Fortnightly review: Hypothyroidism: screening and subclinical disease
BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7088.1175 (Published 19 April 1997) Cite this as: BMJ 1997;314:1175
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Thanks for this information, but it really needs to go out to the
pathology labs. In practice, that's where a typical GP gets his
information on what's normal!
I've personally been aware of some of the symptoms of hypothyroidism
since childhood because of a family history of it. For as long as I can
remember I've had difficulty keeping warm, despite growing up in a sub-
tropical climate, so I've long been suspicious about my own thyroid
function. Every few years I'd request a thyroid function test, and be
told everything was normal. Eventually the problem was recognised at about
the age of 50 by an Endocrinologist I was seeing for something else. I
was put on synthetic thyroxine, and the difference was nothing short of
remarkable. Even so, my body temperature is still low and so is my libido.
Based on the information in this article, I suspect I'm still not being
adequately treated.
Regardless, it's clear to me that this problem should have been
diagnosed decades earlier. I have to ask why.
Probably the first issue is that GPs apparently believe this problem
only affects elderly women. When I was a young man the possibility that I
had a thyroid problem was not taken seriously.
The other issue is that the ordinary GP who runs these tests isn't a
specialist, and can't be expected to know what normal is for each test he
orders. He relies on the pathology lab report to tell him this. And what
does the lab give him? The very wide range commonly seen in the general
population. This does NOT indicate what normal is, but unfortunately the
poor GP has nothing better to go on.
Back in the 1970s, Chereskin & Ringsdorf published their work on
"Predictive Medicine", which opened my eyes to this. It's been 20 years at
least since I read it and I can't remember the fine detail, but here's the
gist of what they did. They tested several bodily substances of
apparently healthy people then followed up with those same people some
years later (10?). The original test levels were widely spread, but
looking at only those people who were still healthy years later, their
early tests had all been VERY close together.
Competing interests: No competing interests
For what it's worth, I was on T-4 only meds beginning in 1985 because
of a TSH of 6.25. T-4 brought my TSH down to 2.2, yet for 3 years before
treatment, and 17 years during, I had debilitating exercise-induced
Dysautonomia. When my TSH (while still on T4 only) rose to a "normal" 3.15
the past year, my dysautonomia became crippling--I couldn't do anything
without suffering debilitating consequences. Only when I switched to
natural hormones, which raised my T3, did my dysautonomia DISAPPEAR, and I
am getting closer to normal as far as energy levels than I've been for
over 20 years!!! Measuring my TSH as the only guide for my overall health
was foolish in my case.
Competing interests: No competing interests
I'm a psychologist working in a small independent mental health
clinic, I have also worked in hospital and medical clinic settings. I
believe that many clients who are referred to me for "psychological"
problems such as depression or anxiety have overlooked thyroid problems. I
worked for 10 years doing basic research in psychoneuroimmunology before
doing a clinical internship. I sometimes sendd clients back to the
referring doctor for another look. I also do a lot of work with chronic
pain using biofeedback and teaching self-hypnosis for pain management. I
always ask my fibromyalgia clients to get a thorough check for thyroiid
problems and allergies. Proper diagnosis and treatment can make all the
difference.
On a personal level, I believe that I had undiagnosied hypothyroidism
for 25 years. When I was charting my basal temperatures in 1976 to track
ovulation, my temperature range was 94.2 to 97.6. The doctor told me this
was normal.
I've tried levoxyl and now thyroid for about a one year period and am much
improved, but still trying to find the right dose. Only my allergist
apologized for missing the diagnosis. One family practice doctor told me
my health problems were simply due to being lazy and uncooperative. My
current family practice doctor is more willing to listen to my opinion and
pay attention to symptoms as well as tests. Physician education regarding
the thyroid is essential.
Competing interests: No competing interests
I've tried to find out when, who & how this "normal" level
was decided on for the TSH test. I've gone to several doctors for symptoms
I've had for years, since Feb. 94 ,I was in a roll over accident which I
believe injured my thyroid, I gained 60 lbs. in 5 1/2 years and the
fatique & depression got so bad, which doctors always blamed menopause
for my symptoms I'm 48. I can now spot a low thyroid woman 10 feet away or
on TV, why can't doctors see this problem in so many of their patients?
This TSH test , I had this test 30 years ago and was "normal" which I
believe I needed thyroid treatment back then, I sure could have avoided at
lot of misserable years. The only time I ever felt like a normal person
was when I went to a Dr. Robert Starks in Denver, CO. 20 years ago, now
he's retired, but I found the doctor who took over his practice, in
Cheyenne WY. even then I have a hard time convincing him that I need just
a little more Armour than 240 mgs. / day,because of going so long before
treatment, but the depression and fatique are slowly going away,hair is
still falling out and a few other symptoms slowly going away, but I've
been treated since Jan. 3 01 lost 34 lbs. have 25 more to go, I just
thought I'd feel better sooner. I wish for myself and so many other women
that something can be done soon about this TSH test, and the normal
levels, when a person has almost all the symptoms why don't doctors treat
the symptoms? I just don't understand. A 9 news health fair in Denver CO
it was found that 13 million people have low thyroid and don't know it,
this is figured out by the TSH only, they did on everyone, this isn't even
the T3 T4 free T3 freeT4 or the TRH tests so I believe there are millions
more that suffer from low thyroid, including people like my son who is
bypolar and I know thyroid treatment would help the symptoms he has,
depression, fatique,weight etc.
Sign me , Frustrated with TSH test, Candie
Competing interests: No competing interests
I would just like to say what an interesting artical, and easy to
read in the B.M.J.
I have currently a personal as well as professional interest in this
article, and found it to be very informative. I have copied off the info,
and will keep it in my Notes.
Many Thanks
Dawn Brighton R.G.N.
Community, Southampton U.K.
Competing interests: No competing interests
Until the second world war, hypothyroidism was diagnosed on the basis
of BMR and a large group of signs and symptoms. In the late 1940s,
promotion of the (biologically inappropriate) PBI blood test in the U.S.
led to the concept that only 5% of the population were hypothyroid, and
that the 40% identified by "obsolete" methods were either normal, or
suffered from other problems such as sloth and gluttony.
During the same period, thyroxine became available, and in healthy
young men it acted "like the thyroid hormone." Older practitioners
recognized that it was not metabolically the same as the traditional
thyroid substance, especially for women and seriously hypothyroid
patients, but marketing, and its influence on medical education, led to
the false idea that the standard Armour thyroid USP wasn't properly
standardized, and that certain thyroxine products were, despite the fact
that both of these ideas were shown to be false.
By the 1960s, the PBI test was proven to be irrelevant to the
diagnosis of hypothyroidism, but the doctrine of 5% hypothyroidism in the
populaton became the basis for establishing the norms for biologically
meaningful tests when they were introduced.
Meanwhile, the practice of measuring serum iodine, and equating it
with "thyroxine the thyroid hormone," led to the practice of examining
only the iodine content of the putative glandular material that was
offered for sale as thyroid USP. This led to the substitution of
materials such as iodinated casein for desiccated thyroid in the products
sold as thyroid USP. The US FDA refused to take action, because they held
that a material's iodine content was enough to identify it as "thyroid
USP."
In this culture of misunderstanding and misrepresentation, the
mistaken idea of hypothyroidism's low incidence in the population led to
the acceptance of dangerously high TSH activity as "normal." Just as
excessive FSH has been shown to have a role in ovarian cancer, excessive
TSH stimulation produces disorganization in the thyroid gland.
Competing interests: No competing interests
Dr Weetman's article brings an important point forward in that there
is no correlation except at extremes between the signs and symptoms of
thyroid problems and the TSH. This is clearly stated by Dr. Anthony Toft
of Edinburgh in Werner and Ingbar's The Thyroid 1991. page 294. Hence why
are we following a test which has no correlation with clinical
presentation? The thyroidologists by consensus have decided that this
test is the most useful for following treatment when in fact it is
unrelated to how the patient feels. The consequences of this have been
horrendous. Six years after their consenusus decision Chronic fatigue and
Fibromyalgia appeared. These are both hypothyroid conditions. But because
their TSH was normal they have not been treated. The TSH needs to be
scrapped and medical students taught again how to clinically recognize low
thyroid conditions.
Competing interests: No competing interests
Re: Fortnightly review: Hypothyroidism: screening and subclinical disease
Congenital hypothyroidism is a major health problem and the main preventable cause of decreased I.Q. in children. Neonatal screening programs for detection of Congenital hypothyroidism in the neonatal period have been widespread in developed countries for the last five decades.
A study using third day blood TSH to screen newborns with congenital hypothyroidism concluded that a cut off value of TSH >20mIU/L is adequate for neonatal thyroid screening in Indian settings.
Objectives of the study: To evaluate the incidence of congenital hypothyroidism among term, and preterm babies born at Srinivas medical college Mangalore.
Materials and Methods
Source of data: Clinical data will be obtained from the case files of the patient. The laboratory data of the subject’s samples will be obtained from hospital laboratory records of Srinivas Medical college.
Method of collection of data
Study design: This is a Cross sectional study.
Study period: January 2013-February 28 2014
Sample size: All consecutive deliveries conducted in this hospital during the study period will be a part of the study (1000 deliveries)
Methodology:
3rd day blood samples from the newborns were collected in a sterile container so as to avoid the physiological changes in hormonal levels and TSH was estimated within 24 hrs by electrochemiluminescence immunoassay.
Results:
The range serum levels of T4 and TSH in the neonates of the study group were 0.68 micro units/ml-19.09 micro units/ml. None of the infants of the study group were found to have congenital hypothyroidism.
Discussion:
Neonatal Screening of TSH maybe performed at the third day of life.
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Competing interests: No competing interests