Editorials

Thyroid function tests and hypothyroidism

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7384.295 (Published 08 February 2003) Cite this as: BMJ 2003;326:295

Open questions to the authors

Dear Sirs,
I have no training or clinical experience of endocrinology, so I will not
attempt to present any evidence which would contradict your views. (
Although my wife developed a hoarse voice with all the other symptoms, the
ENT hospital department have suggested hypothyroidism, but of course they
cannot prescribe thyroxine.)
However as the husband of one of the people you condemm as having "psycho-
social problems" I feel at least I am entitled to ask some very basic
questions.

1) The reference level for TSH for "healthy patients" is 0.5 to 5.0.
Can you explain why certain patients function normally at 0.5 and others
at 5.0 ? If you could accurately predict a healthy patient's TSH from some
other factors, this would remove any doubt about an individual patient's
reference level. If you have no idea, doesn't this suggest some lack of
certainty concerning TSH and the other hormones ?

2) Without knowing a reference level, would you agree there will be
cases where 2 patients both present to an endocronologist with TSH levels,
say 5x their normal level; one patient is diagnosed and treated, the other
patient is told their problems are all due to over-eating, clinical
depression, and the many other symptoms are due to an unfortunate
coincidence or just unexplained.
The reason for this of course is patient A had a reference level of 0.5,
the other had nearer to 5. Patient A despite their 5x increase is still in
the "normal" range, patient B is above the range. Would you agree this is
a thyroid lottery, those lucky enough to be born with a higher level are
more likely to be treated ? If the exact range from 0.5 to 5 is as
irrelevant as you say, why are patients with 5.1 diagnosed hypothyroid,
while 4.9 are hypochondriac ?

3) Reducing the method to its basics:-
All healthy patients have a TSH level of 0.5 to 5.0.
Therefore all patients with a TSH of 0.5 to 5.0 are healthy.
Does it not occur to you there may be a slight flaw in this logic ? In
most fields of science, we would also test the contrary, i.e. do all
unhealthy patients have a TSH range outside 0.5 to 5.0 ? If this test had
been done in 1973, when the hormone test was first introduced, we know the
answer would have been no, many patients present with numerous specific
clinical symptoms (not just overweight and tired) but have TSH in the
normal range. How different the diagnosis of hypothyroidism might been,
if this had been done before taking the TSH range as gospel and throwing
out all the symptoms.

4) Do you or indeed any endocrinologists have any psychiatric
training ? What are your qualifications to diagnose all these patients
with depression ? If you could take the time to read all the patients'
accounts published, you would find that all patients sent to psychiatrists
from endocrinology are diagnosed as mentally normal, the only thing making
them depressed is all the symptoms that the doctor cannot explain. Your
absolute certain diagnosis of every symptom, from hoarse voice, dry skin
and deafness to severe fluid retention as due to "psycho-social problems"
is a very confident diagnosis outside your field, something you deplore in
those outside the endocrine speciality.

5) Would you at least agree that some patients are in-appropriately
treated, after the thyroid cause has been eliminated ? For instance Diana
Holmes was treated for 6 severe conditions such as Myasthenia Gravis,
coeliac disease, etc, treated with massive doses of steroids, antibiotics,
Mestinon, etc (Tears Behind
Closed Doors, Normandi Publishing
2002). None of these had any effect, and she was only cured and
back to full health after being treatd with thyroxine. Of course your
diagnosis would be that all her disabilities were due to some
psychological reason and the thyroxine had the "magic" placebo effect that
can explain everything (but why didn't the previous 6 treatments have this
effect ?). Therefore none of the previous treatments were appropriate.
So why are you so opposed to patients trying a short-term test of a low
dose of thyroxine, to try to cure these symptoms that leave doctors
baffled ? ( A simple medical waiver form would remove any risk of patient
litigation if anything went wrong). The alternatives can be also be
drastic. The antidepressents that you and collegues hand out like sweets
are also not without side effects.

6) If you have seen the patient-oriented websites, you will know that
many patients are having to dose themselves with thyroxine with no medical
supervision, since they cannot find a GP who will consider the symptoms.
Would you not agree that GPs should at least be allowed to monitor and
advise patients even though they are not prescribing the hormone ?

I would be very interested to hear your replies.

You state it is only a vociferous minority who claim that throxine
has cured them ( so obviously they must be wrong). Of course the rest, the
majority of patients diagnosed as normal by the GP and endocrinologist
simply accept the diagnosis, because they are never told that some medical
staff do have doubts. Of this minority who do decide to and have the
resources to research deeper, a much smaller minority actually manage to
find a GP who will try out thyroxine on them. So it is even more
surprising that so many hundreds of people have mananged to find a way
through this process and found a cure.

I have a nagging suspicion that the medical profession have seized on
these hormone levels as an OBJECTIVE method to decide the course of
treatment, without having to make any clinical judgement which they fear
might result in litigation. But gentlemen I must point out that litigation
can work both ways. If one day a high court judge finally decides that
hundreds, thousands of patients have suffered crippling illness and
disability due to medical neglect, the litigation will be severe indeed
against those who so "vociferously" blocked any patient choice.
So once again, are you still totally opposed to seriously disabled
patients being give a small test of thyroxine if all else has failed ?
Your banning policy may not quite be as risk-free as you think.

Competing interests:  
None declared

Competing interests: No competing interests

05 June 2003
Simon R Cains
Senior geophysicist
Not medical