By: Jean Johnson for Medtech1
“I’m glad there’s a flap on hypothyroidism. My grandmother had a goiter, and I come from a long line of women who mostly put on considerable weight as they aged,” said Alice Ciustan of Chicago. “I’ve fought the weight thing all my life and think I’ve had at least some of the symptoms they talk about, but so far no physician has raised the issue with me.”
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| According to the National Library of Medicine within the federal government’s National Institutes of Health: |
An under active thyroid gland causes the body’s normal rate of functioning to slow, causing mental and physical sluggishness.
Risk factors include: Age over 50 years, female gender, obesity, thyroid surgery and exposure of the neck to X-ray or radiation treatments.
Early symptoms can include: Weakness, fatigue, cold intolerance, constipation, unintentional weight gain, depression, joint or muscle pain, thin or brittle fingernails, thin or brittle hair, paleness.
Other symptoms that can appear as the problem develops include: Slow speech, dry flaky skin, thickening of the skin, puffy face and extremities, thinning of the eyebrows, hoarseness and abnormal menstrual periods.
Ciustan said after she heard about the hypothyroidism controversy, she decided to get checked. “I debated on whether I should see an endocrinologist or just my regular physician and ended up just opting for the latter. I wish I’d gone to the endocrinologist, though, because my regular doctor came off with something like, ‘Hey, it’s a simple screening. Either your levels are up or they aren’t. It’s all very routine and something any family practice doctor can handle.’”
Ciustan isn’t so sure, even though her blood tests came back in the normal range. “I’m going to be 58 pretty soon, and they recommend getting your thyroid checked every two years at this age. So next time, I’m seeing an endocrinologist. At least that way, I’ll feel like someone is giving me a more subtle appraisal.”
From many patients’ point of view, the medical community can appear like a united edifice with practitioners all adhering to the same canon of thought and established treatment regimens. But like any field in which humans join together to achieve a particular end, differences in opinion exist.
In the case of hypothyroidism, since the publication of a controversial article in the January 2004 issue of the Journal of the American Medical Association (JAMA), the country’s best endocrinologists have been squaring off over which approach best diagnoses and treats this hormonal deficiency.
Thyroid Stimulating Hormone Levels – What Is Normal?
The JAMA article was written by a team of experts from three associations – the American Thyroid Association, the American Association of Clinical Endocrinologists, and the Endocrine Society. The team was enlisted to review existing evidence and come up with guidelines for physicians. But, the team did not conclude that the medical community needed to be more aggressive in treating hypothyroidism and even stated that patients with slightly elevated levels of thyroid stimulating hormone (T.S.H.) did not need medicine.
Currently T.S.H. blood levels are considered normal if they fall between 0.4 and 4.5 milliunits per liter. Levels that run from 4.5 to 10 milliunits per liter are often labeled “subclinical,” meaning that while this range is slightly elevated, it might not be cause for intervention.
According to an author of several books on thyroid disease and someone who was diagnosed with hypothyroidism in 1995, Mary J. Shomon, “What’s normal for me may not be normal for you. We’re patients, not lab values.”
Shomon’s idea is backed by director of endocrinology and metabolism at the University of Texas Health Science Center in Houston, Phillip Orlander, M.D., “We could all have a different thermostat.”
Similarly, author of “Hormones, Health, and Happiness,” Steven F. Hotze, M.D., takes the position that “You can have a normal blood test and not feel normal. I listen to the patient and if she tells me she has cold hands and feet, brain fog, and lethargy, I put her on a therapeutic trial of thyroid hormone.”
Hypothyroidism – Who is most at risk?
Females are most at risk for hypothyroidism, especially those, like Ciustan, who have a suspect family history and battle obesity. Additionally, women over 60 and all those with Type I diabetes are thought to require more careful monitoring.
How the debate is playing out
The chairman of the team that published the JAMA article and director of endocrinology training at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, Martin Surks, M.D., said of his work, “It provoked a huge ruckus.” That said, Surks observed that “We didn’t say ‘never treat people with subclinical hypothyroidism.’ It’s just that you shouldn’t always reach for the prescription pad when you see elevated T.S.H.”
Au contraire, said Mayo Clinic endocrinologist, Hossein Gharib, M.D. who, with colleagues, published a rebuttal to the Surks article in a following issue of JAMA.
“They say there’s no evidence treatment is helpful, and we argue that there is no evidence that says it’s not helpful,” Gharib said. “What I’ve found in my clinical practice is that it alleviates symptoms even if it’s just a placebo effect.” Gharib estimates that up to five percent of the patients treated at the Mayo Clinic for various problems are diagnosed with hypothyroidism by the prestigious clinic’s physicians.
Another member of the Surks team, a clinical professor of medicine at Mount Sinai School of Medicine, Rhoda H. Cobin, M.D., F.A.C.E., countered that “when a patient has symptoms, there is no controversy about checking for thyroid disease.”
But how symptoms are identified can get fuzzy. President of the American Association of Clinical Endocrinologists Donald Bergman, M.D., said “Dry skin caused by thyroid disease, for instance, is indistinguishable from the dry skin you might get during the winter.”
For her part, Cobin argues that the few studies done on patients with very mild thyroid disease did not give evidence of significant improvement with medication.
But Bergman said, “If someone has symptoms that are vague and has even minimal thyroid dysfunction, it’s worth treating her to see if she feels better. Sometimes a patient who starts medication will say ‘The fog has lifted,’”
Perhaps, said the director of the endocrinology division at Sinai Hospital in Baltimore, David Cooper, M.D. Then again, perhaps not. “I see patients all the time who are miserable and unhappy and want to blame something,” Cooper said. “There are tears and anger when you tell them that it’s not their thyroid that’s causing their problems.”
Alice Cuistan is bothered by Cooper’s statement. “With all due respect, the doctor seems a bit dismissive to me. Like he doesn’t give his patients much credit for being intelligent, rational people. It’s almost reminiscent of all those years women didn’t get their heart attack symptoms taken seriously. Besides, it’s not like I’m a little girl who wants a pill to make it all better, you know? I just want someone to treat my case like the unique one it is instead of simply running through a standardized test. If that’s all diagnosis takes – looking blood levels up on a chart – why do we even need a physician?”
She goes on to muse about not only her medical history, but also that of the other women in her family. “We’ve never been the type to run to the doctor. But now I’m wondering if we’ve erred on the foolish side. When you look at my family tree you see one large farm lady in a print dress after another and none of them look like they had much more energy than I do.
“While it could have just been all the good home cooking and sitting around a bit too much, I really am wondering if there’s been a thyroid problem causing all that lethargy. The idea that generation after generation might not have to have endured all the distress that goes with being obese and sluggish is very compelling for me. And now that I see the symptoms include thin fingernails and dry skin, which I’ve had forever, I really do think I’ll book an appointment with a reputable endocrinologist sooner than later.”