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by Kenneth N. Woliner, M.D., A.B.F.P.* * *
August 2003 -- I would like to clarify the tests that your doctor might order to evaluate whether a low thyroid is the cause (or one of the causes) of your symptoms. I will preface the below recommendations based upon what I do in my clinical practice, and that my opinions are not a consensus statement by any means. I am definitely an “outlier" and I interpret my laboratory tests more generously than my colleagues. I believe I have sound science to back up my practice pattern, but it doesn’t mean that I am 100% right, 100% of the time. Other clinicians may have had other training and other clinical experience, and they may find other diagnostic tests to work better for them. I just seem to get results that I am pleased with (and my patients are pleased with as well).
If you suspect hypothyroidism (underactive thyroid function) – you may consider the following methods and tests to help identify this problem:
Complete a questionnaire on hypothyroid symptoms such as the one found in books by Mary Shomon’s Living Well with Hypothyroidism or Richard and Karilee Shames’
Thyroid Power. You may want to bring a completed questionnaire to your physician for his or her review.
Record your underarm basal body temperature with a glass thermometer (not digital). The procedure for doing so is the following:
1. Get a glass thermometer, not digital (the digital ones stop reading after a minute or two and are not as accurate). Non-mercury glass thermometers are now commercially available at Walgreen’s and other pharmacies (if you have trouble locating a mercury thermometer).
2. Shake down the thermometer the night before you do the test (using your muscles to shake the thermometer will raise your temperature and throw off the test).
Place the thermometer at your bedside with a book (the book will be obvious in a moment).
3. Go to sleep without an extraneous heat source such as a bed partner (spouse, dog, etc), an electric blanket or on a waterbed (they are heated). You are allowed to wear pajamas and use as many blankets as you desire, as they do not throw off the test.
When you wake up in the morning (or if you sleep during the day, when you wake up after at least 4 hours of sleep), use as little movement as possible (all movement moves your muscles and raises your temperature) and place the thermometer in your armpit. Why the armpit? Patients with low thyroid often have allergies or get sinus infections – which raise the temperature inside the mouth. Patients rarely get armpit infections, so this site is more reliable. I have had only one patient who had a difference in temperature between armpits, but that was due to unusual anatomy (she had something called an atrial-venous malformation (AVM) in one armpit). Leave it there for at least ten minutes (hence, you have a book to read. J)
4. Women who still have periods should take their temperature over the first 3 days of their period and average the numbers. Women who have had a hysterectomy but still have at least one ovary will probably want to test over a period of 14 days and use the 3 days with the “lowest" readings. Men and postmenopausal women can test for any 3 days and average.
5. Normal axillary body temperature is between 97.4 and 98.2 degrees Fahrenheit. Temperatures below that are suggestive of low thyroid.
Having your physician perform a physical exam looking explicitly for:
_____ Thinning hair (especially the lateral third of your eyebrows)
_____ Dry skin or signs of eczema or psoriasis
_____ Thick tongue with “scalloping" of the tongue (caused by edema and swelling of the tongue squeezing it against your teeth making teeth marks around the tongue’s edge)
_____ Enlarged thyroid gland or discrete nodules palpated – if so – you may need to have a Thyroid Ultrasound to rule out the potential of thyroid cancer (solid nodules larger than 10 mm are suspect and need further evaluation).
_____ Bradycardia (slow heart rate)
_____ Carotoderma (yellow skin) – this is caused by the inability to convert beta-carotene into vitamin A (you need adequate thyroid hormone to do this)
_____ Bumps on the back of the upper arms - caused by buildup of beta-carotene under the skin)
_____ Myxedema / “non-pitting" edema or swelling of the ankles that “bounces" right back when you push on it similar to the way a balloon would bounce back if you pushed on it. This is not the same thing as “pitting-edema" that stays “indented" for a few seconds after you remove your finger from the skin (like the Pillsbury doughboy). Pitting edema is caused by water retention (which has multiple causes that aren’t relevant to discuss here).
_____ Decreased deep tendon reflexes (such as when your doctor bangs on your knees with a reflex hammer). A “delayed return phase" of the ankle jerk reflex is a pretty sensitive indicator of low thyroid.
Have your physician order the following blood tests:
If You Have Normal Laboratory Tests, Could Your Thyroid Still Be Causing Your Symptoms?
- TSH (thyroid stimulating hormone) – Though the reference range according to the lab I work with is 0.5 – 5.5 mIU/L, I consider anything over 3.0 mIU/L suspect for low thyroid. (Important Note: The recommended reference range for TSH is now .3 to 3.04, according to National Academy of Clinical Biochemistry's revised testing guidelines issued in late 2002).
- Free T4 (not total T4 and not a “reflex T4" if the TSH is abnormal) – those other tests are thrown off for various reasons so the directly measured Free T4 is the most accurate measure. Quest Diagnostics’ normal range is 0.8 to 1.8 ng/dL and I aim to keep my patients greater than 1.4 ng/dL.
- Free T3 (not total T3 or T3RU) – as discussed above, I also like to be in the higher end of the normal range (Quest 230-420 pg/dL) and I shoot for a value greater than 300 pg/dL.
- Thyroid Peroxidase Antibodies AND Thyroglobulin Antibodies – for Quest’s Nichols Institute, any value greater than 2 IU for either test is positive for Hashimoto’s Thyroiditis.
- Reverse T3 – there is debate on whether any lab reliably tests this hormone. I have been “underwhelmed" by the reliability of every lab I have tried to use, so I have discontinued ordering this test for now.
- You will not be able to order a “TSH following TRH test" as Thryel (the brand name for TRH) is no longer being made by Ferring Laboratories and there is no other supplier of this test substance.
- It is not necessary to order a thyroglobulin as we are testing free levels of T3 and T4. Thyroglobulin, however, is important to follow in patients recovering from thyroid cancer, and would be ordered in such cases.
There are many things that can cause weight gain and inability to lose weight. There are many things that can cause fatigue. There are many things that can cause cold hands and cold intolerance. In fact, there are many things that can cause many of the symptoms commonly associated with low thyroid. When my patients come in with a constellation of symptoms, I use my patient’s clinical history more than anything else to figure out where the true problems lie. When many symptoms that can be caused by thyroid dysfunction are all going on at the same time, it is highly likely that those symptoms are all being caused by thyroid, rather than by six or seven different things, each causing only one or two symptoms each.
Despite “normal" laboratory tests, low thyroid can still be the cause of your symptoms. There are some types of thyroid hormone resistance that are not clearly identified with laboratory tests currently available. As I mentioned above, I hold the opinion that “Reverse T3" is not reliably tested and is not sensitive enough to detect all patients that have this problem. So despite a “normal" test, I cannot “rule out" this phenomenon from existing. There are also other tests for thyroid hormone resistance such as Thyrotropin-Binding Inhibitory Immunoglobulin, Anti-T3 Autoantibody, and Anti-T4 Autoantibody. When I have spoken to the pathologists specializing in endocrinology at the Nichols Institute, they have not encouraged me to order these tests, as there still are problems to be worked out with the reliability of the assays currently used.
Just because one can’t reliably test for thyroid hormone resistance, it doesn’t stop the hormone resistance from occurring, and it should not stop the clinician from offering effective treatment. This concept is not new. In adult-onset diabetes, insulin hormone resistance is the hallmark. Most doctors do not know what causes this condition (Dr. Diana Schwarzbein, M.D., is perhaps one of the closest to tweaking this out), but that doesn’t stop doctors from giving extra hormone (insulin) when other less aggressive treatments fail. Unlike thyroid – they know better than to test levels of insulin hormone, but instead test insulin’s effect on the body (it’s ability to regulate blood sugar levels). When I suspect thyroid hormone resistance (whether proven by positive thyroid antibodies or not), I stop testing levels of thyroid hormones and monitor thyroid’s function instead (patient symptoms, body temperature, and physical findings).
A Final Word: Bewere the “Tack Rule"
One of the biggest problems that my patients have to deal with requires them to understand that they may have more than one underlying condition causing their symptoms. Some people only have one concern (such as low thyroid), but most of my patients have let their condition progress to the point that they now have multiple causes for their problems and complaints. Dr. Sidney Baker, MD describes “The Tack Rule". If you sit on a tack, removing it makes you feel a heck of a lot better. But if you sit on two tacks, removing one does not result in a 50% improvement.
Along with low thyroid, I often see other hormone imbalances of the adrenal glands (adrenalin, DHEA and cortisol); imbalances of sex steroid hormones (estrogen, progesterone, testosterone and DHEA); and insulin resistance. Vitamin and mineral deficiencies are common and can be both the cause and effect of low thyroid function. Toxicities of heavy metals such as mercury and cadmium can affect thyroid function, and low thyroid can predispose to infections of candida (yeast) and other bad bacteria and parasites.
Yes, hypothyroidism is distressingly becoming more prevalent in the United States and the rest of the civilized world; but the same is true for diabetes, adrenal fatigue, and other “Western" diseases. So, just because you were fortunate to find a clinician who was able to diagnose your thyroid condition, do not forget about these other potential issues as well.
ABOUT KENNETH WOLINER, MD
Dr. Kenneth Woliner is a board-certified family physician in private practice in Boca Raton. Though he often recommends vitamin supplements, he does not sell them due to conflict of interest concerns. He can be reached at Holistic Family Medicine, 2499 Glades Road #106A, Boca Raton, FL 33431; 561-620-7779. E-mail: firstname.lastname@example.org
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