Prior to the 1950s, doctors relied exclusively on good clinical judgment, based on the clinical presentation of the patient (symptoms and signs). The only treatment available was natural desiccated thyroid (NDT) which contained both the T3 and T4 thyroid hormones that the thyroid gland produces. This approach worked very well for most patients.
Synthetic T4 (Synthroid, Levothyroxine) was first introduced in the 1950s. Current thyroid lab tests were invented in the 1970s. Modern laboratory testing methods and medications ought to have improved thyroid patient health. Clinical judgment and the patient’s clinical presentation (symptoms and signs) should still have been paramount.
But we have gone backwards, and patients are worse off today than they were prior to modern lab tests and new thyroid medications. Nowadays, T4-monotherapy (Synthroid, Levothyroxine) is almost always the only treatment on offer. All that most doctors focus on are the patient’s laboratory test results. Often it is just TSH. If a patient is lucky enough to have FT4 and FT3 tested, their doctor usually tells them that they are adequately treated if the results appear almost anywhere within the wide population reference range.
This situation is worldwide. It is not just a UK issue.
The current thyroid treatment approach is broken and this is why so many thyroid patients never get well.
If thyroid treatment was a vehicle it would have been redesigned a long time ago.
Wagon Analogy
Imagine we are the very proud owner of a wagon. It has an engine, a simple wooden plank seat and two axles. Unfortunately, all the wheels are different sizes, they are made from wood and there is no suspension!
When the wagon moves, it is a very unstable and uncomfortable ride. If any bends in the road or slopes are encountered, it can tilt over in a very dangerous manner. Invariably, most passengers usually suffer from some degree of travel sickness, ranging from mild to horrendous!
It can be a perilous ride, but it is the only wagon we have! It is uncomfortable, slow, dangerous, makes us ill, and rarely gets us to where we want to go on time.
Our wagon is not fit for purpose. This reminds me of the movie ‘Jaws’, in which one of the besieged guys says, “We need a bigger boat!”, but in this case, “We need a better wagon!”
Now, we can choose to redesign our wagon a little. But basically, our wagon design is truly useless. We need a better wagon!
Current thyroid treatment is utterly flawed.
Within the current broken paradigm of thyroid treatment, endocrinologists and doctors foolishly fiddle around with thyroid medication dosages in an attempt to manage TSH or FT4 to some level within the reference range. If the patient is lucky enough to have a doctor who thinks FT3 is worthy of testing, then this may also be looked at by the doctor to ensure it is somewhere in its lab range.
The entire TSH-centric, laboratory test-centric, T4 monotherapy-centric paradigm is flawed. It is beyond minor tweaking.
Thyroid Treatment Requires a New Paradigm:
- It needs to be symptoms and signs led, using the clinical judgment of physicians, who are well-informed about thyroid treatment.
- FT3 needs to be observed during treatment, as it ought to rise. FT3 is the only thyroid laboratory test result that actually tracks symptoms. As FT3 changes, so do symptoms. This has been shown to not be the case for TSH and FT4. FT3 needs to be observed, seen to rise and clinical presentation assessed. Frequently, a higher in-the-range FT3 without excessively high rT3 can work but the individual patient and their clinical presentation need to be the focus.
- TSH and FT4 (and Reverse T3) can be observed to see how they alter, and if they behave how they are expected to. However, decisions based on TSH and FT4 will not suffice alone, as they do not focus on the patient’s symptoms and signs or on the active hormone FT3.
- There should not be specific targets for any of these lab results, as we do not know what the individual person ranges are for each patient. Simply having FT4 and FT3 results somewhere in the wide population ranges is not sufficient to guarantee good health. We know from research that, for those on T4 monotherapy, FT3 ought not to be above the very top of the reference range, but TSH can be zero – and that is about all that is really known. We also know from research that a thyroid patient’s symptom improvement has to be the most important focus – far more than the lab test results that only provide some insight into what the medication is doing.
We need a new paradigm for thyroid treatment! We need a better wagon! There is plenty of research now to back this up.
My latest book, The Thyroid Patient’s Manual, discusses many aspects of thyroid diagnosis and treatment. The book refers to some of this new research. It describes the new paradigm of thyroid treatment. It describes how thyroid treatment should be done so that thyroid patients can recover from hypothyroidism as fast as possible.
Best wishes,
Paul
(Updated January 2023)
