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Is thyroid replacement a performance-enhancing drug?

Has one physician uncovered the secret to Olympic Gold medals? And is that secret as simple as undiagnosed low thyroid function? That’s the question posed in a recent Wall Street Journal column entitled U.S. Track’s Unconventional Physician. Like the story that Steven Novella described yesterday, this narrative describes the medical practice of Dr. Jeffrey S. Brown, who sees thyroid illness where others see normal thyroid function. He has his critics, but his high-profile athlete patients have won a collective 15 Olympic gold medals. Case closed & Q.E.D.? Not quite. The WSJ actually does a pretty good job questioning the validity of Brown’s claims, which are far removed from the current medical consensus:

In athletic circles, Brown is a medical hero. He’s a paid medical consultant to Nike. The most renowned running coach at Nike, Alberto Salazar, calls Brown the best sports endocrinologist in the world. And athletes in growing numbers are coming to share Brown’s belief that heavy training can suppress the body’s production of the thyroid hormone, leaving them too exhausted to perform at peak. On the wall of the medical office of Jeffrey S. Brown is a photograph of Carl Lewis, the nine-time Olympic gold medalist. Lewis is one of several former or current patients of Brown’s who have climbed the Olympic podium, including Galen Rupp, who won a silver medal in the 10,000 meters at the London Olympics. “The patients I’ve treated have won 15 Olympic gold medals,” said Brown. Among endocrinologists, Brown stands almost alone in believing that endurance athletics can induce early onset of a hormonal imbalance called hypothyroidism, the condition with which he diagnosed Lewis and Rupp. Brown said he knows of no other endocrinologists treating athletes for hypothyroidism, a fatigue-causing condition that typically strikes women middle-aged or older. Several endocrinology leaders had never heard of hypothyroidism striking young athletes.

Now when I read “unconventional” and “stands alone” my skeptical alarm starts ringing. There is no shortage of debate about thyroid disease, ranging from the utter nonsense offered by “alternative health” practitioners to valid scientific discussions about the thresholds where normal function is considered abnormal and subject to treatment. Brown is an endocrinologist, however, and he’s treating elite athletes who are pushing their physical conditioning far beyond that seen by most medical doctors and almost all endocrinologists. So what’s the basis of the concern? The WSJ story goes on to discuss two different issues: What the proper threshold is for thyroid disease, and whether thyroid replacement is performance enhancing.  Let’s take each of these in turn. I’ve covered thyroid diseases and its related pseudoscience before, and a summary of the standard approach is necessary before we look at the some of the broader questions that have emerged from the story. All I know about these patients is what the WSJ is describing, so for the sake of brevity I’m going to focus on the types of cases that Dr. Brown appears to be identifying and ignore other causes of thyroid disease, which would require different treatment approaches.

The Diseased Thyroid
Simplistically, they thyroid gland acts as a sort of thermostat for the body. If it runs too high, you’re hyperthyroid: heat intolerant, anxious, a high heart rate, and maybe some diarrhea. If it runs low, you’re hypothyroid: cold, tired, constipated, and possibly even depressed. These multi-organ effects are triggered by the presence or absence of two thyroid hormones: thyroxine (T4) and liothyronine (T3). Normal thyroid function is something you never notice. But low thyroid function is common (4-10 % of adults), particularly in women. The overwhelming majority of cases (95%) of low thyroid, or hypothyroidism are primary, and the major cause of primary hypothyroidism (in parts of the world where we get adequate iodine) is autoimmune thyroid disease (Hashimoto thyroiditis). That is, the body attacks its own thyroid. As the thyroid’s function decreases, and T4 levels drop, the pituitary releases thyroid stimulating hormone – it’s effectively trying to “turn up the thermostat” to continue my analogy. A highly elevated TSH signifies thyroid dysfunction. There are other tests that can be done to confirm the diagnosis, including measurements of circulating T4 and antibody measurements, but TSH is the test we rely on as the primary diagnostic test.

Like any laboratory measurement, what’s considered a “normal” TSH is based in part on clinical studies, but also on the testing standard. Most labs identify an upper limit of TSH at 4 to 5 mU/L, but there are proponents of both higher and lower thresholds. Consequently there will be variations in practice between physicians in what they consider a “high” TSH and what’s considered “normal”. There is also some debate about a condition called “subclinical hypothyroidism”, where there are some laboratory signs of a thyroid dysfunction (a “normal” T4 and a slightly elevated TSH), but it’s not sufficient to warrant a diagnosis.  A Cochrane Review suggested that treating subclinical hypothyroidism doesn’t seem to result in meaningful differences in symptoms or quality of life, nor does it decrease cardiovascular morbidity. But neither did these studies look at the performance impact in elite athletes.

Not unexpectedly, Dr. Brown is a proponent of a using a low threshold to diagnose thyroid disease, setting a threshold that most endocrinologists consider normal:

According to American College of Endocrinology literature, the range of normal TSH level is broad, from 0.5 to an upper limit of near 5, depending on a patient’s gender, age and other factors. In practice, many endocrinologists consider TSH levels above 4—combined with symptoms such as fatigue—evidence of an underactive thyroid. Brown and a small camp of other endocrinologists argue that thyroid insufficiency can be signaled by a TSH level as low as 2, for which Brown cites some recently published research. By their standards, about 10% of the population is hypothyroid—double the 5% that is cited by mainstream endocrinology. Jeffrey Garber, American College of Endocrinology president, said hypothyroidism increasingly is being diagnosed in people who don’t have it, by endocrinologists whom Garber labeled as “alternative.” “The alternative crowd is saying, ‘Gee, this is why you’re not feeling better, because these [mainstream] doctors are clueless,’ ” Garber said. So if this reporting is accurate, Brown is looking at the same test results and seeing what he believes to be thyroid disease, where his peers see normal thyroid function.

Perhaps not surprisingly, Brown has his defenders, including bloggers who rail against “mainstream” endocrinologists who “stubbornly cling to the outdated ideas that hypothyroidism is easy to diagnose”. Sound like familiar rhetoric? It will if you’re a regular reader of this blog – every “maverick” physician will invariably have their defenders. But they’re usually not Olympic gold medalists:

Medical privacy rules forbid Brown from naming all the athletes he has treated for that condition. But among those who have publicly acknowledged being treated for thyroid problems by Brown or unnamed other physicians are American runners Ryan Hall, Galen Rupp, Amy Yoder Begley, Bob Kennedy and Patrick Smyth. “I knew hypothyroidism was kind of like something that was being diagnosed more among elite runners,” said Smyth, a marathoner who in 2011 started feeling chronically tired. When a physician near his California home found no evidence of thyroid dysfunction, Smyth flew to Houston to see Brown, who conducted some blood tests and diagnosed him with the condition. Smyth, now retired, said the medication never enhanced his performance.

The WSJ suggests that there may be some relationship between the rigorous training and the thyroid function itself, in which case the thyroid supplementation is simply restoring “normal” function. This seems to be what Brown believes, seeing dysfunction where other physicians see normal thyroid activity. Setting aside whether or not these athletes actually do have “low” thyroid, we can ask if thyroid treatment is actually offering a performance benefit when administered to patients with a TSH between what appears to be Brown’s cutoff of 2 and the standard cutoff of 4 or 5. Certainly Brown thinks so, or he wouldn’t be prescribing thyroid replacement. Given the extent to which these athletes push their bodies, even a subtle amount of fatigue, if ameliorated, could potentially improve performance. And overtraining leading to fatigue is likely a risk for athletes training at this intensity. From this perspective, it raises the question of whether thyroid replacement can be considered a form of doping – a recovery-enhancement or fatigue-deferring boost not available to athletes who didn’t go see Dr. Brown. T4 is a hormone, after all, and it will have effects on fatigue and recovery from exercise.

One of the differences that thyroid replacement has from other forms of sports supplementation is that there is a clear peak point – normal thyroid function. Thyroid replacement in the absence of real deficiency could create a hyperthyroid state which would possibly hurt athletic performance as much a hypothyroidism. Overt hyperthyroidism causes anxiety, insomnia, weakness, perspiration, and mood swings – nothing an athlete wants. Even subtle hyperthyroidism could have negative effects for elite athletes. And the long-term consequences are significant. Thyroid replacement is a life-long commitment. And long-term it has side effects including cardiovascular and bone risks – excess thyroid is a definite “bone eater”, with bone resorption stimulated and osteoporosis being the result.

Conclusion
The Wall Street Journal‘s profile of Dr. Brown and his unorthodox management of elite athletes raises interesting questions about the basis of disease, the conditions for drug treatment, and the implications on the ethics of sports.  Over time, thyroid replacement could go one of two ways. It could continue to be treated like inhaled anti-asthma medications, where asthmatic athletes who require treatment would otherwise be at a serious disadvantage in athletic competitions. We’d consider this simply a leveling of the playing field for those athletes. Or it could be that thyroid replacement could be scrutinized even more closely, perhaps requiring better documentation to justify use in an athlete, requiring clearly-demonstrated medical need based on a specific set of parameters, recognizing that there’s thyroid replacement, and then there’s unnecessary supplementation. From my personal perspective, I’m skeptical of medical mavericks who haven’t yet produced enough evidence to convince their peers and change the medical consensus. Until I see the evidence, I’m staying skeptical of Dr. Brown’s approach.

Posted in: Medical Ethics, Science and Medicine

Leave a Comment (29) ↓

29 thoughts on “Is thyroid replacement a performance-enhancing drug?

  1. Scott: Have you looked at this criticism of synthetic thyroid medications:
    http://www.stopthethyroidmadness.com/doctors-need-to-rethink/

    Would like to hear your opinion on it and the alternative natural dessicated thyroid hormones they propose as a better medication.

  2. goodnightirene says:

    Golly Scott, the link from FBA takes you to a site that puts “peer review” in scare quotes! That should convince you.

    On another note, every woman wanting to lose a few pounds and feeling fatigued (however that is defined) wants to get her thyroid checked and is crestfallen when the test comes back as normal. I have had the name of an “understanding” doctor whispered to me more than once and was sorely tempted. Luckily, reason prevailed and I lost the weight without the quack or the alteration of my thyroid activity.

  3. 8bitsdeep says:

    Read through this and the older thyroid article you wrote, Scott. Thanks for writing them. I’ve been struggling with hypothyroid symptoms for about two years now, despite taking first Levothyroxine and then brand-name Synthroid. I was also on Cytomel briefly, though I stopped due to nausea. Occasionally my Synthroid dose would be bumped up and I’d feel better briefly but my symptoms always seem to come back within a few months.

    My endo recently switched me to Armour, which I was a bit weary of because of the possible dosage variance, but at this point I’m willing to give it a shot.

    I’m wondering if my troubles might point to the secondary hypothyroidism you mentioned briefly in your other article. Any good resources or advice would be greatly appreciated. It’s so hard to find good info with all the rubbish quack sites around.

  4. masskk says:

    I’m certainly not an endocrinologist, but am curious about this. Perhaps, I’m stating the obvious, but (as a dietitian) I’m wondering if these athletes body composition/low body weight isn’t factoring? Could it be possible (in the men) that something like the “female athlete triad” is occurring? Chronic low energy intake (relative to output) under extensive training regimens. If so, wouldn’t treating with thyriod have negative impact on bone? The male athletes mentioned all weight less than 140 pounds.

  5. WilliamLawrenceUtridge says:

    Heh, it’s got a “TM” right on the webpage title, and a nine-point manifesto. Point 1 is “Big Pharma” mixed with a little “doctors don’t know everything” (which re-appears at point 8, which itself contains false dilemma and straw-man). Points 3 and 6 are an appeal to nature. Point 5 is unsourced. Point 7 blames the patient (and doctors). Point 9 is a bit of “THINK OF THE CHILDREN” that FBA seems so fond of. And, because no quackery is complete without a nod to other types of quackery, chapter 15 is about shilling supplements and diet changes.

    And the whole thing is an advertisement to buy a book, published by a company which appears to publish only one thing – the same book. Real research is published in peer reviewed journal articles, which are pretty much free.

    Why would you consider this book credible, but distrust what doctors and researchers, who live and breathe nothing but actual research and experimentation on thyroid hormone’s effects on the body?

  6. Harriet Hall says:

    There are good reasons to use synthetic thyroid meds. See http://www.quackwatch.org/01QuackeryRelatedTopics/armour.html

    But there is also a reason some patients are switched to the “natural” version: http://www.ncbi.nlm.nih.gov/pubmed/9971866

  7. @WLU:

    Yes, there is some anti-establishment rhetoric there, but understandable coming from a person misdiagnosed for 20 years.

    I havent read the book, this site was sent to me by a patient who is hypothyroid, and is convinced hypothyroidism is both underdiagnosed and badly treated.

    The thesis is that on diagnosis side, measuring TH4 is not enough, measuring TSH is not useful, and synthetic levothyroxine does not provide the full range of needed hormones for some hypothyroidism sufferers.

  8. windriven says:

    @FBA

    “there is some anti-establishment rhetoric there”

    “Rage against the machine” is anti-establishment rhetoric.

    “No matter what research, statistics, your medical school, the Pharmaceutical Rep, or your peers say…” is ignorant and delusional.

    OK, not regarding the pharma rep.

  9. @windriven

    I think she’s frustrated nobody wants to run a clinical trial testing animal thyroid extract as a treatment, and make it legit in the eyes of the medical community.

    From what I gathered reading Harriet’s piece, the main criticism of animal thyroid extracts is that the ratio of hormones is different in a pig than a human (4:1 vs 14:1). Well, synthetic levothyroxine is not exactly what human thyroid produces either.

    Results from treatment of hypothyroid patients with Synthroid only show that their blood tests seem to improve but their wellbeing isnt! See the study here: http://www.ncbi.nlm.nih.gov/pubmed/12390330

  10. mousethatroared says:

    My experience with fatigue, various symptoms, thyroid levels and auto-immune disease(s) was summed up by Shakespeare.

    ‘There are more things in heaven and earth, Horatio,
    Than are dreamt of in your lab tests’

    or something like that.

    I think, yes, mainstream or SB medicine is somewhat clueless when it comes to all auto-immune diseases. There is still a lot to learn in that area. The doctors I’ve had the most success with seem to try to not over estimate what they know and incorporate the patient’s reported symptoms into diagnoses and treatment.

    On the other hand all areas that are not well understood by science attract woo like a moth to a flame and it can be hard to separate who’s science based and who’s not in endocrinology. I personally wouldn’t trust a doctor who was willing to prescribe a lifelong medication that can has risks like synthroid based on patient reported symptoms alone. I try to tread with caution and do what I can to balance possible risk, cost and convenience with possible benefit and quality of life and then I hope for the best.

  11. WilliamLawrenceUtridge says:

    Addressing my criticisms of a website through links found within the same website is more of an ouroboros than a meaningful response.

    Patients are often convinced of things, and the things they are convinced of may be wrong. While I may have sympathy for the suffering of patients, that suffering does not mean that they are right and the doctors are wrong.

    We are back to the same position we were in regarding Burzynski last week – if this is a true effect and not merely unsbustantiated or pseudoscientific rhetoric, it can be demonstrated through research. Not carrying out said research but stridently continuing to promote the idea from a patient-advocate perspective reduces the chance that said research will be conducted.

    Profiting from the lack of research by self-publishing a book criticizing the medical establishment and Big Pharma seems rather hypocritical and is also a rather obvious conflict of interest.

    A web page that implies it is superior to actual research because it is based on “a massive amount of first-hand reports by a large body of thyroid patients” shows a failure to appreciate the importance of controls and systematic observation, as well as the ability of the mind to create false correlations that are never tested.

    A web page that conflates hypothyroidism with numerous easily-verified conditions like anemia and low B12, not to mention unverifiable conditions like chronic fatigue syndrome on the basis of symptoms also seems questionable.

    Yes, these are claims. Whether they are true is completely separate. Doctors are constrained to offer treatments for which there is good evidence. The person writing and self-publishing this book (and claiming “it’s the fluoride“) has no such constraints. Well-intentioned false hope is still false hope. A web page recommending naturopaths, the American College for Advancement in Medicine and functional medicine is probably selling false hope.

    Again, it would be nice if we had effective, safe, evidence-based treatments for all health problems and symptoms. Failing to have this does not mean that anyone proclaiming they have The Cure is correct.

  12. mousethatroared says:

    FBA – From what I’ve heard (from my endocrinologist) the main problem with Armour is that the levels of thyroid hormones tend to be more inconsistent that the synthetic. Since hyperthyroidism has health risks the inconsistency is a concern.

    Also, there has been availability problems.

  13. mousethatroared says:

    Which is not to say I’m against Armour. I don’t think it’s a good match for me, though.

  14. nickmPT says:

    Better living through chemistry. Seriously though, athletes will go to all manners of “performance-enhancement.” Some stick kinesiotape all over their bodies, some where those power bracelets, some have rituals/superstitions, others apparently go see the “Athlete’s endocrinologist.” The tried and true, of course, just go the traditional route of steroid or HGH or EPO.

  15. The Dave says:

    Another downside of Armour Thyroid is, apparently is smells horrendous. When we were learning about thyroid dysfunction and the drugs to treat it, our professor told us it smells horrible and the next time we were in the pharmacy on our rotations to take a whiff of it.

    Oddly enough, I didn’t smell anything. I had one of the techs smell it and they said it smelled bad. I then tested my nose against penicillin and definitely smelled that. I thought it was kind of strange.

  16. windriven says:

    @FBA

    “Results from treatment of hypothyroid patients with Synthroid only show that their blood tests seem to improve but their wellbeing isnt!”

    I had a look at the abstract of the Clinical Endocrinology study you linked. I don’t have access to that journal and am not interested enough (no reflection on the issue – it is just outside of my area of expertise) to spend the money to jump the paywall. But one thing hit me immediately. This may, of course, be addressed in the body of the article.

    “Over 1% of the UK population is receiving thyroid hormone replacement with l-thyroxine (T4). ”
    “Computerized prescribing records of five general practices were used to identify 961 patients who had been on thyroxine for a minimum of 4 months…”

    My first question is whether or not the patients in the Tx group were all accurately diagnosed and that the “persistent lethargy and related symptoms” owe to hypothyroidism. Saravanan, et al cited 1% of the UK population receiving T4 replacement. But Hollowell* puts clinically evident hypothyroidism in the US at only 0.3%. Is hypothyroidism in the UK over-diagnosed? If so, T4 supplementation may be as useful for lethargy in this population as antibiotics are for viral infections.

    *Hollowell J, Staehling N, Flanders W, et al: Serum TSH, T4, and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002;87(2):489-499.

  17. 8bitsdeep says:

    @TheDave Odd, I hadn’t heard that. Just took a sniff and it smells kinda like dry cat food to me, but it’s not a strong smell at all.

  18. mousethatroared says:

    Windriven, I believe that clinically evident hypothryoidism is just based on high TSH. There are still reasons to treat sub-clinical hypothyroidism. Check out https://www.aace.com/files/position-statements/subclinical.pdf

    So, I’m not sure that the .3% number is a good estimate to look at for people who should be on thyroid replacement.

  19. David Weinberg says:

    Using Dr. Brown’s reasoning, Lance Armstrong wasn’t doping, he had anemia and growth hormone deficiency. Since he’s an elite athlete, the normal values for these parameters don’t apply to him.

  20. DavidRLogan says:

    Fun read, Scott! A couple thoughts:

    1) I don’t think the problems of taking thyroid in this manner (absence of real deficiency) are going to be problems for Olympic athletes. For instance, if you’re taking modafinil before every race, insomnia from thyroid’s going to be the least of your problems…and you will be ready to run at the gun! Lots of the drugs they take are to hide the side effects of the other drugs, which you obviously know (like aromatase inhibs for anabolics, etc. etc.) And this group is not notoriously the most forward thinking of human beings…

    2) Another thing you (or the skeptic generally) might say in response to this guy is that these people are doing so many things to enhance performance (taking boatloads of drugs as mentioned by commenters above, getting constant PT, etc.) it’s a bit much for this doc to suggest this one intervention makes for champions (I am surprised his athletes got labs done at all). Given all the investigative journalism of the past 10+ years it seems a bit much to think only his athletes were taking thyroid (it is readily available…particularly for someone at that level…usually taken to shred fat not to “improve performance” which is quite vague), or that every athlete is clean unless they work with a doc like this, or that every cheater has been caught, etc.

    WLU nice use of “ouroboros”. I had to look that one up (not that it matters….I’m a blockhead).

  21. WilliamLawrenceUtridge says:

    It’s the kind of word you try to work into conversations whenever possible. Omphalos is another, but one with which I have had no success. How does one work “Greek navel stone” into a conversation?

  22. Davdoodles says:

    “He has his critics, but his high-profile athlete patients have won a collective 15 Olympic gold medals.”

    And don’t forget the Placebo-Band effect. If gold meddalist X wears one, I’d better do that too. And soon there’s a gaggle of them, all quacking about how great Thyroxine is.

    I’m guessing Dr Brown is already bronzing for his starring role in an infomercial.
    .

  23. BillyJoe7 says:

    Scott,

    If the TSH is equivocal, why wouldn’t you then measure T4, T3, and antibody levels to confirm Hashimotos?
    If all levels are within the normal range, how could a diagnosis of hypothyroidism be justified?

  24. BillyJoe7 says:

    8bitsdeep,

    “I’m wondering if my troubles might point to the secondary hypothyroidism”

    In primary hypothroidism, your TSH would be high. In secondary hypothyroidism (meaning secondary to a pituitary disorder) your TSH would be low. There is also tertiary hypothyroidism due to a hypothalamic-pituitary axis disorder and, likewise, your TSH would be low.

    Google is your friend: http://en.wikipedia.org/wiki/Hypothyroidism

  25. MaryShomon says:

    This post mentions the “valid scientific discussions about the thresholds where normal function is considered abnormal and subject to treatment,” but does not fully acknowledge that the very real controversy about thyroid blood testing is at the heart of the issue and underlies Dr. Brown’s approach. In the past decade, the endocrinology world has gone back and forth regarding the reference range for the TSH test, and how to diagnose subclinical hypothyroidism. Today, a patient can walk into an endocrinologist’s office with a TSH of 4.49, a family history of autoimmune disease, and a long list of thyroid symptoms, and be sent away with nothing but a prescription for an antidepressant. That same patient with a 4.51 TSH would be diagnosed and treated by the endocrinologist. At the same time, they can cross the hall to another endocrinologist’s office, and with that 4.49 TSH test result, be diagnosed with and treated for hypothyroidism. This is far from science-based.

    There is also the issue that many endocrinologists and physicians do not test for autoimmune Hashimoto’s disease — despite peer-reviewed, double-blind, journal published evidence that even when TSH levels are in the normal range, if antibodies are present, treatment may help with symptoms and prevent progression to overt hypothyroidism. For those patients, even normal TSH, Free T4 and Free T3 levels — alongside elevated thyroid peroxidase antibodies — may cause hypothyroidism symptoms which in some cases are relieved with treatment that supplements, but does not push them out of the reference range for these hormones.

    As can be seen in my article that you linked to, not all of Brown’s defenders are mere bloggers. The article you linked to includes comments from a number of prominent physicians who successfully treat thousands of thyroid patients each year.

    Finally, iatrogenic hyperthyroidism does have risks and side effects, but improved athletic performance is not a typical side effect of overmedication on thyroid medication. If anything, iatrogenic hyperthyroidism is debilitating, and would have a negative impact on athletic performance. At the same time, there is no evidence supporting the idea that treating borderline or subclinical hypothyroidism — and maintaining patients within the reference range, even a narrower one — has the same impact as hyperthyroidism, whether subclinical or overt, much less negative side effects.

    As long as endocrinologists are incapable of agreeing on the interpretation of the one test they hold up as the so-called “gold standard” for diagnosing and managing hypothyroidism, fail to understand, diagnose, or manage Hashimoto’s disease, and do not understand the complexity of hypothyroidism and thyroid hormone replacement treatment, attempts to discredit physicians like Dr. Brown seem like just more familiar rhetoric to the community of patients and forward-thinking physicians.

  26. @MaryShomon

    Hypothyroidism is a condition that seems both underdiagnosed and overdiagnosed, as strange as it sounds.

    On one side, there are people who have subclinical hypothyroid, dont get taken seriously by the MD and go home with an “antidepressant pack”.
    On the other, there is Karl Lewis and the athletes who dont need any medication, but take it for doping purposes, or as a weightloss aid.

    What would you like to see change in diagnosis of thyroid disease?

  27. MaryShomon says:

    @FastBuckArtist

    There is certainly some genuine overdiagnosis of hypothyroidism, but the total number of people affected pales in comparison to the vast underdiagnosis (and misdiagnosis) of hypothyroidism. Some studies have estimated that as many as half the hypothyroid population in the US is undiagnosed.

    The TSH reference range is just that — a reference — and there is growing evidence that individuals have unique thyroid setpoints, which argues for more in-depth interpretation by physicians who consider symptoms such as energy, metabolism, reflexes and such — as well as family history and status of other hormones — as additional data upon which to ultimately make a diagnosis.

    There is also evidence that time of day of TSH testing, as well as the handling/heat exposure/exposure to elements of blood samples, can affect the resulting TSH test result, making the test somewhat inaccurate in some cases. This is why a thorough thyroid panel should also measure Free T4 and Free T3 – the actual circulating thyroid hormones in the bloodstream – to see if they are at optimal levels. TPO antibodies should also be measured to establish whether autoimmune Hashimoto’s disease is present. The standard practice, however, is to measure only the TSH – and even then, there isn’t agreement as to what constitutes the normal reference range, as I noted.

    This means that it is controversial at best to declare that these athletes are “doping” with thyroid medication, when they may in fact be receiving treatment for subtle thyroid insufficiency or autoimmune Hashimoto’s disease that is only detectable with a more comprehensive and knowledgeable assessment that few doctors conduct.

    And again, since there is no evidence that iatrogenic – or any other — hyperthyroidism improves athletic performance (but there is evidence that it hinders it) – the argument against Dr. Brown’s approach falls apart, and starts sounding more like sour grapes from less successful colleagues, than science-based criticism.

    Not long ago, high blood sugar levels that were under the line for a Type 2 diabetes diagnosis were dismissed by many endocrinologists, but treated by integrative physicians. Now, those same levels are universally considered to be evidence of insulin resistance/metabolic syndrome — and treated by most doctors, to prevent progression to full diabetes. With varying interpretations of TSH levels still the norm, we are in a similar period of flux for hypothyroidism diagnosis. “Mavericks” like Dr. Brown — and many integrative physicians — are likely practicing in a way that most endocrinologists will eventually be practicing — albeit a decade down the road or more–as more data becomes available and as practitioners gain a more comprehensive understanding of the complexity of thyroid diagnosis.

  28. @MaryShomon

    This is why a thorough thyroid panel should also measure Free T4 and Free T3 – the actual circulating thyroid hormones in the bloodstream – to see if they are at optimal levels.

    Do you factor the patients’ dietary choices into whats a “normal” level? From working with people on low carbohydrate weightloss diet, I know their thyroid hormone levels are different from a high carb eating person. Some study on this topic: http://www.ncbi.nlm.nih.gov/pubmed/2742328 and other types of nutritional stress that cause low levels of T hormones in blood like Euthyroid sick syndrome.. a condition that is not considered to require any treatment.

    What I am trying to say is, what is “normal” seems to be quite variable. How did you come to the conclusion that hypothyroidism is vastly underdiagnosed and more than half of hypothyroiders are not getting the treatment they need?

  29. MaryShomon says:

    @FastBuckArtist

    I’m not a practitioner, I’m a patient advocate. But knowledgeable practitioners do factor in dietary issues — as well as stressors, adrenal hormone status, sex hormone status, other medications being taken (i.e., lithium, cordarone) — into evaluation and diagnosis of thyroid disorders.

    So yes, what is normal IS somewhat variable, from person to person, and also factors in the extent of symptoms.

    There are thyroid patients who have a TSH of 30 who feel generally fine, and others who have a TSH of 6 who feel awful — both “hypothyroid,” but experiencing very different symptoms. Two thyroid patients can also both have a TSH of 2.5, one has optimal Free T4/Free T3 and no antibodies, and may feel fine, another has low normal Free T4/Free T3 (and/or elevated TPO antibodies) as has multiple hypothyroidism symptoms.

    One size does not fit all when it comes to hypothyroidism diagnosis and treatment. But many members of the endocrinology community — not to mention the professional skeptics — seem convinced otherwise. It’s gotten to the point where diagnosing and treating hypothyroidism (by the book, at least) doesn’t require or involve any advanced training or specialization…it’s as easy as 2nd grade math:
    TSH within .5 to 5 = NORMAL
    TSH 5-10 = SUBCLINICAL HYPOTHYROIDISM
    TSH > 10 = HYPOTHYROIDISM

    Rarely is there consideration of actual circulating thyroid hormone levels, autoimmune status, family history, personal history, symptoms, etc.

    Re: underdiagnosis, it’s not my conclusion — it’s the conclusion of a number of researchers. There are a number of studies — including the NHANES, and various studies by Dr. Fatourechi (see PubMed) that have estimated substantial underdiagnosis. And the uber-official American Thyroid Association says “An estimated 20 million Americans have some form of thyroid disease. Up to 60 percent of those with thyroid disease are unaware of their condition.” That would be 12 million undiagnosed, by their count.
    http://www.thyroid.org/thyroid-events-education-media/about-hypothyroidism/

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