questions....
Michelle
well. However, we have been monitoring her TSH and it is heading
towards hypothyroidism, based on the old standards. Her last TSH was
4.57, up from the previous value. Her internist said that when the
TSH value reached 5.0, he would treat her. Before her next TSH, which
is scheduled for January, her internist will leave town and we will
see the doctor who replaces him, so that is a bit of an unknown
quantity. (We live in a rural area, so there aren't many choices.)
Anyway, her primary symptoms are feeling cold when everyone else is
warm and memory problems. The memory problems are erratic, and seem
somewhat dependent on her energy level, but not entirely. Of course,
I do realize that she is 84 and the memory issues may be simply due to
age and not directly related to her developing thyroid condition.
Okay, so after that long-winded explanation, here is my question: If
her TSH does not reach 5.0 on the next test, where I am almost assured
she will be treated, should I try and push the doctor to treat her
anyway? I've been reading the group and realize that many now regard
the 5.0 value as being outdated.
Best regards,
Michelle
Wooly
The physician is out of date on thyroid ranges. Typical lab range is
now 0.3 to 3.0. 4.5 is hypo.
Michelle
>
> - Show quoted text -
That's what I've gathered. Unfortunately, it is the lab (Quest Labs,
btw) that is reporting the upper limit of the range to be 5.0. The
doctor is following the lab guidelines. Could you steer me toward a
site that cites the new range? I'd like to go with all the info I can
in order to "influence" the doctor.
Thanks!
Michelle
Wooly
>
> That's what I've gathered. Unfortunately, it is the lab (Quest Labs,
> btw) that is reporting the upper limit of the range to be 5.0. The
> doctor is following the lab guidelines. Could you steer me toward a
> site that cites the new range? I'd like to go with all the info I can
> in order to "influence" the doctor.
>
> Thanks!
> Michelle
>
http://www.aace.com/pub/pdf/guidelines/hypo_hyper.pdf
See specifically the section entitled _Subclinical Hypothyroidism_ which
starts on p6, col2.
The following may also be useful, especially in that the AACE guidelines
for TSH are clearly stated; see items 1-4.
http://www.aace.com/pub/positionstatements/subclinical.php
Basically what those two documents are saying is that standard lab range
for TSH should be 0.3 - 3.0 and numbers outside those ranges warrant
further diagnostic testing and treatment. Since Granny is exhibiting
hypo symptoms the time to get her started on meds has passed - find a
new physician, or beat the current one over the head and steal his Rx
pad, but get her started on some Synthroid.
Odd that Qwest should be reporting lab standard upper limit as 5.0.
I've had work done before by Qwest in Texas, my reports show an upper
limit of 3.0
That is, however, irrelevant - the physician is supposed to interpret
the lab results. The fact that he's relying on the lab to tell him what
the range is for TSH tells me that the physician is clueless and most
likely won't be bothered to remedy that situation.
Remember that physicians are consultants. Drive farther to find a
competent one if you need to.
Michelle
Thanks so much for the links. I'm going to enjoy reading them and
getting the facts! These will help immensely.
You are totally correct that it is the doctor's to interpret the lab
work. Good point! My grandmother will see a different doctor next
time since her doctor is leaving (a blessing in disguise?), so perhaps
my worry will be a moot point and the new doc will be up the latest.
If not, I intend to bring the updated information to her attention.
The Qwest lab reporting the upper limit as 5.0 is in Nevada. One
would think they would all be the same, but perhaps it takes time to
make the change over?
Thanks again!
Michelle
Wooly
> You are totally correct that it is the doctor's to interpret the lab
> work. Good point! My grandmother will see a different doctor next
> time since her doctor is leaving (a blessing in disguise?), so perhaps
> my worry will be a moot point and the new doc will be up the latest.
> If not, I intend to bring the updated information to her attention.
I'm the primary healthcare advocate for my mother-in-law who is in her
early 80s. I've learned the hard way over the past year that physicians
like to dismiss health complaints in the elderly as "simply old age"
when in fact there is often a problem that can be treated properly if
the physician will but take the time to diagnose it.
In your shoes I'd send the information to the doctor tomorrow, phone on
Thursday to follow up and at the same time request that the physician
prescribe a low dose of Synthroid so that in January Granny can be
titrated for a dose adjustment. Based on what you've said Gran is
clinically and symptomatically hypothyroid, the physician needs to treat
now, not in January.
Alan B. Mac Farlane
bookb...@gmail.com wrote on 10/9/07 10:33 AM:
> here is my question: If
> her TSH does not reach 5.0 on the next test, where I am almost assured
> she will be treated, should I try and push the doctor to treat her
> anyway? I've been reading the group and realize that many now regard
> the 5.0 value as being outdated.
>
> Best regards,
> Michelle
Well michelle darling ... the doctor could ... just for an experiment on
your mother play around with clinincal hyperthyroidism.
If you read the PDR (Physicians Desk Reference) there is a big black warning
area in the the few columns devoted to Synthyroid (or what ever thyroid
replacement therapy you would be considering).
Hyperthyroid is a bad thing to do to people, especially old people, as their
candle has only so much wax to burn and when you speed it up ... it might
look like murder if one is not taking due care and diligence.
Not really wanting to play around with dear old mom's life when really all
you are looking for is symptom reduction or symptom management ... not
really reaching a number on the blood labs if you will is the important
thing.
So a more gentle approach is being recomended by me if it was my mom and
giving a good listen to what the doc has to say with a worn down defense
structure working its googlie.
sumbuddie wear blind sea
:)
Alan B. Mac Farlane
bookb...@gmail.com wrote on 10/9/07 11:43 AM:
> The
> doctor is following the lab guidelines.
good idea and gets my vote !!!
Alan B. Mac Farlane
bookb...@gmail.com wrote on 10/9/07 11:43 AM:
> Could you steer me toward a
> site that cites the new range?
go with that 'lab' with the new range is my IMO ... as the old lab as old
range that is wise to stick with.
new lab, new range, then stick with that ...
again, work the symptoms ... not the numbers.
even when you get the new numbers.
gas tank says full, but the engine is sputtering, then maybe the problem is
not the gas but the timing is off ... numbers are fine, symptoms are shit.
been there, done that
Herman Family
"Alan B. Mac Farlane" <al...@sonic.net> wrote in message
news:C3318F31.40EE5%al...@sonic.net...
Your statement is correct for situations where a new test is introduced
with (hopefully) improved results. This is a frequent occurence, and one
would do well to remember your advice on this in those cases. There have
been a lot of folks who disregarded such wisdom and ended up with more
problems.
In this case I don't believe there are any "old labs". In this case,
the tests themselves were not changed, only the limits of normal. In cases
where the tests were changed, they were standardized to the older values.
It is unlikely that the lab is going to have significantly different
results than the other labs. They most likely do a lot of quality control
and round robin testing to make sure that the are all getting pretty close
to the same values.
A few years ago, the endocrinogists finally decided that "normal" should
include mostly folks who actually had functioning thyroids, rather than
include those who were off. I think they upgraded some of their statistical
methods too. At any rate, they moved the interpretation points of the
results. This has been a large factor in many of us feeling a lot better.
It wasn't the test per se, it was that they finally learned more about
reading it.
As far as feeling, it's important to look at the symptoms. In this
case, both the symptoms and the numbers are pointing in the same direction.
It's just that the doctor isn't reading them right. It doesn't make any
sense to have them get worse. The quality of life would be a lot better
with the medication.
Getting a good life quality is hard enough with thyroid problems without
out of date lab limits and doctors getting in the way.
Michael
Michelle
wanting to overly stress an elderly person. However, my basic concern
is my grandmother's memory. Given her age, I realize that the memory
problems may not be related to her developing hypothyroidism. But as
Wooly pointed out, lots of symptoms can masquerade as "old age" when
they're not. And if her memory issues are related to the
hypothyroidism, then it seems insane not to address it.
I read the first site Wooly recommended. However, if I'm reading it
properly, it also suggests not treating hypothyroidism until the TSH
reaches 5.0, although it says treatment should strive for a TSH
between 0.3 and 3.0. I haven't had a chance to study the second site
yet.
I certainly appreciate everybody's help!
Best regards,
Michelle
kgrh...@alum.mit.edu
Severe Hyper- is dangerous. However, long-term untreated hypo- is
also dangerous. There are permanent changes to the heart, and
other cardiovascular problems are worsened. Also, osteoporosis
can result from poor calcium absorption due to hypo- or from changed
bone remodeling dynamics due to hypo.
The doctors know that for SEVERE cases, hyper is worse than hypo.
They then tend to think that for moderate to mild cases the same
is true, when all the data says it isn't.
TSH levels above 3.0 are NOT normal -- no matter what reference
range the lab uses. There is evidence that TSH values above
2.x may well not be normal.
Several competent medical groups, including the American College
of Endocrinologists (I may have the name not quite right), indicate
that for TSHes above 3ish with hypo- symptoms that starting
thyroid hormone replacement is the recommended course.
Overblown and inappropriate fears of medically induced hyper-
are just that -- overblown and inappropriate. In the highly
unlikely case that hyper- should be induced, it is easily
detected and dealt with, as it will be mild to moderate
and self-correcting upon removal of the thyroid hormone.
Not starting treatment for that reason would be like staying
out of a hotel swimming pool for fear of shark attack.
MHOO -- YMMV
Kevin
amanita
> Severe Hyper- is dangerous. However, long-term untreated hypo- is
> also dangerous. There are permanent changes to the heart, and
> other cardiovascular problems are worsened.
Here's a recent article about a new study of the risk of heart conditions
with hypO.
Even Mild Thyroid Problems Double Risk of Heart Conditions
http://www.newswise.com/articles/view/534000/
Newswise - Individuals with subclinical hypothyroidism-a mildly underactive
thyroid only detectable by a blood test-are twice as likely to develop heart
failure, compared to those with normal thyroid levels, according to a new
study being presented on Thursday, Oct. 4, at the 78th Annual Meeting of the
American Thyroid Association (ATA) in New York. Heart failure, also called
congestive heart failure, is when the heart can't pump enough blood to the
body's other organs, which can cause fatigue, ankle swelling and shortness
of breath.
Although previous studies have shown that hyperthyroidism-an overactive
thyroid-and hypothyroidism can cause heart problems, this is the first time
that a large study found a negative effect on heart function when the
thyroid was only mildly under-active.
June
Thanks for this, Kevin... As you say, severe hyper is dangerous, atrial
fibrillation being one of the dangers. Dr. Ken Blanchard (What Your Doctor
May Not Tell You About Hypothyroidism) has some interesting comments. Here
is a quote. Speaking about atrial fibrillation he says:
"This condition is mostly associated with hyperthyroidism, but I suspect a
hypothyroid origin in many individuals. In a monumental study of 2,575
patients over the age of sixty with atrial fibrillation, 101 of them had low
TSH. Of these about half were taking thyroid hormone, and of these 50
patients, 44 were found not to have hyperthyroidism. This is just one of the
many studies in the cardiac literature noting that atrial fibrillation
presents with a low TSH but without other clinical or laboratory evidence of
hyperthyroidism.
My rational for a hypothyroid cause relates to excessive T4 - T3 conversion
at the cardiac muscle cell. This results in T3 hyperthyroidism at the level
of the cardiac muscle cell, even though the patient suffers from
hypothyroidism in peripheral tissues. It is of interest that the most
effective drug to prevent recurrent atrial fibrillation is amiodarone, which
is known to block T3 receptor sites in cardiac muscle cells."
Of course this raises other questions. Dr. Blanchard also comments on
myxedema coma which he claims happens almost exclusively in older
individuals (after age 60) and mostly in women who are untreated. He
mentions that this may happen when the patient is hospitalized and undergoes
surgery which places sever stresses on body systems. (See my earlier post
which discusses the problem with the plunge of T4 especially, but T3 also
during surgery or severe illness).
Also, Michelle, like your grandmother I am 84. What the medical profession
considers *old* always seems to be around 60. That was a long time ago.
Could it be that this changes things? My doctor still warns me at every
appt. how dangerous too much T3 can be. I think it's difficult to keep
second guessing them and trying to understand the subject outselves and
decide what the proper treatment might be. I have surgery coming up in a few
weeks. Your grandmother is lucky to have you.
June
<kgrh...@alum.mit.edu> wrote in message
news:1192046419....@k79g2000hse.googlegroups.com...
Michelle
>
> - Show quoted text -
Hi June,
Thanks for your input and additional information. Since you are my
grandmother's age, may I ask how old you were when you were
diagnosed? And what was your TSH? Symptoms? I'm afraid of being
overly aggressive and encouraging medication that might make her feel
worse since she is on the cusp, so to speak. On the other hand, if
treating her developing hypothyroidism would make her feel better....
Well, you can see my confusion.
I found the information about amiodarone especially interesting
because my grandfather takes it for fibrillation. It works
wonderfully for him. However, his TSH is always where it's supposed
to be.
I'm going to read the articles people have recommended that I haven't
gotten to yet.
Many thanks,
Michelle
June
"Michelle" <bookb...@gmail.com> wrote in message
news:1192127788....@k79g2000hse.googlegroups.com...
Hi, Michelle:
I think, like so many, that I have actually been hypo for most of my life. I
certainly had many of the symptoms. I had polycystic ovaries which were
discovered when I was in my thirties. I was unable to conceive for 11 yrs.
Due to the cysts the doctors decided that I should have a hysterectomy,
something which has caused me many problems since then. But that's when this
idea was in vogue! After reading this newsgroup and reading books I decided
myself that I was likely hypo, but my TSH always flirted with upper limits
for that time, around 6 or so. Since treatment wasn't given then until a TSH
was at ten I was never treated. Eventually an alternative doc made the
diagnosis but was only able to prescribe something that had tyrosine in it
which caused stomach problems. Eventually I found the doctors who could
prescribe armour and then compounded medications. That was about six years
ago. One bonus is that my allergies are gone.
But I have never been able to keep the "sweet spot" when I found it. It
would last only a few weeks at most. Others here have the same experience.
So, I guess my history isn't very useful to anyone else. Good luck!
June
Michelle
> "Michelle" <bookbug2...@gmail.com> wrote in message
>
> - Show quoted text -- Hide quoted text -
>
> - Show quoted text -
Hi June,
Thanks for sharing your history. I found it interesting that your
allergies disappeared after you had treatment. Although my thyroid
tests were normal at last check--several years ago--I have some of the
symptoms of hypothyroidism myself. Low blood pressure, slow pulse,
fatigue, achey joints sometimes. However, there are many other
symptoms I don't have. Anyway, one of my biggest problems is
allergies. I've been through desenstitations shots twice, and finally
moved to the desert. Very little grows here, but I'm still allergic
to the few things that do. I keep wondering if a slight boost in
metabolism will help. However, when the docs don't want to treat even
the borderline cases, I'm sure they won't consider a trial for someone
who tests normal regardless of symptoms of a rather slow metabolism.
Again, thanks. I'm still reading all the info I can get. I'll be
prepared to tackle my grandmother's case soon.
Best regards,
Michelle
Wooly
> Thanks for sharing your history. I found it interesting that your
> allergies disappeared after you had treatment. Although my thyroid
> tests were normal at last check--several years ago--I have some of the
> symptoms of hypothyroidism myself. Low blood pressure, slow pulse,
> fatigue, achey joints sometimes. However, there are many other
> symptoms I don't have.
Make an appointment with your doc and request a full set of thyroid
tests. Results that were "normal" several years ago may not be "normal"
now, and much can change in a few years.
Michelle
This is true. As soon as I get my grandmother's thyroid problem
addressed, I will investigate mine. Fortunately, all the reading I'm
doing for her applies to me too! This brings me to a question I have
about the info from the AACE link you sent me. Unless, I'm missing
something, here's what it says about treatment of subclinical
hypothyroidism:
"We believe treatment is indicated in patients with TSH levels > 10
mIU/ml or in patients with TSH levels between 5 and 10 mIU/ml in
conjunction with goiter or positive antithyroid peroxidase antibodies
or both." This is on page 9.
However once treatment begins, the information states that TSH levels
should fall between 0.3 and 3.0 mIU/ml. "The target TSH level should
be between 0.3 and 3.0 mIU/ml." This also on page 9.
Seems like a big discrepancy between when to treat and what the levels
should be after treatment. Am I missing something?
Thanks!
Michelle
Wooly
> This is true. As soon as I get my grandmother's thyroid problem
> addressed, I will investigate mine. Fortunately, all the reading I'm
> doing for her applies to me too! This brings me to a question I have
> about the info from the AACE link you sent me. Unless, I'm missing
> something, here's what it says about treatment of subclinical
> hypothyroidism:
>
> "We believe treatment is indicated in patients with TSH levels > 10
> mIU/ml or in patients with TSH levels between 5 and 10 mIU/ml in
> conjunction with goiter or positive antithyroid peroxidase antibodies
> or both." This is on page 9.
>
> However once treatment begins, the information states that TSH levels
> should fall between 0.3 and 3.0 mIU/ml. "The target TSH level should
> be between 0.3 and 3.0 mIU/ml." This also on page 9.
>
> Seems like a big discrepancy between when to treat and what the levels
> should be after treatment. Am I missing something?
Well, yes, that is contradictory. "Subclinical" usually means "lacking
symptoms". Your Granny is symptomatically hypothyroid per what you've
reported, as well as having an elevated TSH so really I shouldn't have
pointed you at that particular section.
Bottom line: Granny needs a physician who will trial her on Synthroid.
Michelle
>
> - Show quoted text -
Agreed! I'm working on it. :-)
Thanks,
Michelle
kgrh...@alum.mit.edu
It is rare for someone to get every symptom on the hypo- symptom
list, it is not common to get most. What is common is that someone
will get several of the symptoms on the list and not the others. THat
is
what makes diagnosing by symptoms hard.
Now, when you had thyroid tests, were these TSH only? Or did you
ever have a thyroid panel with T3 and T4 and binding or uptake tests
in addition to TSH?
TSH only testing is prone to missing borderline cases. Many MDs
with years of experience will say that symptoms arise months,
sometimes years, before TSH goes out of range. Yet the history
will show a highish level with a rising trend in many cases.
Several doctors recommend trying a period of low dose thyroid
hormone replacement when symptoms exist even if TSH is
normal, but highish. Normal TSH is NOT a reason for not trying
thyroid replacement. It indicates against that, but does not rule
it out. When there is sufficient other reason to suggest it, you
try the replacement, if symptoms alleviate, you continue.
Disclaimer -- my doctorate is NOT in medicine
Michelle
wrote:
>
> - Show quoted text -
At the time, I did have the T3 and T4 done in addition to the TSH.
Both were normal, although the T4 was on the low side. The normal
range at that particular lab was 4.5-11.0. I came in at 6.3.
Definitely not near the edge, but I remember wondering how I'd feel if
my T4 were around 8 or 9. ;-)
Thanks for the information.
Michelle
kgrh...@alum.mit.edu
>
> At the time, I did have the T3 and T4 done in addition to the TSH.
> Both were normal, although the T4 was on the low side. The normal
> range at that particular lab was 4.5-11.0. I came in at 6.3.
> Definitely not near the edge, but I remember wondering how I'd feel if
> my T4 were around 8 or 9. ;-)
>
> Thanks for the information.
> Michelle
On a linearized rescaling to the lab's reference range, 6.3 maps to
27.7%ile.
We've found for our two hypo-s that we need to keep freeT4 and totalT3
in
the 40%ile to 70%ile band for them to feel well. For my son, with a
T4
level under 30%ile, his allergies are severe, he gets every cold or
flu
around, doesn't sleep well, is highly irritable and constantly achy.
When doctors talk "normal" ranges, they seem to be unaware (or have
totally forgotten) that the "normal" here is the technical statistical
usage,
being the Gaussian distribution, a.k.a., "normal" distribution, and
has
ABSOLUTELY NOTHING to do with "normality" in the common usage
sense. A value can be within the Gaussian reference range for the
lab and be highly ABnormal.
Now, that does not mean that this value is ABnormal. It just means
that
being within the reference range is NOT PROOF OF NORMALITY in
the common meaning for "normality".
Personally, I believe the use of "normal" for labs should be
abolished,
and only "Gaussian" should be used. That way people are not being
set up for misinterpretation of the meaning of the lab values.
But, hey, what do I know? I ain't no M.D. I only have Ph.D. from MIT,
and have taught this !@#$%^& statistics stuff.
Pardon, is my sarcasm showing?
Michelle
wrote:
Yes, just a bit, but I am enjoying it. ;-) I'm going to have to look
up an explanation for the "Gaussian" distribution. I'm familiar only
with the Bell Curve standard deviation that is used to figure the
dreaded "normal ranges". I was a medical lab technologist and am well
aware of the factor that doctors are not scientists and often quote
dogma.
I couldn't help but be interested in your son's symptoms. I also
suffer from aches of unknown origin from time to time, and moved to
the freakin' desert because my allergies were so bad. Did two rounds
of desensitization shots, and kept getting allergic to new things.
Even with only 4 inches of rain per year, I still manage to be
allergic to the relatively few things that grow here, but it is an
improvement. Naturally, the achiness and allergies seem to go hand in
hand.
I've found a place online where I could order thyroid Armour, but have
been hesitant to use myself as guinea pig because I would have no way
of monitoring the levels. I'll admit though that some days it seems a
better alternative than fighting with doctors. I'm mulling.
Thank you, Doctor (not of medicine) :-)
Best regards.
Michelle
Michelle
talking about what I call the Bell Curve. Now I see what you're
saying. Although the normal ranges were originally determined by a
Gaussian distribution equation of "healthy" individuals, the doctors
have forgotten what that normal range really means. The patient's
result may fall within that 2 standard deviation, but it doesn't mean
that it is optimal.
Additionally, I have to wonder about the definition that was used to
define healthy individuals. When I was newbie lab tech, the normal
ranges for cholesterol were age dependent on age, with the normal
range for little old ladies being as high as 300 mg/dl. Later science
came to feel that everybody's cholesterol should be below 200 mg/dl
despite any appearance of supposed health. (Of course, I could argue
that as well, but that's another conversation entirely.) So were the
people deemed healthy when determining thyroid ranges really optimally
healthy?
Best regards,
Michelle