Challenges: Testing, Part 2

Updated 2018-07-20

Access to T3 and T4 thyroid hormone tests

TSH is not enoughA very distressing trend threatens to limit our access to important tests. There is an international movement, now being applied by the organization called Choosing Wisely Canada in connection with major medical associations in Canada, that attempts to save health care expenses by preventing “unnecessary” thyroid ultrasounds and “unnecessary” thyroid hormone tests and antibody tests, except in very limited circumstances. [17, 18]

Inflexible and superficial thyroid testing algorithms are now in use in provinces throughout Canada. [13, 15]

Most worrisome to thyroid patients is that the measurement of Free T4 and Free T3 is being discouraged in monitoring of therapy. Failing to detect deficiencies within these reference ranges can do significant harm. The T3 hormone is the most essential and active form of thyroid hormone. On the standard L-T4 therapy, we are more at risk of having our T3 levels drop low within range and cause hypothyroidism even while TSH or T4 levels still look fine (see our rationale).

Therefore, when we are symptomatic on therapy despite a normal TSH and T4, our doctor must have the ability to assess our T3 level and T3:T4 ratio. In the context of our signs and symptoms the doctor can then sensitively adjust dosage and, if it may solve a possible T3 deficiency, suggest that a patient try another thyroid hormone therapy modality.

If we are only being routinely tested and monitored once a year, a correct adjustment can alleviate signs and symptoms of hypothyroidism for an entire year or more.

The consequences of not testing are blindness to underlying imbalance, and sooner or later, illness. Under the current system of TSH normalization, patients’ symptoms and signs of hypothyroidism often do not resolve. How do we make sense of such patients’ continual complaints? We shift the blame to disorders in other organs or systems. We prescribe patients antidepressants, statins, and blood pressure medications, some of which can further imbalance their thyroid hormone metabolism.

Alternatively, we believe that symptoms are caused by the patients’ stress levels, age, diet, and lifestyle choices. This creates an unnecessary burden of guilt and shame for the patients if symptoms might actually be caused by inappropriate thyroid hormone levels that are not being monitored or interpreted.

When other medicines and lifestyle improvements do not fix the remaining symptoms of thyroid deficiency, doctors then counsel patients to accept their diseases and reduced quality of life.

Thyroid patients do not wish to be a financial burden on the health care system, but thorough testing can help us prevent other costly tests and treatments as a result of health disorders that arise from chronic hypothyroidism.

Hormone therapy requires sensitive adjustment as the human body changes over our entire lifespan. We encounter changes in our health status from time to time, such as pregnancy, menopause, and significant changes in our lifestyle or diet. Appropriate adjustments require appropriate testing.

The economic costs of insufficient thyroid testing have not yet been calculated because it is impossible to do so—one can only guess at what would happen if even a small percentage of patients were denied necessary tests to make the finely-tuned adjustments in a lifelong course of therapy.


Thyroid-antibodiesThyroid antibody testing it is often dismissed and misunderstood as clinically irrelevant. However, autoimmune thyroid disease is the most prevalent cause of hypothyroidism and autoimmunity affects our entire body, not just a single gland.

Some thyroid patients never get tested for antibodies, and if they are tested the patient is rarely told straightforwardly that they likely have Hashimoto’s thyroiditis, Graves’ disease, or Atrophic thyroiditis.

There are significant health costs to delaying a correct autoimmune diagnosis. It is necessary for the physician and patient to be aware of common comorbidities that are associated with thyroid autoimmunity. One study found the following associations in 500 adults with Hashimoto’s disease:

  • Autoimmune arthritis
  • Connective tissue diseases
  • Skin diseases such as vitiligo and uticaria (hives)
  • Celiac disease and other gastrointestinal diseases
  • Addison’s disease
  • Multiple sclerosis
  • Type 1 Diabetes (may include Latent Autoimmune Diabetes of Adults –LADA). [19, 20]

We lack access to one important antibody test in Canada.  It appears to be little known outside of Japan that TSH-receptor blocking antibodies exist in hypothyroidism as well as in Graves’ disease. In hypothyroidism, these antibodies can cause Atrophic Thyroditis.[21] Japan’s guidelines note that the “blocking” TSH receptor antibodies can cause primary hypothyroidism.[22] This is relevant not only to disease prognosis, but to the interpretation of test results because it can make hypothyroid patients’ TSH fluctuate in illogical relationship with T4 and T3 levels (see our section on Autoimmunity).



Next section: Challenges: Therapy, part 1

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