Today is Canadian Thanksgiving Day.
Today all thyroid patients in Canada and all over the world can reflect with gratitude toward all our good thyroid doctors past and present.
To guide reflection and thanks, I’d like to outline 10 of the important things good thyroid doctors know and do.
We all know there is no such thing as a perfect thyroid doctor. Nobody knows everything about thyroid therapy; we are all on the path of learning.
We admit that well-educated thyroid patients like those who follow this campaign have high hopes. We ask for a lot from doctors.
Let’s put our HIGH hopes and expectations in context.
The medical system has incredibly LOW standards and expectations for thyroid therapy.
Thyroid therapy guidelines today are about restrictions. They mainly put limits on testing and pharmaceutical choices. They encourage and sometimes even enforce blind guideline-conformity. Doctors reassure each other they are doing the right thing by herding us all like sheep into the normalized-TSH pen once a year. In our medical system, there is no accountability for thyroid therapy failures within the TSH reference range that can truly ruin the rest of our lives.
There are no medical system incentives or rewards for thyroid therapy enhancement. There are no considerations for our safety and long term health, because there is such blind faith in TSH as a “surrogate endpoint” instead of open-eyed measurement of FT3-FT4 relationships and their more direct effect on health outcomes. There are no guidebooks telling doctors how to ensure we can survive Low T3 Syndrome during critical illness when T4 therapy can be totally useless and even counterproductive. There are only incentives to manage us more efficiently and treat us as if we are all the same, as if one medication and one lab test ensures our lifelong thyroid hormone health.
As a result, it’s getting rarer nowadays to find a doctor that even scores 1 out of 10 on this “good thyroid doctor attributes” list.
In spite of this very dire situation, there are some very good thyroid doctors out there.
There are even some amazing ones that can earn more than 7 out of 10!
Sadly, we can’t name our good doctors publicly because it puts them at risk of being torn down by their envious peers and guideline-worshipping watchdogs. There are people who zealously guard the fallacies that maintain a strict boundary beyond a score of 3 out of 10. (see note*)
But we can, in private, fan the flame of the doctors who do try to improve their thyroid therapy knowledge and skill to treat us well within the purview of science.
We can publicly tell the stories of the (unnamed) doctors who have heroically improved our lives.
In posts like these, we can publicly share our respect and applaud every way that our doctors may go beyond the limited thyroid therapy training they received in medical school or workshops.
Patients, consider sending a thank-you card or note to your thyroid doctor.
Consider saying thank you in person next time you see them, naming specifically the thing you appreciate the most!
SOME ATTRIBUTES OF GOOD THYROID DOCTORS
Some of the good things doctors can learn and do are very simple and easy.
Others are far more challenging or can even be frightening for a doctor.
I’ll start with the most important and accessible things, and advance to the rarer attributes of high excellence.
#1. They know about T3 hormone action across the entire body.
These are doctors who know about and genuinely care about how thyroid hormone levels affect our entire body and every organ’s health:
- They understand that thyroid hormone supply affects every organ and tissue in the human body and that both overdose and underdose can worsen our other chronic diseases and our mental health.
- They listen to us talk about our thyroid-related symptoms, and they do not mock us or dismiss our experience of living every day while taking thyroid hormone. They respect the fact that over the years, we get to know how thyroid underdose and overdose affects our own body differently from anyone else’s body.
- They know that once we are officially diagnosed according to standard guideline criteria and placed on thyroid therapy, there is a lot of room for adjustment within thyroid reference ranges. Research proves symptoms correlate with Free T3 relative to an individual’s healthy set point.
- They understand that many tissue biomarkers are very sensitive, specific indices of thyroid hormone sufficiency in tissues. The most powerful two are Total Cholesterol and Sex-Hormone Binding Globulin (SHBG). These are significantly manipulated by FT3 levels in liver when other health conditions do not interfere. Effective thyroid therapy can be more powerful than statins at reducing high cholesterol as the liver clears these molecules from the blood more efficiently. The body’s SHBG is affected beause sex hormones and thyroid hormones have an intimate relationship. That’s why these indices are tested in the more comprehensive trials of thyroid therapy such as Escobar-Morreale et al, 2005, Celi et al, 2013 and Ito et al, 2017.
- They also know that the cheapest and oldest thyroid health test of all does not require a lab test requisition but can be measured in the office by an experienced practitioner — ankle reflex response speed. This test is highly specific to FT3 levels as T3 supply in blood exchanges with the muscoskeletal system. There used to be a machine called the photomotogram that measured response speed in milliseconds.
#2. They know diet and nutrition can influence thyroid hormones.
They consider thyroid hormone health in a total-body context, understanding the power of nutrition.
- They know that gastrointestinal tract health can impact thyroid hormone absorption and conversion (Kyriacou et al, 2015). Therefore, they consider ways of optimizing our T4-T3 conversion and overall human health through diet and nutrition, and when necessary, supplementation.
- They realize that the vast majority of thyroid hormone conversion that supplies T3 to bloodstream occurs within the thyroid gland itself, in the liver, and in the kidney
- They understand that thyroid hormone conversion is managed by a complex interplay between three deiodinases (D1, D2 and D3) and that thyroid hormone levels and chronic diseases can upset the balance between them (Chatzitomaris et al, 2017; Bianco et al, 2019).
#3. They know thyroid autoimmunity is powerful.
They understand the effects of thyroid autoimmunity and how to minimize the harms of thyroid antibodies on the thyroid gland as well as the rest of the human body:
- They understand that thyroid antibodies can have effects beyond the thyroid gland (Mussig et al, 2012),
- They know that there are several types of TSH-receptor antibodies and that they can stimulate or block TSH receptors. They know these receptors are not just located on the thyroid gland but throughout the human body, including bone cells.
- They know that thyroid autoimmunity often goes hand in hand with autoimmune gastritis (Cellini et al 2017) and is highly associated with many other autoimmune diseases.
- They understand the well-researched role of selenium supplementation and autoimmune-protocol diets as of ways to minimize antibody attack on any remaining living thyroid tissue (Gartner et al, 2002; Choi et al, 2017).
- They understand that gluten-free diets are not just for Celiacs, not just a silly fad, and why science suggests going gluten-free can help many people who have not only thyroid antibodies but other autoimmune diseases or a significant genetic risk of autoimmune diseases (See world-leading Celiac disease & gluten researcher Dr. Alessio Fasano’s video lecture, “The gut is not like Las Vegas”).
#4. They fully understand the limits of the TSH test.
These are doctors who know the scientific facts about the limits of TSH as the only guide to thyroid therapy:
- They understand that the “normal TSH” reference range is too large to fit any individual’s optimal thyroid hormone health, even a perfectly healthy person.
- They understand that especially during thyroid therapy, the TSH test is not as specific or as sensitive to thyroid hormone levels in peripheral tissues and blood as many are led to believe. TSH signals a local tissue response based only on thyroid hormone conversion and T3 action in the hypothalamus and pituitary. These are organs that metabolize T4 hormone at a highly efficient rate because of their former role in regulating a healthy thyroid. During therapy for thyroid disease, TSH plays a different role in the body. TSH is one set of tissues’ testimony; it cannot speak for the thyroid hormone status of 99% of the human body.
- They understand that TSH can be artificially lowered by dieting, exercise, many medications, many chronic illnesses (Chatzitomaris et al 2017)
- They know that TSH can be manipulated at the pituitary ultrashort feedback loop by TSH-Receptor stimulating antibodies found in 10% of Hashimoto’s hypothyroid patients and even more frequently in people with atrophied thyroids. There are so many things that influence TSH secretion beyond thyroid hormone levels in blood.
#5. They are not mindless robots programmed by flowcharts.
They understand the limitations of thyroid testing flowcharts like the one in use currently in British Columbia:
- They know that these flowcharts use “thyroid screening” logic that applies mainly BEFORE thyroid hormone therapy has been initiated.
- These flowcharts are based on variations of the ARUP consult algorithm — this image demonstrates that TSH-first testing is best used to initially detect gland failure due to “thyroid disease.” If you look carefully at this flowchart, you will see it has nothing to do with thyroid “therapy” management.
- Good doctors are aware that one flowchart cannot apply simultaneously to people who are NOT on thyroid hormones and those who are. They are aware that these flowcharts, based on the intact HPT axis, do not transfer well to the broken feedback loop, the HPT-axis-distorting conditions of thyroid therapy. In therapy, TSH can become a mere puppet of dosing. In therapy the TSH is no longer an unbiased, independently fluctuating regulator of hormone supply; it is daily bribed by a hormone pill to stay silent about FT3 loss.
- They are aware that flowcharts often incorrectly assume that when TSH is normal, Free T3 will be optimized. This is often incorrect during thyroid therapy. At any given TSH level within or below reference range, a thyroid patient’s FT3 can be anywhere but is usually lower than the mid-point of the FT3 range. Yes, these wise doctors are well aware that in standard thyroid monotherapy, FT3 often falls far below the population average found in healthy controls whose FT3 is 40 to 50% of the reference range (Gullo et al, 2011, Hoermann et al, 2019).
- They care more about our health outcomes than pleasing their administrators by conformity to penny-pinching thyroid testing rules. They discover ways to navigate their region’s local thyroid testing policies and do what they can to get around unreasonable roadblocks to Free T3 and Free T4 testing in therapy.
#6. They understand the true causes and signs of thyrotoxicosis.
These are doctors who understand how to truly detect thyrotoxicosis during therapy, if it ever occurs:
- They know that thyrotoxicosis cannot be induced without excess FT4 & FT3 combined being delivered to tissues from bloodstream supply, resulting in excess T3 binding to cellular receptors.
- They understand that a lack of TSH molecules cannot independently cause thyrotoxicosis, and that this is one reason why the definition of thyrotoxicosis is not dependent on TSH levels at all.
- They know that the word “hyperthyroidism” is a more specific medical term than thyrotoxicosis. It primarily refers to the phenomenon of overstimulation of the thyroid gland usually by hCG hormone in pregnancy, by excess TSH, or by stimulating antibodies in Graves’ disease, or by a T3-secreting thyroid nodule.
- They know that technically, thyrotoxicosis cannot exist without multiple signs and symptoms beyond the TSH. They know that in overt thyrotoxicosis, the resting heart rate remains continually elevated day and night, and so does basal body temperature. They know that cardiovascular symptoms (like microvascular angina induced by endothelial dysfunction) can be induced by low T3 levels, not just thyrotoxicosis.
- They are aware that studies of risk from low TSH are largely based on studies that do not measure Free T3 levels, and that there’s still no proof that low TSH alone can cause osteoporosis.
#7. They can interpret TSH, FT4, FT3 within reference.
Here is where things get way more tricky for even the doctors smart enough to surpass #3 above.
More advanced, educated and experienced thyroid doctors are those who know how to analyze the inseparable yet shifting “triangle” of TSH, Free T3 and Free T4.
- These doctors know it is not biologically correct to treat each hormone and its reference range as if they are independent from each other.
- They know that T4 and T3 are two forms of the same hormone, largely inactive vs. most active, and that TSH has a complex and variable response to both hormones.
- These doctors test more than just TSH when investigating patients’ symptoms and adjusting doses, knowing that each individual has an optimal Free T3 and Free T4 that is as narrow as 38% of the reference range.
- They care about ensuring that we have enough Free T3 supply in blood to supply the critical tissues and organs that do not convert T4 hormone locally very efficiently. They know there are tissues that depend largely on FT3 supply from blood, like our cardiovascular system.
- They know that FT4 in the upper half of reference or above can never make up for FT3 being low or below range. They understand this is based on a biological principle, that T4 hormone itself causes ubiquitination of the Deiodinase Type 2 that converts most of our T4 to T3 throughout the human body. This principle applies everywhere in the body — except in the hypothalamus and pituitary, which continue to convert T4 at an efficient rate even when T4 is high. Elsewhere in the human body, the less T4 converts to T3, the more of it converts to Reverse T3, via Deiodinase type 3. This is the science underlying the paradox in thyroid therapy of a normal or low TSH even when FT3 is too low for an individual’s health.
- They know that more FT3 is needed in blood to compensate when FT4 is lower in reference or below range. They understand that because T3 is the most essential thyroid hormone, enough FT3 can always compensate to acheive global euthyroid status across tissues and organs even when FT4 is below reference range or absent. (Celi et al, 2013)
- They may even be aware of clinically-tested free diagnostic tools like SPINA-Thyr, an endocrinologist-developed tool that analyzes data from TSH, FT4 and FT3 concentrations either before therapy or during T4 monotherapy. This advanced app provides indices of thyroid hormone conversion, thyroid gland health, and even hypothalmic-pituitary health.
#8. They continually learn about thyroid hormone health.
We must applaud any thyroid doctors who take the time to study thyroid therapy publications beyond the TSH paradigm.
- These are the doctors who are not arrogant about their advanced thyroid education. When we bring some thyroid science to the doctor’s office, they are not intimidated, offended, or defensive. They realize that they don’t know it all and are eager to learn more, even from a thyroid patient.
- They do not mock patients for learning about their own thyroid hormone health. They never chide us for naively consulting “Dr. Google” because they know well that even PubMed medical articles are also available “on Google.”
- These are the doctors who also encourage thyroid patients to study reliable sources on thyroid hormone health. If you ask them, they will know what to recommend to you. They may know that reputable doctors publish good books on thyroid health for laypeople, such as Dr. Izabella Wentz (thyroidpharmacist.com), and that Mary Shomon has some great articles on Verywell.com that are medically reviewed by MDs.
- They are aware of the vast treasures of scientific publications of the best thyroid therapy scientists working today, such as
#9. They can think critically about thyroid therapy guidelines
There are wise, intelligent doctors who know enough about thyroid science to be able to detect fallacies and flawed paradigms of thyroid therapy.
They can think critically about the many influences that go into shaping thyroid therapy guidelines, especially the too-dominant American Thyroid Association (ATA) thyroid therapy guidelines:
- These doctors realize that guidelines are not absolute laws, but are historically-developing consensus-based statements that offer “recommendations.”
- They understand that like any group of doctors, guideline committees will tend to cherry-pick their favorite research articles, ignore others, lose touch with the treasures of thyroid science history, and conduct a biased review of that evidence informed by their own education, experience, and therapy paradigms.
- They know the only way to prove where guidelines are incomplete or too restrictive is by carefully analyzing their citations and reasoning, and by studying the authoritative recent research they don’t cite. Consensus is accountable to science.
- They are well aware from their deep reading that the ATA is the association that historically promoted the market-based monopoly of LT4 monotherapy since the 1980s; they know whose guidelines they are reading.
- They understand that TSH-centric definitions of thyroid hormone status in guidelines continue to reinforce a limited therapy paradigm that does not acknowledge the centrality of bloodstream levels of T3 hormone in human health.
#10. They can safely optimize therapies beyond LT4 monotherapy
And finally, the most advanced doctors are those who have the knowledge and experience to manage more than just standard LT4 monotherapy.
These are the doctors who know how to detect when standard thyroid therapy is not working for an individual patient.
When a thyroid patient continues to exhibit hypothyroid symptoms on standard LT4 monotherapy at any dose that does not cause thyrotoxicosis, and this persists despite diet and other supportive therapies, these doctors apply their deeper knowledge of TSH-FT4-FT3 relationships. They can understand what is going wrong with the individual’s thyroid hormone metabolism.
They also know that some thyroid hormone metabolism handicaps do not manifest in bloodstream FT3 and FT4 levels, such as problems with receptor sensitivity. Science has not yet been able to explain why some patients fare better with T3 therapy even when their biochemistry looks fine on T4 monotherapy.
These are the doctors who realize that “thyroid pharmaceutical prejudice” is unscientific because all thyroid hormone pharmaceuticals, even the wrongly maligned and former gold standard medication, desiccated thyroid (NDT), will supply bioidentical thyroid hormone to the bloodstream.
They are willing to prescribe thyroid patients a therapy option that includes T3 hormone, even when a thyroid patient simply asks for a trial.
They have taken the initiative to learn how to safely and effectively optimize thyroid therapy that includes T3 hormone, whether desiccated thyroid (NDT / DTE) or synthetic T4-T3 combination therapies. They can delicately adjust FT3 and FT4 levels and relationships until the individual patient is stable and healthy.
- When these doctors substitute part of our LT4 dose with LT3, they understand the true pharmacological equivalence of LT3 to LT4 is approximately 1:3. This helps them avoid underdose when making a partial substitution (See the more recent pharmacological equivalence to TSH studied by Celi et al, 2010).
- They understand that the transition from LT4 to a T3-containing medication should be gradual, allowing the body to adjust while Free T4 gradually reduces in bloodstream to accommodate higher FT3 levels from the more quickly absorbed LT3 dosing.
- They test more than just TSH whenever we are on a therapy that includes T3 hormone. They do this not just for basic safety reasons, but to ensure our thyroid hormone levels are not too low within or below reference range when the TSH starts to become deceptively low or low-normal due to the TSH-suppressive T3 dosing effect.
Some doctors even know the more advanced aspects of managing T3-based thyroid therapy, such as the ones described next.
Lab testing times:
When they treat us with medications including T3 thyroid hormone, they understand that a FT3 test is most reliable and useful for guidance from test to test when it is consistently performed 12 hours or more after the last dose.
Why 12 hours? The most scientific of thyroid doctors are aware of the graphs in thyroid science that show the volatile post-dose FT3 peak and crash. (see Jonklaas et al, 2014, Figure 2a). They know from a variety of publications that this graph is generally the same shape over time at any T3 dose strength.
They realize the lab test should be taken after that peak has passed, when FT3 levels are more stable and capable of reflecting our baseline or daily average rather than rising or falling significantly while we are waiting in the laboratory for 20 minutes or an hour.
They understand that because dosing T3 hormone will involve Free T3 fluctuations (see Figure 2a link above), the subgroup of patients who have low cortisol levels and poor adrenal health can suffer acutely from minor FT3 fluctuations. These are covered in the explicit cautions in the monograph for Pfizer’s Canada’s Cytomel (LT3 / liothyronine).
Oversensitive patients may fare better on lower LT3 doses or slow-release T3 available from Canadian and US compounding pharmacies, while others may have to wait until adrenals heal, or take expert guidance from advanced T3 therapy books by Paul Robinson that show how adrenals can be healed over time by T3 dosing. As Robinson explains, careful timing of T3 doses can partly imitate the natural circadian rhythms by which cortisol and T3 interact in healthy people.
These are doctors who know that except for certain T3-hypersensitive patients, no science has ever proven that FT3 fluctuations are harmful to the human body while FT4 is concurrently lower in its reference range, counterbalancing a higher FT3.
Fear of FT3 fluctuations is a modern phenomenon promoted largely by people who are far less experienced with optimized desiccated thyroid therapy and LT3 monotherapy. Endocrinologists in the 1970s who first studied serum T3 fluctuations were not thrown into a panic by them. Why? Desiccated thyroid (NDT) was the gold standard of therapy, and patients were faring perfectly well on it at all sorts of doses. Today’s thyroid therapy experts know, as our historical thyroid doctors once knew, that average levels over a 24-hour period matter more to the human body than the transient FT3 peak levels post-dose.
Now we know how the human body can manage these fluctuating peak FT3 levels: Deiodinase type 3 is always vigilant, ready to convert excess T3 hormone to T2 in cells before it reaches the nuclear receptors (see Bianco et al, 2019).
Let’s keep learning!
Thank you to all doctors who have taken the time to learn even a small fraction of these principles above.
Dear doctors, we know that you are not perfect, and that thyroid therapy knowledge keeps evolving.
We appreciate your every effort.
Please do what you can to work toward earning a full 10/10 on this “good thyroid doctor” attributes list.
[NOTE: Caution to doctors. See a new British Medical Journal article about a UK thyroid doctor being punished with a suspension. I can’t help but see that this doctor was not well prepared to present a strong case. Doctors must always protect themselves and their patients with scientific knowledge based on published research and lab tests, not merely based on symptomatic presentation. Ordering tests dismissed by guidelines is not an unforgivable medical sin, but tests require a scientific framework for ordering and interpreting them. Clinical guidelines are neither mere suggestions nor absolute laws. Guidelines are accountable to the quality of the science they cite and fail to cite to back up their recommendations. Doctors really have to know the science if they ever bend the guidelines to save a patient. There is no room for improvisation or over-reliance on one’s own clinical expertise, and all medical decisions and diagnoses must be carefully documented.]