and uncomfortable. To compound the problem, the doctor and patient then may wrongly assume that thyroid replacement has been a mistake. A tremendous opportunity for better health has now been missed.

While uncomfortable, this dilemma can become a diagnostic tool. The doctor could then gradually add thyroid and adrenal hormone together, with the patient eventually taking optimal levels of both. This careful attention and delicate calibration are demanding on the practitioner and patient. Nevertheless, we have seen patient after patient dramatically improve with such dedication.

Also, interactions between your hormones are sometimes as important as the direct action of the hormone itself. Some adrenal hormones assist in the conversion of T-4 to T-3, and perhaps assist in the final effect of T-3 on the tissues. Some scientists believe that even the entrance of thyroid hormone into our cells is under the influence of adrenal hormones. Thus, if your adrenal level is low enough, you might do well to take both adrenal and thyroid hormone together.

Mary Shomon
I've heard that often the problem is that the adrenals are too high. Is the real problem one of excess of deficiency?

Drs. Shames
A failing adrenal gland goes through a hyper phase before it becomes totally exhausted. In the 1950;s, the famous researcher Hans Selye divided the physiology of fight or flight into three phases. In the first phase, "adaptation," a person intermittently secretes slightly higher levels of the fight or flight hormones in response to a slightly higher level of stress.

The second phase, called "alarm," begins when the stress is constant enough, or great enough, to cause sustained excessive levels of certain adrenal hormones. This can be the very earliest glimmer of what later can become stress-induced illness.

The third phase is called "exhaustion," wherein the body's ability to cope with the stress is now depleted. At this point, adrenal hormones plummet, from excessively high to excessively low. It is this latter phase of adrenal exhaustion that sometimes accompanies, or is confused with, low thyroid.

Where do low thyroid and adrenal stress intersect? If you find yourself in the alarm phase of adrenal stress (high levels of ACTH and high levels of cortisol), one result might be altered conversion of T-4 into T-3, or thyronine. Thus, your adrenal situation might profoundly affect the availability of biologically active thyroid hormone.

Research shows that even success and positive change can result in the stress response described above. In other words, even activities that you perceive as enjoyable, such as working hard on an exciting project, or striving for and receiving a promotion, can be perceived by the body as stress. This positive stress, called "eustress," can accumulate and affect bodily responses in the same way as its negative counterp art , "distress." In addition, some of the activities that are encouraged to help relieve this situation might actually make it worse, as in the following example.

Mary Shomon
How would a low thyroid person determine if he or she were low adrenal?

Drs. Shames
It would be wonderful to have a simple, reliable method of assessing a person's adrenal function. Many tests are available, but none are widely used. One reason for this is that most medical doctors consider that the adrenal system is always functioning smoothly, except in two very severe and rare circumstances. One of these is caused by extreme excess adrenal function, and it is called Cushing's Syndrome. When there is extreme decreased adrenal function, this is called Addison's Disease. When it is clear to a physician that you do not have either Cushing's or Addison's, the topic of adrenal metabolism all too often is shoved aside.

Another reason why doctors may not be sufficiently involved in this topic is that adrenal tests are even more challenging to interpret than thyroid tests. The biochemistry is extremely complex, and, until recently, the testing technology had not been useful except to diagnose Cushing's and Addison's, the two main types of adrenal function. Now the measurements are more sophisticated. Current technology can be divided into roughly two camps: conventional medical evaluation; and the more recently developed alternative adrenal tests.

Mary Shomon
What exactly are the conventional options?

Drs. Shames
The conventional medical evaluation for adrenal function includes measurements of ACTH (adrenocorticotropic hormone) from the pituitary, as well as cortisol (hydrocortisone) from the adrenal glands themselves. Both of these are simple blood tests. In addition, doctors will sometimes obtain a 24-hour urine sample for cortisol and related cortex hormones. This involves having patients collect urine in the same large container every time they empty their bladder for an entire 24-hour period. One drawback with this measurement is that it is not illustrative of variations within the 24-hour period, because the whole day's worth of urine is mixed together in one bottle. The level of adrenal hormone is naturally high in the morning, progressively diminishing through the afternoon, reaching its lowest levels in the evening. In the case of the 24-hour urine sample, the doctor can determine if the total amount of hormone is high or low for the whole day, but will not know at what time of day major variations occurred.

Also, a normal level for 24 hours might mask very high levels at one point in the day, with very low levels at another p art of the day. The total for 24 hours would be normal, but the patient may go through half the day with excessively high levels, and the other half excessively low. Complicating this test is the fact that the blood cortisol level is dependent on the protein molecule that carries it around in the bloodstream. The amount of this molecule can change for a variety of reasons, which changes the level that is measured.

Complicating this test is the fact that the blood cortisol level is dependent on the protein molecule that carries it around in the bloodstream. The amount of this molecule can change for a variety of reasons, which changes the level that is measured.

Liver trouble can lower the amount of this carrier protein, which will alter your test result. Abnormal estrogen levels will also alter the amount of this protein. In addition to all this, one's level of activity can change the result of the test.

The person's stress level has a significant impact too. Someone may have rushed to get to the lab or come from a stressful meeting at work. That would yield a different level than a patient who was calmly sitting in the waiting room for half an hour before the test. In addition, the conventional tests have a normal range that is very wide, so that only the most severe, out-of-range abnormalities qualify as being diagnostic of abnormal adrenal function (sound familiar?). For these reasons, many doctors do not order adrenal tests at all. If they do, they generally focus not on cortisol, but on evaluating adrenaline levels. You should tell your doctor that you would like the cortisol testing, and that you want both a "free" and a "total" cortisol level. The free fraction is available in more recently-developed tests, and has more revealing information for thyroid sufferers.

Mary Shomon
Are the new alternative-medicine tests for adrenal function better than those of standard medicine?

Drs. Shames
It is true that conventional medicine's evaluation of mild adrenal insufficiency is stymied by the adrenal system's subtleties. What do the alternative practitioners have to offer? They have chosen laboratories that try to assess adrenal function somewhat differently. A number of labs will do urinary measurements as described above, but instead of using 24-hours' worth of urine, they use four separate samples collected at 8 A.M. , noon , 4 P.M. , and midnight . Testing four different samples taken throughout the day is an attempt to obtain a more complete adrenal profile than one sample would provide. This allows a more detailed picture of the patient's daily cyclic adrenal function, and better distinguishes between alarm the alarm phase and the exhaustion phase.

In addition to increased determinations per day, the new test measures more than cortisol levels. Also commonly tested is DHEA, a precursor to almost all the other adrenal hormones. (A precursor is a chemical that is not as far along on the chemical pathway chain as the final product.) The resulting set of numbers, which some labs call the Adrenal Stress Index or ASI, can be then be used to initiate and monitor therapy.

Saliva measurement is another type of test not yet considered p art of a conventional adrenal workup. The determination of hormonal levels in saliva is, however, being researched for its effectiveness in assessing glandular health and balance. One such saliva test is similar to the urinary ASI above. It tests four saliva samples, collected at four specific times of day ( 8 A.M. , noon , 4 P.M. , and midnight ). Like the urinary tests just mentioned, more than cortisol levels are measured. Some saliva labs will check cortisol, DHEA, and pregnenolone. Pregnenalone, like DHEA, is a chemical precursor to many of the important adrenal hormones. The saliva measurement is a good choice because of its ease of collection and affordability, but its degree of reliability remains to be fully evaluated. Some alternatitve practitioners are claiming improved success with salivary testing.

Mary Shomon
In the debate about which kind of adrenal testing is best, what do you recommend?

Drs. Shames
We feel that the alternative testing of urine and saliva, evaluating four separate samples in a 24-hour period, is the preferred choice. It seems to reveal more of what is actually occurring when a patient experiences disturbingly low points in his or her day, or when proper thyroid treatment does not go well. However, these alternative tests are unlikely to reveal the true level of adrenal reserve.

Mary Shomon
How is adrenal reserve measured?

Drs. Shames
The method for measuring adrenal reserve has been largely solved by a conventional medical test, the ACTH stimulation test. Testing for adrenal reserve in this fashion is similar to the definitive thyroid test of TSH reserve (TRH Test) described in Step 4 in our book, Thyroid Power.    

An interview by Mary Shomon as it appears on her website Thyroid-Info
http://www.thyroid-info.com/articles/shamesadrenal.htm

 

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3 February 2011 - 4:21pm

3 February 2011 - 4:21pm

Help Ensure You Get The Best Thyroid Treatment

An interview  by Mary Shomon as it appears on her website Thyroid-Info
http://thyroid.about.com/cs/shames/a/secondopinion.htm

Mary Shomon
From your book and prior art icles, we know that you both have been involved with thyroid work for over 25 years -- personally and professionally. What is your stance on patients getting a second opinion?

Drs. Shames
As health professionals, we are extremely supportive of personal empowerment and self-care. In addition to books, friends, and the Internet, we feel it is essential to maintain a beneficial relationship with your doctor. 
A good practitioner can assist you in proper diagnosis and optimalmanagement of your thyroid issue, saving you years of distress, expense, and hardship.

But, keep in mind that all doctors have their limits. Their time, knowledge, and clinical experience are not infinite. It is standard medical practice to call in another opinion when needed. Usually it is the doctor who decides when another view is needed on the case. In the thyroid arena, it is becoming more and more common that the patient is making this decision. As a doctor - nurse team, we are entirely supportive of this more recent and much-needed development. 

Mary Shomon
What do you feel would make a patient st art thinking along these lines? 

Drs. Shames
For thyroid patients, it generally st art s early in the diagnosis phase, or later in the treatment discussions. For example, at the onset of a possible thyroid problem, a knowledgeable practitioner takes a complete history, listening carefully to nuances, and identifying patterns. Then, he or she performs the proper physical examination and orders appropriate laboratory tests, to ascertain exactly what is causing the symptoms. In this way, you can accurately determine which treatments will be most helpful to you. Don't sell yourself short. Make sure from the beginning that your situation is properly diagnosed. If your regular doctor does not check for thyroid as closely or as carefully as you would like, by all means speak up. This is especially true if you have any thyroid disease in your own or any of your family's medical history. 

If you have obtained information from friends or web sites related to your condition, it would be a good idea to share this with your practitioner to obtain further input. In these instances, be alert to the response of your practitioner. If your doctor acts as if your questions are a bother, or doesn't answer directly, consider whether you are receiving optimal treatment. You may need to augment this doctor's care with an additional opinion. If your doctor doesn't know the answers to your questions, ask if he or she can find out for you, or direct you to the proper resource. You may need to shop for this additional attention, just as you would shop for the right mechanic, contractor, or other service you value.

Mary Shomon
Why do you in feel a prospective thyroid patients need to shop around?

Drs. Shames
Many primary physicians do not seem to be aware of the excessive prevalence of low thyroid in the population, or of its collective toll on the nation's health. As we have noted in our book, investigations by university medical centers, as well as by the Mayo Clinic, have determined that the prevalence of thyroid conditions is quite high -- compromising the health of as much as 10% of the population, and appears to be very much on the increase. It has taken a long time for the medical commu nity, which is largely focused on critical care, to become aware of this dramatic situation. 

Since the condition is usually not severe or life threatening, it may simply not grab the attention of busy doctors. Also, since the thyroid system controls so many aspects of physical and mental functioning, the patients' long list of complaints can seem unrelated and excessive to the clinician. The patient may have a skin problem, a stomach problem, fatigue, weight gain, hair or nail problems, emotional ups and downs, feel chilly some of the time, and hot at others.

When confronted with this seemingly global array of symptoms, the physician is often skeptical, and, rather than suspecting low thyroid, may believe that this patient may have a psychiatric problem like depression. Now the stage is set for a diagnosis of depression, or something similar, with a prescription for Prozac or Zoloft. This misses the true underlying diagnosis of low thyroid, which is causing the symptoms that include depression. If you feel strongly that you are one of the millions of thyroid sufferers being misdiagnosed in this way, then you may well need to shop around and get a more detailed second opinion.

Mary Shomon
What about a patient who perhaps has had a second opinion with a more open-minded doctor, has had a more complete panel of thyroid tests, is diagnosed (maybe for years already), and treatment still isn't going as well as she or he would like. What then? 

Drs. Shames
It is well known that this unfortunate situation of less than satisfactory treatment is all too common. Let's say your p art icular problem is not with the diagnosis of a thyroid issue, but with the ongoing interpretation of symptoms and tests that could result in more optimal management of the condition. When blood tests are read, the range defined as normal for thyroid is frequently so large that what is considered a satisfactory level can actually disregard the unique metabolic needs of an individual person. 

Such people can feel miserable for years with a variety of significant complaints, despite their lab work having returned to "normal". Regardless of the patients' protests, some doctors insist that if your TSH is fine, then your thyroid is fine. The thyroid patient, however, may be gradually feeling worse and worse, and perhaps eventually becoming despondent. If you are in this boat, you may want a second opinion from a doctor who considers lab work as only one p art of the whole thyroid story. 

Mary Shomon
Unfortunately, my readers and I have found that doctors like that are relatively few and far between.

Drs. Shames
That may be true, but there are more and more of us. In our practice, we do primary care as well as second opinions. Lab tests are just one of the factors that go into our decisions and suggestions. There are plenty of other doctors like us. Patients just need to seek them out. Your Top Doctors Directory is an excellent place to st art . 

For example, consider the doctor's "bible", the Physician's Desk Reference (PDR) . In all the thyroid medicine sections, there is a subheading called "laboratory tests." Here physicians are advised not to rely solely on any one p art icular blood test for managing low thyroid. Instead, they are reminded to combine the knowledge obtained from laboratory evaluation with good clinical judgment. Yet, with managed care dictating protocol, physicians are by and large ignoring this advice. A few physicians, however, are indeed following this proper procedure; patients just need to find these doctors. Then the patients can obtain a second opinion that hopefully will inspire their primary doctor to be more open-minded about treatment discussions. It may be that a simple increase in medication dose or a simple change in brands of medicine will be a big improvement. Maybe the second opinion will suggest combining two thyroid medicines, which is sometimes better than any one medicine alone. An open-minded primary doctor then can utilize the second-opinion suggestions on a trial basis and see how well it works. 

Mary Shomon
Many patients are not seeing the kind of doctors you are describing. Why do you think there aren't more physicians who take a similar approach to yours?

Drs. Shames
Since the THYROID POWER book came out, we have been hearing from people all over the country, voicing dissatisfaction with what has been called "the tyranny of the test", or with the unwillingness of their doctor to try something new and different. 

We can readily understand why many providers would not want to practice in this manner. It is extremely time-consuming, requiring an extra dose of patience to monitor each patient's fluctuating progress. The process demands that the caregiver walk side by side with the patient, educating and supporting the person who is in the midst of this (sometimes) roller-coaster existence. The managed care environment does not allow practitioners to devote the careful attention that is called for, to find just the right dose, of just the right medicine(s), for each person.

In addition, the patients aren't usually acutely ill. Their condition is more of a longstanding, chronic condition that moves slowly. Some health providers do not have strong interest in this mild situation.

It is also risky for the doctor to step out of the standard mold, to try something slightly different. Keep in mind that physicians are monitored, and are expected to practice in accordance with a certain community standard. That means that if seven general practitioners in a given city never prescribe anything but synthetic thyroid, and the eighth GP sometimes uses synthetics and sometimes uses natural thyroid, that eighth doctor is not considered to be practicing in accordance with the standards of the community. The actual legal risk is minimal, yet it still discourages many doctors from innovation.

Mary Shomon
I can understand all that. What I, and many of my readers have trouble with, is when the doctor's seem haughty or obstinate. 

Drs. Shames
Oh, that's a much bigger issue. Health care in general is long overdue for a needed paradigm-shift in doctor-patient relationships. It needs to become more of a co-equal and mutually-sharing p art nership for learning and healing. Many doctors are trained to think that an omniscient demeanor is most reassuring to the patient. In some cases this is true, perhaps mostly with older patients, who have been indoctrinated to believe the doctor is infallible. We believe, instead, that our job is to educate and motivate, rather than dictate. The doctor should be open-minded, willing to try a variety of different medicines, and to help the patients decide which one is really working best for them.

We consider that p art of our role as caregiver is to empower and honor the individuals who seek our knowledge, wisdom, and support in safeguarding their health.

It is well documented that patients' beliefs play an integral role in healing. It is also well documented that an empowered patient does much better than one who simply follows orders . 

We strongly consider that what the patients believe to be good, or not good, for them is of utmost value in planning our approach. If a patient has had negative experiences with certain medications, we respect their concerns and experiences. We encourage health care consumers to be sure to art iculate feelings and beliefs about treatment. If your health provider is not interested in hearing your feelings or beliefs, you may then definitely want to consider getting another opinion.

Mary Shomon
Can you sum this all up into a "nuts and bolts" recommendation list for patients? 

Drs. Shames
Absolutely. Here is when a thyroid patient should st art thinking about getting a second opinion:

  • If your doctor does not explain your lab results or provide the actual numbers (this is especially true if you ask for results and cannot get them at all)
  • If your doctor or office representative will not return your phone calls
  • If your doctor says that all of this must be in your head, or be stress-related or PMS or menopause related (of course it's all related, but thyroid often needs to be considered as a primary cause)
  • When your doctor says a p art icular symptom you've seen on this website "couldn't possibly be due to low thyroid" (red flag)
  • When you've been on the same treatment for years and are still not feeling your old self, but your doctor is unwilling to change anything
  • If you are lucky enough to have a cooperative doctor, but he or she has been trying things that don't seem to be working, or are making you worse (your doctor may need some help to find just the find tweaking for you)

Mary Shomon
Finally, how can a second-opinion experience achieve a positive result for patients?

Drs. Shames
Here's what we've found is most helpful.

  • It is best is to let your primary doctor know that you would consider attending to the second opinion suggestions as a "temporary" trial of something new. If it doesn't work, you'll be content to continue working with your doctor perhaps in another direction, or at the very least, going back to what you had been doing before.
  • Tell your primary doctor that you are willing to take full responsibility for any adverse outcome in trying out a second-opinion suggestion. In fact, you are willing to sign such a statement in the ch art (this relieves a lot of pressure for the doctor, and puts you in the drivers' seat).
  • Let your primary doctor know that you understand that optimal thyroid management is a very individualized and sometimes "hit and miss" situation, that you are perfectly willing to engage in, and that - in fact - you consider it good medical care to engage this way because you are suffering with an "intractable" and perhaps unnecessary disability in your life (that medical lingo will get more of your doctor's attention than simply saying "I don't like feeling tired".)

An interview by Mary Shomon as it appears on her website Thyroid-Info.
http://thyroid.about.com/cs/shames/a/secondopinion.htm

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3 February 2011 - 4:19pm

3 February 2011 - 4:19pm

Finding Your Optimal Dose of Thyroid Medicine

by Richard Shames, M.D. & Karilee Shames, Ph.D, R.N.

An art icle as it appears on Mary Shomon's website Thyroid-Info
http://thyroid-info.com/articles/shamestsh.htm

As a General Practice physician who has been providing thyroid care for over 30 years, I am continually surprised by my patients' stories of their experience with endocrinologists. Many times patients tells me that they had just begun to feel slightly better on thyroid medicine when their specialist said, "This is it. We can not increase any further. Your tests tell me you're presently at just the right dose." Evidently they had st art ed working with this doctor right around the time of the low thyroid diagnosis. They had begun a low dose of maybe 75mcg. of Synthroid, and were beginning to feel better than rock bottom, but not great. Now, some years later, they are still feeling only p art ially back to their original full self. 

They keep telling this to their specialist, who then keeps responding, "we can't increase the dose any further. Your tests are fine now."

When confronted with what may be unfair tyranny of the test, I generally tell my patients they have several options. Any one of their choices might boost them up from their present p art ial recovery to perhaps 90 or 100% of their prior full function.

These options include:

  • Controlled trial of more thyroxine
  • Switching brands of thyroxine.
  • Adding some T-3 (Cytomel) to the thyroxine regime.
  • Switching to Thyrolar (brand name mix of T-3/ T-4).
  • Trying animal thyroid (Armour or Nature-throid).
  • Boosting any medication with natural therapies.

This present discussion will focus only on option #1. 

First of all, 75 or 100 mcg. of thyroxine are a modest dosage for most adults. A well-known professor of endocrinology is convinced that a good "rule of thumb" eventual dose for most of his patients is one microgram per pound of body weight. For instance, a woman who weighs 137 pounds might do well with 137 mcg. of thyroxine (a few brands other than Synthroid are available in pills at this exact dose). A man who weighs 175 pounds might do well with the 175 mcg. pill. Before acquiescing to your doctor's test-result edict of final dose, you might want to ask for a short clinical trial of the medical center professor's protocol of "one mcg per pound of body weight". Keep in mind that the rule of thumb dosage is only a general initial guide, and that it might not apply well in cases of obesity.

If your doctor says "no, I realize you would like more medicine, but I don't think that is wise considering your test results," then you might want to look at your tests very carefully. Most likely your doctor is talking about the level of TSH (thyroid stimulating hormone). Many physicians are wrongly seeking to have their patients arrive at a TSH level that is in the mid-normal range. In actuality, the mid-normal range is a great target goal for most blood test results. However, it is not generally the most sensible goal of therapy for thyroid patients taking thyroid pills. Instead, for most thyroid sufferers, the goal of therapy should be to achieve a TSH near the low end of the normal range. Let us explain why.

The "normal" range of the TSH test generally runs from 0. 4 – 5.2. When I consult with people who call me from different p art s of the country, I suggest to them a therapeutic target range of 0.3 – 0.5. This is at the low end of the test's normal range, not the mid-normal. The reason I do this is that most people who are suffering from low thyroid are ill because of antibodies from the immune system wrongly attacking the thyroid gland, and thereby compromising its function.

This immune attack is often lessened when the thyroid gland is stimulated as little as possible by TSH. Recall that TSH means "thyroid STIMULATING hormone". Rather, the person generally does better when her body runs on thyroid hormone pills, allowing the gland to be in a mostly unstimulated, resting state. The gland thereby receives a well-deserved vacation, in order to heal and repair the immune system damage that caused the illness in the first place. 

Sometimes, both patients and doctors are concerned about this maneuver -- called "TSH suppression" -- where the TSH level is suppressed to just at or just below the lower end of the normal range. They evidently feel that giving the thyroid gland a healing vacation will cause harm or result in the gland being irreversibly turned off. After working in this way for a great many years, consulting for with numerous university specialists, and combing the relevant medical literature, I am totally convinced that thyroid glands are not at all injured by this maneuver.

If you haven't yet begun to feel as well as you would like, then you get to look at this TSH issue very carefully. If the dose of thyroxine you are currently taking (Synthroid, Levoxyl, Unithroid, Levothroid, L-thyroxine, Levothyroxine) has not resulted in a TSH that is down to the lower end of the normal range, then you may not be taking enough medicine. Neither I - nor any other doctor - can promise you that simply taking an amount of thyroxine to reach a TSH of 0.3, or 0.4, or 0.5 will give you full and lasting resolution of your thyroid difficulties. But I can tell you this – it is the next thing to try on your journey to full recovery. You may well be getting short-changed due to an under-informed or overly cautious medical provider. 

Just last week I provided phone advice follow up appointments for four or five people from different parts of the county with this exact TSH issue. It is evidently quite common. I had advised them each, in earlier telephone consultations, to tell their practitioners that medical center endocrinologists commonly aim for a TSH of 0.2 before saying "That's enough thyroxine. More will not be a good idea". They know that insisting on a TSH well within the normal range often condemns patients to less than full recovery of function and enjoyment of life. All of the patients I spoke with in follow-up were pleased to report an improvement. The additional increase in their thyroxine dose resulted in a lower TSH level and also resulted in less symptoms.

One patient, who lives in St. Louis , had previously said his general practitioner was concerned about the possible adverse effect of thyroxine on the heart . When I asked the patient if the doctor had now found anything about heart function that was amiss, he said, "no, she did not." She had reported to the patient that the pulse, blood pressure, he art sounds, and cholesterol levels were actually all improved on the higher level of thyroxine that resulted in the lowered level of TSH. Nevertheless, she was still concerned about possible he art side effects. I was able to put both the patient and his doctor at ease with a quick call to the doctor. I reassured her that without any symptoms on the p art of the patient or clinical signs able to be spotted by the doctor, the likelihood of adverse cardiac problems due to a lowered TSH was negligible. Only those people with a known history of he art arrhythmia, mainly atrial fibrillation, need to be so concerned. 

Another phone consult patient was from Chicago . There, a doctor had told her that he did not want her TSH to go below 1.0 because he was concerned about osteoporosis from too much thyroxine. 

First of all, as we detailed in our book Thyroid Power, this possible adverse effect of thyroxine is not really an issue unless the TSH is suppressed to a level that is below 0.1. (The laboratory results of a TSH that is clearly too low are often shown on lab reports as "less than 0.1", or 0.06, or "less than 0.01"). There is a world of difference between a TSH going below 1.0, which is quite okay to try, and going below 0.1, which should be discouraged.

Secondly, this factor is more of an issue in people who have osteoporosis in their family lineage, or who are already showing signs of osteoporosis themselves. Keep in mind, however, that many people who are being treated for low thyroid have early signs of osteoporosis BECAUSE OF UNTREATED OR LESS THAN FULLY-TREATED HYPOTHYROISISM. These two conditions are known to cause osteoporosis, worldwide they likely have in the past caused much more loss of bone density than has over-treatment with thyroid hormone. Appropriate doses of thyroid medication are not harmful to the bones of hypothyroid individuals. 

The benefits of a full dose of thyroxine are enormous. A full dose could possibly lead to a full recovery. Many people are being prescribed less than a full dose, and are told to be satisfied with it. If you are going to take thyroxine, and just thyroxine alone, at least take an optimal amount of it. The actual proper amount of medicine varies tremendously from patient to patient. Also, keep in mind that taking thyroxine alone is not always your optimal choice.

You deserve to live the fullest life possible. Knowledge is power. We wish you full recovery and empowerment on your thyroid journey! Next art icle we will expand upon the topic of how to obtain additional benefit in symptom relief by simply switching brands (such as replacing Synthroid with Levoxyl).

NOTE: Also in the Thyroid Power book, we have a special section that can help you enormously in getting the dose you need from your health provider. It is called "Show This To Your Doctor". In addition to this support, we have another powerful suggestion for you. In asking your practitioner to aim for a low-normal TSH, you might have better luck in if you write up your own disclaimer ahead of time. A simple statement, inserted into your medical ch art , could go as follows: "I understand that Dr. _________ has advised me that the amount of thyroxine on which I feel most comfortable results in a TSH level that is considered less than optimal by the doctor. I hereby release and hold harmless the doctor for allowing me a clinical trial of this dose. The pro and con have been explained to me."

Keep in mind that this high a dose of thyroxine, and this low a TSH result may not be needed forever. Optimal thyroid dosing is an ongoing process. The ideal level is always a moving target, depending upon many factors. These may include age, constitution, illness, stress, pregnancy, menopause, other life crises, and – in addition - how long you have been on thyroid medicine.

An art icle as it appears on Mary Shomon's website Thyroid-Info
http://thyroid-info.com/articles/shamestsh.htm

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