Incorrect Hypothyroid Diagnosis Affects One Third of Patients

Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. This is Dr. Ruscio. Welcome back to Dr. Ruscio Radio. Today let’s discuss a pivotal piece of evidence that further supports something you’ve heard me mention on the podcast many, many times, which is this over-diagnosis of hypothyroidism that seems to be harming a decent subset of individuals. In my opinion, there was a crucially important paper published titled “Clinical Outcomes After Discontinuation of Thyroid Hormone Replacement: A Systematic Review and Meta-Analysis,” hot off the press in the journal Thyroid, 2021, May 31st. The short summary is this study examined the data from 17 observational studies, looking at a total of 1,105 patients. Get this — roughly a third, 34%, were able to successfully discontinue thyroid medication and maintain normal thyroid function. That’s really encouraging, and it reinforces something I’ve been harping on the podcast for years now. Those diagnosed with true hypothyroidism prior were, shocker, less likely to be able to successfully discontinue medication. Only 11%.

DrMR:

There’s one caveat here, which is there is some risk of bias in this data set because it’s predominantly observational data, there was a lacking of adjustment for confounding variables, and the sample size was somewhat small. However, this is the best data we have to date to give us a quantification of how often are people being incorrectly labeled with hypothyroidism and therefore undergoing lifelong thyroid medication therapy.

DrMR:

So even though the data is not perfect, this is the pinnacle of the pyramid. It may be lower down on the pinnacle, but remember an analogy I discussed which I think was in Healthy Gut, Healthy You. Let’s say the Ferrari is the best car; this might be a Porsche. So it’s still a sports car in terms of how levels of evidence go. So let’s unpack some of the details of this very important study. Again, the bottom line here to contextualize is that in the clinic we are seeing an alarmingly high number of individuals who are incorrectly diagnosed as hypothyroid, but this does permeate both into conventional medicine and functional medicine realms. I think this study helps us better understand that.

Subclinical Hypothyroidism

DrMR:

So here is a bit of context or additional context. Quoting the paper, “Levothyroxine is one of the most commonly prescribed medications. Although considered a lifelong replacement therapy, T4 therapy can be discontinued for some patients.” So let’s continue on to a few other key notes. Treatment of subclinical hypothyroidism does not lead to benefit and more likely harms the individual. This is my summary; I’ll read a quote here in a moment. I just want to say that again. Treatment of subclinical hypothyroidism, as we’ve discussed on the podcast in the past, does not lead to benefit and more likely harms the individual.

DrMR:

Now subclinical hypothyroidism is essentially having elevated TSH with normal T4. There’s one exception to this rule, which is those who are very young, perhaps teens and or those who are infertile and trying to get pregnant and are subclinical hypothyroid do benefit from thyroid hormone replacement therapy. And it’s important to acknowledge that. Outside of those subgroups, the majority of people, they do not benefit from being given thyroid hormone medication when their lab work finds subclinical hypothyroid.

DrMR:

What does this look like? This looks like you go to a provider with, let’s say, fatigue, brain fog, and insomnia, and they say, “Oh, your TSH is 4.8. You’re hypothyroid. You need to be on medication.” Well it’s well-intentioned, but that doesn’t seem to be what the majority of data report.

DrMR:

So let me read a quote. “Observational studies have shown an association of untreated subclinical hypothyroidism with an increased mortality,” key point right here, “but randomized trials have not found that T4 therapy decreases risk of death. In addition to the treatment burden associated with thyroid hormone use, approximately 50% of patients older than 65 who take thyroid hormones develop iatrogenic hyperthyroidism, increasing their risk for arrhythmias angina pectoralis, bone loss, and fractures. After an extensive review of the available evidence, a guideline panel recently concluded that almost all adults with subclinical hypothyroidism do not benefit from thyroid hormone replacement.”

DrMR:

I will add behind this, that in the clinic we see overzealousness with thyroid hormone prescribing harming a patient really once per week now. There’s this WhatsApp thread with a few of the doctors in the clinic where once per week you’ll get a notification from someone just sharing a few notes from a case study that is just egregious. We are collecting these, and we do plan to publish a case series write-up of some of these horror stories and publish it in a medical journal so we can start putting some evidence out there.

DrMR:

Okay, we understand that providers are trying to help people, and they’ve probably been educated that a cast of symptoms may be caused by thyroid. They may further be educated to disregard the Labcorp ranges or the conventional lab ranges because they’re more based upon sick care. These are understandable theories, but when we have outcome data, when we have higher quality data than theory data, and we’re ignoring that, this is when things start to get a little bit dicey as these quotes are supporting.

DrMR:

So a little bit more on subclinical hypothyroidism and a few more quotes. “Although many factors likely play a role in the extensive prescription of T4, an increase in the treatment of subclinical hypothyroidism is a contributing factor. Subclinical hypothyroidism is a common biochemical diagnosis which affects approximately 10% of adults and is accompanied by either non-specific symptoms or no symptoms at all.” In fact, we’ve discussed on the podcast there was recently a paper that reviewed a decent cohort of individuals and found no association between subclinical hypothyroidism and any type of symptomatic presentation.

DrMR:

Continuing with the quote: “Once thyroid hormone replacement is started, nine in 10 patients with subclinical hypothyroidism continue thyroid hormone therapy indefinitely. Although the benefits of T4 use for patients with overt hypothyroidism are clear, no benefits have been demonstrated with respect to quality of life or thyroid related symptoms for patients with subclinical hypothyroidism.” This is one of the main evidence points that I cite, the disparity between outcomes in those given thyroid hormone medication who are truly hypothyroid versus those who are subclinical hypothyroid. And just to perhaps unpack this a little bit more, most of what seems to be occurring in realms of integrative, functional, and natural medicine, again, probably with only the best intentions, seems to be these, termed loosely, subclinical hypothyroidism cases.

Overreading the Lab Results

DrMR:

Sometimes they’re not even subclinical hypothyroidism. Sometimes they’re squarely normal thyroid, but the overreading of the labs is so aggressive that they’re labeled hypothyroid even though they’re not even subclinical hypothyroid. So this is why this is so important, because if we have a good amount of data where researchers say, “Okay, perhaps these mild elevations of TSH are something that leads to disease and impair quality of life. Let’s give them hormone and see how they do.” We’ve had enough studies here to be able to firm this up.

DrMR:

So if someone who has a TSH of seven doesn’t benefit, if you were to see a provider and they say, “Oh, well, you may have seen in your Labcorp labs that your TSH shouldn’t be above 4.5. However, the functional ranges say you should be below 2.5. So the fact that you’re 2.8 tells us your thyroid is sluggish and you need thyroid hormone.” Do you see how egregious that is? If we’re treating patients with a TSH elevation that’s below 4.5, but we have data that tell us that treating people who have TSH elevations below 10 doesn’t help, then how do you extrapolate downward?

DrMR:

So I hope that’s making sense. Said again, to try to make this very clear even for someone who’s newer to this conversation: the higher TSH goes, the worse it is generally speaking. The lab cut off for TSH is 4.5. When you go above that, you’re considered subclinical hypothyroid until you get to about 10, and then you’re considered true hypothyroid. Again, loosely stated. There’s pretty ample evidence that treating people with TSH elevations between 4.5 and 10 vectors no benefit. But some in the functional community are going even further and saying, “Well, we can treat people who have TSHs between two and 4.5,” which is ignoring data that says a worse thyroid finding does not benefit from thyroid home medication. And you’re saying that even despite that data, you want to be even more aggressive. So despite disproof of your hypothesis, you’re doubling down and going even further in terms of how aggressive you’re interpreting labs.

DrMR:

Again, to be careful and to be clear, I don’t think any of this is being done with misintention. In fact, for years in practice, I kind of followed some of these functional integrative guidelines until I started asking questions and really saw that patients oftentimes were being harmed. This is why I’m eager to share this, because I think we need a broader understanding of the evidence base that’s developing that’s illustrating to us that some of these early and well-intentioned hypotheses don’t really seem to be holding water. And what I’m hoping we can do collectively is use this to adjust some of our thinking.

DrMR:

And I get it, right? There was a point in time where I had to go through the uncomfortable process of having had ordered adrenal tests on a bunch of patients and then going through that uncomfortable internal banter with myself regarding, “I’ve been taught this, I’ve been doing this, but I’m starting to question if this is something I should be doing.” I think to feel a little bit uncomfortable would be natural.

RuscioResources:

Hi, everyone. Just a few fairly important updates. I’ve been working diligently behind the scenes tweaking and updating our paperwork, our clinical systems, our treatments, our data gathering, data organization, reporting, and patient monitoring. I’ve refined the algorithm to be even better than it was before. And how confident am I in our clinical team? Well, my mother is working with our health coach and my father just started working with one of our doctors, so about as confident as you can get. Collectively, we are moving towards our goal of reforming functional medicine. We are gathering data on our patients and working toward publishing our data. We have taken big steps in this direction. So you are part of something big here. You’re not only a patient we aim to serve and help, but also, as one of our patients, you become an example of how people can improve their health in less time and for less money compared to what appears to be commonplace in the functional medicine field. So I encourage you to look forward not only to potentially working with me, but also with any of our tremendously skilled, attentive, and empathetic clinicians. And so thank you for being a part of it or thank you for waiting to be a part of it if you’re about to be seen soon. And if you have not yet reached out and you’re in need of help, we would be pleased and honored to work with you.

DrMR:

Okay, so continuing on, here are a few other points from this study. They did exclude certain patient groups that could of, in my opinion, confounded the data. Those who had radioactive iodine treatment, Graves’, those who had thyroidectomies which is ostensibly normally due to cancers, and those who had postpartum thyroiditis were removed from this cohort. I think that’s really important to keep in mind, especially the postpartum thyroiditis bit, because postpartum thyroiditis is temporary, and that could falsely inflate the numbers and make my position falsely inflated. So if those are excluded from this, they actually cut against my hypothesis, but they make the data more true, and that’s what’s most important. It’s not about me reinforcing my hypothesis, it’s using the data to instruct what my position will be. Hence the evolution of my position as the data has evolved.

Discontinuing Therapy

DrMR:

In terms of discontinuation regimens, how were people stopping the medication? There were generally three approaches that were used. Discontinuing therapy within two weeks, so first having the dose at week one and then discontinuing the remaining dose at week two. That’d be your faster discontinuation. Another approach was having the medication dose successively every four weeks until someone got down to about 12 micrograms, and then they discontinued after that. And the third and final approach was essentially having the dose until you hit two months or decreasing by 25 microgram reductions until you’re fully discontinued. So there’s a few different approaches used in terms of how quickly one comes off.

DrMR:

What I would offer you here is that there has not been a best protocol identified yet. So I would say depending on your constitution and your comfort level, you may want to do this quickly, especially if you’re someone who is suspecting there may be side effects like insomnia, fatigue, palpitations, hot flashes. And if you’re someone who’s not sure, then you may want to go a little bit slower.

DrMR:

There’s an argument to be made for either case. The argument to be made for a more rapid discontinuation is if you are someone who has a return of symptoms after stopping the medication, you’ll have a clear signal. It’ll hit you and it’ll be more apparent. This is also something that I think is worth discussion when it comes to finding the minimal effective dose of some sort of support like a probiotic. Having someone stop cold turkey may actually be a better way for them to more clearly be able to identify if certain symptoms started to partially return after they stopped using probiotics as an ongoing support. So there are pros and cons to this approach, but sometimes there’s value in eliciting a stronger signal. But in any case, there are a few different approaches that can be used there.

DrMR:

Now to the question of did people develop symptoms after stopping thyroid medication? This is important because we want to look at two things. We want to look at the level of hormone and if their hormone levels remained normal. That is almost for certain the most important. Why? This is my opinion, but why? Because thyroid symptoms are non-specific, and we at the clinic have seen droves of patients who were falsely attributing their symptoms to thyroid for years. So there’s a lot of potential bias, nocebo, and placebo regarding people going on medication for thyroid or stopping it and expecting it to help them, or when they stop it, expecting that to harm them. So in my opinion, the more important thing to look at is their thyroid hormone levels. That will be considered heresy by some, but I would counterargue that approach is probably harming more people than it’s helping.

DrMR:

But what do the data here show? Four studies tracked this. Two studies found no symptoms return. One study found 15% of patients developed symptoms after discontinuing their thyroid hormone medication. And one study found that 71% of patients experienced symptoms, all of whom had become hypothyroid once discontinuing. So what this sums out to is the majority of data suggest no symptoms will return in those who remain normal thyroid after stopping their thyroid hormone medication. It’s also important to mention there were essentially no major adverse events reported from discontinuation.

Will Discontinuation be a Success?

DrMR:

Now what about the question of what predicted who could successfully discontinue thyroid hormone replacement medication? There were a few factors here. Abnormal ultrasound findings, or what’s known as heterogeneous echogenicity, meaning you should have homogeneity, the ultrasound should reverberate, if you will, showing the same sort of density throughout the tissues. When there’s heterogeneity in the ultrasound findings, that means some pockets are denser, meaning inflamed and damaged, and others are more porous, meaning healthy. So if you have an abnormal ultrasound, that is a predictive factor that suggests you will not be able to stop medication. It doesn’t guarantee, but it’s one risk factor. In this study, if someone had a TSH over eight or nine, then it was suggested that they wouldn’t be able to discontinue.

DrMR:

What’s nice about this is it pretty much overlaps with the majority of data finding that TSH over 10 is the level at which we should really be considering this something that needs to be treated and addressed. So we’re talking about a one point delta in between the two. It’s still giving us that ballpark of a TSH of about 10 being the cutoff we should be looking at. So that was another risk factor, and TPO antibodies being positive was a third.

DrMR:

So you can start to put together a kind of predictive analysis to give you some prognostication if you’ll be able to successfully discontinue your thyroid hormone. If you don’t have this data, I don’t think it’s a big deal. With your provider, you can go through the exercise of discontinuing, doing follow-up testing at the six to eight week interval mark, and then seeing where your levels come back.

DrMR:

Again, I just want to mention that there was a risk of bias in this study, but I wanted to clarify one thing. This is not the colloquial use of bias, meaning these researchers were kind of hunting for data that reinforced their hypothesis, throwing everything else out, and cherry picking what fit their hypothesis. This was the more research-centric use of bias. And I’ll read their quote: “We judged the observational studies to be at a moderate high risk of bias. On the basis of representativeness of the exposed cohorts, most were select groups of users. There was a lack of blinding and a lack of assessment of confounders.” So what this means is it’s not the über-scientific pinnacle of randomized, blinded, controlling for confounders in really large sample size.

DrMR:

Again, it’s important to mention that it’s not the colloquial use of bias, meaning these researchers are kind of super conventional, conservative, and looking to hunt down and disprove anything that’s a new theory or hypothesis. Which does exist, and we’ve discussed that in other areas. That seems to exist with some of the narratives regarding probiotics.

DrMR:

Another point here, education is key. To quote: “Shared decision-making is fundamental for a successful de-prescribing intervention, as patients are more likely to consider de-prescription if they, one, understand why the medication is inappropriate, two, have their concerns related to stopping the medication addressed, and three, understand the de-prescribing plan and feel supported by the clinical team. De-prescribing conversations should be focused on raising awareness about alternatives, discussing the risks and benefits of de-prescribing, and understanding the patient’s preferences.”

Moving Forward

DrMR:

So, I would summarize this into the following actionables. You may have been incorrectly diagnosed. A recent meta-analysis found there was a one in three chance, or one-third of patients were essentially incorrectly diagnosed. The medication might even be making you feel worse. In my observation, palpitations, bone loss, insomnia, and fatigue are somewhat common. There is a cause of your symptoms, and we will work to investigate that.

DrMR:

It’s really important to make that tie-in. We have this kind of internal rule at the clinic, which is always keep a patient moving forward. So if we close a door or discourage further forays into thyroid evaluation, we want to make sure to open another door of inquiry. So we’re always progressively moving toward investigating and addressing the underlying cause. So I think it’s very important not to just shut this down and offer patients no alternative, because if not, they’re going to revert back to whatever lifeline they have. And if that’s incorrect thyroid, if that’s all they have, they’re going to grab on to that.

DrMR:

And final point here, we will monitor you and make sure you remain normal thyroid after stopping, and if not, we can reinitiate medication. It’s important to articulate you’re not looking for a certain outcome. You’re just wanting to ensure that they actually need and are benefiting from the medication that they’re on.

DrMR:

In conclusion from this meta-analysis: “Low quality evidence suggests that up to a third of patients remained euthyroid,” meaning normal thyroid, “after stopping T4 medication with a higher proportion of patients with an initial diagnosis of subclinical hypothyroidism remaining normal thyroid than patients with an initial diagnosis of overt hypothyroidism.” Okay. And what you can do is check the labs that diagnosed you. The actual lab report and not what your provider wrote in. Are you true hypothyroid? Do you have a flagged high TSH plus a flagged low T4? Again, flagged by the lab, not by the provider, because we’ve published a case study where I think the TSH was something like 3.8 and the provider wrote next to it, “Hypothyroid — call for Armour prescription.” Or is your TSH over 10?

DrMR:

Now, as a reminder, the TSH ranges below 4.5 are normal, 4.5 to 10 is subclinical hypothyroid, and said loosely, over 10 is hypothyroid or those who will most likely benefit from medication. Again, caveat rules are slightly different for those who are very young and for those who are infertile. Free T4, you’re looking at about 0.8 to 1.8 as the normal range. And if you’re essentially below 0.8, then that accompanied by high TSH diagnoses hypothyroid.

DrMR:

Speak with your doctor, very important here, and if this seems warranted, discontinue under their care and observation. I am not advocating for people to do this willy-nilly on their own, but discontinue under their supervision and then retest TSH and free T4 at the six to eight week mark. If your doctor seems biased, get a second opinion. Also feel free to contact my office. If you need help with this, we will be more than happy to walk people through this. I understand that not everyone is in possession of a provider that they have confidence in, so we do have this as a resource that we can help you with.

DrMR:

I will also link to Figure 5, an algorithmic approach to de-prescribing thyroid hormone. I hope you have come to appreciate the value of algorithms as I’ve been really harping on the gut algorithm that has done so much. And we’ve also developed a thyroid algorithm which we’ve actually expanded, and that is able to be accessed through the Future of Functional Medicine Review. Formerly I’ve referred to that as a newsletter. We’re really taking some steps now to develop that more into a reference database with practice guidelines, and we’re going to be doing a lot more with that over the next six months to a year. There is a thyroid algorithm in there that gives you kind of a stepwise process to go through, and I’ll also include this flow diagram with a specific mini algorithm for de-prescribing. We essentially just talked through it, but having a schematic sometimes is helpful.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to DrRuscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly-efficacious functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who have been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our Probiotic line, and other gut-supportive and health-supportive supplements. Health coaching. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you’re a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review, which I’m very proud to say we’ve now had doctors who’ve read that newsletter find challenging cases in their practices, apply what we teach in the newsletter, and be able to help these patients who are otherwise considered challenging cases. Everything for these resources can be accessed through DrRuscio.com/resources. Alrighty, back to the show.

Take-Aways from Study

DrMR:

And a few closing thoughts. I estimate that this third of patients is what will be found in individuals seeing conventional doctors in the conventional care model mostly. I suspect that in functional medicine circles, it’s likely higher and closer to that of which was found in the Volta paper, which we’ve discussed published in Thyroid, 2018, which found about 60% of patients could discontinue thyroid hormone. But this is my speculation. There is that one data point, the meta-analysis, the more thorough analysis found one third, about 34%. However, again, that’s likely a population skewed more towards conventional medicine in the box, not in the progressive paradigm of functional and alternative where there does seem to be much more of a leaning toward liberal diagnosis and use of thyroid hormone. So I suspect that would be closer to Volta’s 60%, but again, outside of his paper, I have no references to point to other than my clinical experience, which has been fairly alarming.

DrMR:

Second point. It has become increasingly unsettling and common to see this in the clinic. It’s something that I really struggled at first thinking that this was my bias, I was confirmation biasing myself in defining more of these cases than existed, or I was just seeing a higher sample of those. But as we’ve had clinicians who read our newsletter who are not even connected to our practice or my practice at all sending in their feedback that they’re seeing the same thing, and now doctors Joe and Rob, and now progressively Hannah and Omar, as I mentioned earlier in our internal, clinical, shared WhatsApp thread, we’re seeing at least one case of this per week. And I’m assuming that I’m not getting a WhatsApp ping for every single case a provider finds, it’s more so the ones that are egregious.

DrMR:

And when I say egregious, I mean people who have TSH that look like they have Graves’ disease. I mean, their TSH is 0.001 because their provider is so fervently trying to get their free T4 to the upper end of the range. And this poor person is tired and they have insomnia. Ironically, there’s this disconnect that overuse of thyroid medication, can cause the exact symptoms that you’re trying to prevent or to treat, insomnia being one and fatigue being another. So it’s important to mention that.

DrMR:

I hope those who have been a bit more liberal with their diagnosis of hypothyroidism and their use of medication will start to rethink this. Check the references of those making the other argument against my references and see who has better data, because that’s really what this all comes down to. It’s not picking on a position just at random. It’s trying to make the decisions that are most proximal to the truth, most informed by the data, and most likely to improve our patient’s well-being.

DrMR:

And what I’m hoping you’ll see when you check my references and you check references from a different camp, so to speak, is I’m predominantly referencing outcome data and interventional trials and the other camp is maybe cherry picking one or two outcome studies, but then the rest of it tends to be mechanism and theory. And I know this because looking at the whole example of the ratios of T4 to T3 and is T4 alone better than T4 plus T3, we went through an exhaustive review. What was disconcerting to see is some proponents of the alternative hypothesis answered back and said, “But what about this study? What about that study?” This is essentially the one or two studies that found T4 plus T3 was better whereas eight to 10 studies found that it was not better or may have actually made people feel worse. So this is what I’m talking about. That’s by definition, cherry picking.

DrMR:

So I hope that we can all appreciate that we’re on the same team and hopefully embrace a culture of open-mindedness and constant change toward better instead of defending prior beliefs and practices. And I really think that we can do this, we can correct this, and we can get this adjusted, this way of looking at, interpreting, and treating thyroid to a point that’s going to be more on the bullseye for what is best for patient well-being.

DrMR:

I think we’re all trying to hit the same mark, which is what’s best for people. People come in, they’re not feeling well, they’re tired, they’re depressed, they’re constipated, they have dry skin, they have thinning hair. A lot of this sounds like thyroid. There was a book written or a well-done CE seminar that made a compelling case that there’s this epidemic of missed hypothyroidism cases and these people desperately need hormone. I think that’s all being done with the right intentions, but as more and more data has come in, what we’re seeing is this hypothesis doesn’t seem to hold water, and is probably actually antithetical to well-being.

DrMR:

So what I’m trying to offer up here is another pretty compelling data point, really the best one that we have that gives us a quantification for how often are patients incorrectly diagnosed as hypothyroid and to what degree of harm is being done from that. So if you have not, especially if you’re a provider of any sort, I invite you to subscribe to our Future of Functional Medicine Review, and you’ll see there’s an index. Through that index, you can find our thyroid algorithm where you can read through our suggestive method of analyzing and interpreting antibodies, interpreting lab work, and how to filter out for confounding noise that may be coming from gut/brain.

DrMR:

So some of these depression, mood, fatigue, insomnia symptoms may be gut-driven. There also may be thyroid hormone malabsorption secondary to pathology or imbalance in the gut, and there also may be female hormone imbalances that look very similar to this. And there also may be true hypothyroidism, but it’s sussing all this out so that you have a sequential method to work through that essentially manifests as this therapeutic algorithm that will allow you to navigate this most efficiently and go through the order of operations that allows you to start with the problems that are the most common.

DrMR:

As an example, functional gastrointestinal disorders, which can cause thyroid-like symptoms, or the same symptoms that are attributed to hypothyroidism, affects 40% of the population. True hypothyroidism is about 0.5%. Hypothyroidism plus subclinical hypothyroidism is about 4.5%. So we should probably be starting with gut. Unless there’s overt hypothyroidism, then we’d want to start with gut and overt hypothyroidism. And then if we want to get into the nuances of thyroid, let’s get the confounding GI-induced noise out of the way first.

DrMR:

So this is part of what we’ve laid out in the thyroid algorithm so that we can continually be moving a patient toward their goal of feeling better, but doing it in the most efficient sequence of steps as possible. Again, we’re trying to reduce all of the noise, which can be very challenging. In an individual system, there’s a lot of noise, there’s this natural up and down, and there are various inputs that are leading to symptomatic outputs. Managing these variables is essential in being able to really get your hands around what’s going on and move someone to consistent improvement.

Episode Wrap-Up

DrMR:

Okay, so that is the paper. Again, the title is “Clinical Outcomes After Discontinuation of Thyroid Hormone Replacement: A Systematic Review and Meta-analysis,” published in the journal Thyroid, 2021. I hope you found this podcast insightful. And remember, if you want to see our full thyroid algorithm which has already incorporated this meta-analysis into some of the de-prescribing guidelines of the algorithm, the website is DrRuscio.com/review. And if you’re a patient in need of help here, if you’re unsure about your doctor, it never hurts to get a second opinion and the clinic will be more than happy to help you with that if that’s what you need.

DrMR:

Okay guys, hopefully this was insightful. I welcome feedback. And again, we are all on the same team here, so hopefully we can use this information to move forward and make amendments to the current thyroid model. Okay. Talk to you next time. Goodbye.

Outro:

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What to do?

• Check the labs that diagnosed you, the actual lab report and NOT what your provider wrote in

• Are you true hypothyroid? 

• Flagged high TSH + flagged low fT4? Flagged by lab, not provider.
• Or TSH over 10 
• TSH normal ranges:
  • below 4.5 = normal.  4.5-10 = subclinical hypothyroid.  Over 10 = hypothyroid.
• Free T4:
  • 0.82-1.77 LabCorp,
  • 0.8-1.8 Quest

• Speak with your doctor, discontinue, and then retest TSH and fT4 after 6-8 weeks.

• If your doctor seems biased, get a second opinion.  Feel free to contact my office if you need help.

• Ruscio Institute
• Dr. Ruscio’s Additional Resources