This post engages in a moral argument, not a scientific one. Thyroid pharmaceutical prejudice is part of a paradigm that is refusing to shift. We need to keep asking key questions and fight together for this shift.
Look around you today. Thyroid guidelines and health care systems currently treat all thyroid patients as one undifferentiated mass who must be efficiently managed through a system.
There are millions of us, so managers want us to be processed through a single assembly line of TSH testing and levothyroxine monotherapy, whether it is good for us individually or not.
If you are not on that assembly line, you are in the minority. Various institutions are openly and actively trying to put you on this assembly line. This is the modernistic vision of how our disease ought to be “managed” en masse.
This factory mindset, this monolithic mass-therapy paradigm, is inhumane because it has become blind to real human suffering of those whose bodies don’t fit that model.
The guidelines in place are not expanding the boundaries of thyroid health. Instead, they are actively restricting and oversimplifying therapy and fighting against change, doing everything in their power to limit options and delay a paradigm shift from a TSH-T4 centered paradigm to a T3-hormone and whole-body paradigm for thyroid therapy.
WHAT ARE GUIDELINES SUPPOSED TO DO?
Let’s think idealistically for a second.
Can even the most “evidence-based” guidelines, the most benevolent, the most fair and unbiased guidelines ever written, predict which thyroid hormone therapy is best for an individual patient?
Medicine does not treat a statistically average patient.
Medicine’s proper role is to treat individual people who suffer very different types and levels of hypothyroidism.
Today’s factory-based monolithic thyroid therapy paradigm, the “guideline-based therapy” model, exalts guidelines into absolute biological laws rather than therapeutic suggestions.
It denies the very real possibility that an individual thyroid patient sitting in your office tomorrow may have a genuine clinical need for a thyroid therapy that includes far more T3 hormone than is secreted by the average healthy human thyroid gland at a TSH of 1-1.5.
No single biased review of published evidence on thyroid therapy, no medical association’s guidelines, has biological authority to rule out or predict an individual patient’s needs or responses to thyroid hormone medications, ratios or doses.
Guideline-writers must remain humble and open-minded and be careful what they dictate and forbid based on their current ignorance and bias.
Guideline-readers and appliers must realize the medical and moral limitations of guidelines.
Thyroid therapy should never be about restricting the type or ratio of thyroid hormones a patient puts into their mouth.
There is no way of prophesying or predicting health outcomes in a single patient based on one pharmaceutical input and the testimony of a single gland. The exact same medication and ratio will yield very different T3/T4 ratios and levels in the blood of each patient and different T3 levels in various organs and tissues in their body.
Thyroid therapy should not be about worshipping the response of a single gland representing 1/1000th or so of the human body’s organs and tissues (the TSH) as a validation that a pharmaceutical intervention is effective.
There is no single magic thyroid medicine, no single thyroid test to rule them all. Therapy is about discovering the best holistic physiological accommodation for a disability that impacts the entire body–the loss of living thyroid tissue. Thyroid therapy is a clinical art, a gentle and respectful process of discernment and adjustment. It should be about body-wide health challenges and health outcomes.
WHAT KEEPS THE PARADIGM FROM SHIFTING?
What is so threatening about the prospect of changing the thyroid therapy paradigm from a TSH-T4 dominated paradigm to a T3-defending paradigm?
Maybe the sheer scale of change makes people afraid of the consequences. This therapeutic impasse affects millions of people, mostly visibly women over 40. Invisibly, it also affects the sick and vulnerable patients of all ages and sexes, even those with “healthy” thyroids, who suffer chronic lower T3 and never get it measured or fixed.
What are the forces behind this effort to oversimplify and over-control thyroid therapy and push every patient into a mindless machine with two buttons?
Why must thyroid therapy be tied to a one-drug one-test model established in the 1980s, while other diseases proliferate pharmaceuticals and tests?
Is it a symptom of medical arrogance and protectionism? Can endocrinology as a profession never humbly admit that historically, they erred when they made the pituitary TSH hormone test apply to all thyroid investigations and dismissed all other signs, symptoms and measurements of thyroid hormone sufficiency?
Can our doctors not handle the complexity of the biological fact that thyroid hormone sufficiency can entail a challenging pharmaceutical balancing act in the absence of a healthy gland that does all the work for you?
Can they never admit that TSH is mainly useful as a convenient surrogate marker in the screening of untreated patients prior to therapy, and that’s where the mass usefulness and cost-savings of TSH monotesting ends?
Can they ever admit that mere TSH normalization is not actually a health outcome within the context of thyroid therapy?
Can doctors not see their reverse cause-effect logic and realize that some lab tests measure local organ responses and are not drivers of health?
Are doctors that simpleminded? Are they that mechanistic and uncaring that they have to treat thyroid hormones by means of simple flowcharts and lab test numbers alone?
Is it too challenging for the majority of doctors to learn about thyroid hormones and individualize patients’ thyroid therapy as if we all had an unknown degree of thyroid-hormone-dosing-induced central hypothyroidism? (and indeed, we probably do…)
Why are medical associations given the right to rig the thyroid hormone marketplace by pushing certain prescriptions and denying others?
Why should medical associations have the right to demand new randomized controlled trials to re-validate meds that already have a long history of safe and effective use and have never stopped being used?
Why are medical associations effectively shutting down all research and clinical practice on thyroid therapies against which they have engaged in continual ideological warfare since the 1970s.
Why can’t people see that the American Thyroid Association guidelines are not an infallible Bible but an expression of one of the most conservative stances within an international medical debate?
Today, one American association’s guidelines are being given the biological right to declare in advance that medication input X and test result Y will yield health outcome Z in all patients. And that’s effectually what people are using them to declare every day in certain countries, provinces, and doctor’s offices all over the world.
The deafening consensus is dismissing patients’ and doctors’ valid arguments, separating us each into mere individuals who can be silenced and controlled.
Ask these questions.
Ask them more loudly.
Keep asking them until you help more people see the true nature and scale of this mind-numbing paradigm and the institutional systems, economies, prejudices that it supports.
THE WAY FORWARD
Okay, let’s look for a way to move beyond this paradigm’s tyranny.
Consider medical justice and ethical therapy within the context of advancing or regressing medical knowledge and practices.
While medicine engages in its eternal battles and health care systems drive us to penny-pinching assembly-line medicine, there must be a check and balance in place to prevent real harm from these powerful and faceless institutional forces.
Who is responsible for limiting these powerful forces?
Who has the power to hold back a paradigm that is steamrolling over individual doctors and patients?
Who draws the line? Is it government? Industry? Medical associations? Pharmaceutical companies? Hm. You must realize that currently each of those parties has a major stake in keeping the status quo, since generations of doctors have been trained in this old thyroid paradigm, health care systems look for cost savings, the TSH tests are continually being manufactured and shipped, and battles between companies offering different formulations of levothyroxine keep those prices relatively low while they profit by every pill sold, at a massive scale.
So let’s look at who’s talking about significant change.
Who is advocating for poorly treated thyroid patients today? Who is educating the masses of thyroid patients who may not know they are poorly treated because they are told their TSH is normal so their therapy must be working just fine?
Who is advocating for the most powerful and essential thyroid hormone, T3, to gain its rightful place at the center of thyroid hormone therapy and the healing of the thyroid patient? Which researchers are inquiring into the T3 hormone’s connection to human health outcomes within and beyond thyroid therapy?
At present, some do. Small camps of courageous questioners engage in skirmishes at the frontiers of endocrinology and thyroid patient activism. It’s just that the public and public health discourses are not yet listening to our arguments and our evidence.
Therefore, I call on the grassroots of all who are involved on this side of the debate; let’s work together. Let’s open public debate to gradually enlighten people and move the institutional machinery.
Mass enlightenment. Scientific literacy. Ethical and legal discussion.
This is the type of change that broke the power of slavery in certain countries. It is the type of change that is still involved in ensuring that women are treated equally to men.
All we’re asking is for a thyroid disability and a thyroid hormone imbalance to be treated like any other chronic disease that affects the entire body.
Like those struggles, this is a struggle involving millions awakening to awareness that there is a problem, against those who will always say “there is no problem” and “what you’re advocating for is inherently dangerous” and “you’re not evidence-based because you don’t have my medical degree or specialization.”
Scientists, doctors, and enlightened patients should work hand in hand to push the boundaries of medical knowledge and question these old prejudices and paradigms, not hide and cower in fear and discouragement.
- Tania S. Smith