Healing After An Incorrect Diagnosis of Hypothyroidism: Why It’s Important to Start with the Gut
A patient came to my office with a diagnosis of hypothyroidism by a “famous thyroid doctor” who had written books on the subject. When I checked her lab results, even by a conservative measure, they could not be considered hypothyroid. Yet the patient was put on medication, making her more ill. In this episode, learn more about these clinical case study details—that appeared in the January edition of the Future of Functional Medicine Clinicians Review—and how practitioners can avoid making this harmful mistake. Also, learn which markers can be false positives in two of the most popular functional medicine stool tests.
Dr. Michael Ruscio, DC: Hi, everyone. Welcome to another episode of Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m looking forward to discussing a few pearls with you, again taken from our clinicians newsletter. This one is one of the more infuriating case studies that I’ve published in our newsletter.
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Dr. R’s Fast Facts Summary
Case Study – January 2019 Edition of the Future of Functional Medicine Review
- Patient felt worse on Thyroid treatment
- Patients labs were well within the normal range (falsely diagnosed Hypothyroid)
- Chief complaints – gas, bloating, diarrhea, fatigue, constipation, insomnia
- Used basic gut therapies – 6 wks – all improved
- Be wary of False Positives in Functional Medicine Testing
- See Dr. Ruscio’s Comparison of Two Popular DNA-based Stool Tests
- Doctor’s Data Parasitology x3 with H. pylori
This case study was entitled “Questionable Diagnosis of Hypothyroid by ‘Famous Thyroid Doctor’ Results in Harming Patient Only to Later” end up in my office and “See Great Results by… Starting with the Gut.” So that’s going to be the main thrust. But I also want to touch on what the two best functional medicine stool tests are. So that’s what we are going to go into more detail about in today’s episode.
But before we jump into that, I want to make sure to make sure to mention that these are direct excerpts from our Future of Functional Medicine Review Clinicians Newsletter, a monthly publication I put out, which includes case studies and research study reviews to help deliver to clinicians exactly what they need to be effective and efficient with functional medicine.
Now, if you’re new to our audience or you haven’t had a look at this yet, I would highly recommend you do. To make it as easy for you to do so as possible, I’ve made your first month of all access—which includes up to nearly three years of back editions—only $1! So if you sign up during the month of September, you will get one month of all access for only $1. This way you can have a look and see if it’s something that you feel would benefit your practice.
If so, then I’d love to have you on board. We desperately need more providers out there who understand how efficient, effective, and gut-centered functional medicine can produce results when others have failed. Oftentimes others fail after misdiagnosis, as we’ll discuss today. Or just excessive amounts of lab testing that both frustrates the patient financially and also makes the patient feel that there’s far more wrong with them than there actually is. We’ll also tie in—in the testing aspect of today’s episode—details on how functional medicine tests, as great as they can be, do also suffer from false positives. Let me also make sure to say the web address to go to learn more is drruscio.com/review.
Case Study: Incorrect Hypothyroid Diagnosis
So let’s jump into this first case study. This comes from the January 2019 edition. By the way, everything that we’ve been discussing throughout these podcasts, showcasing the content from the Future of Functional Medicine Review, is only from the first six months of 2019. So imagine that times about six. That’s about what you get with this nearly three years of content.
So the case study as it appears in the newsletter was “Questionable Diagnosis of Hypothyroid by ‘Famous Thyroid Doctor’ Results in Harming the Patient Only to Later See Great Results by… Starting with the Gut.” Here’s what was disconcerting about this. We’ve talked previously about the case study from Dr. Robert Abbott who undiagnosed a patient incorrectly diagnosed as hypothyroid, and how, in that case study, the various providers were pursuing thyroid treatments and other treatments, all at the expense of the gut.
So this case study reinforces that same concept.
Now, as part of this patient’s history—and I detail all of this in the writeup, I’m just going to share with you some choice selections—you see that she had tried various thyroid medications and she always felt worse after trying whatever medication it was.
So this in and of itself should give a strong indication that the thyroid is not the cause of the problem. But maddeningly, we can put together the fact that she never responded to any of the numerous thyroid medications she tried with this famous thyroid doctor (who literally has books out on hypothyroidism and Hashimoto’s). You would think that that would be enough. Again, we can piece this together with the fact that her labs clearly do not substantiate she is hypothyroid. Not even close, not even subclinical hypothyroid.
It’s these case studies that practitioners really need to see, need to read. Because it’s hard to conceptualize that errors could be this egregious without actually reading through what a living patient’s case study looks like, that articulates these concepts. So as you’ve probably heard, I now double-check the hypothyroid diagnosis in many cases.
In this case, and in the newsletter you’ll see the actual photo of the labs, TSH was 1.8. The normal range is 0.5 to 4.5, so even by the most persnickety standard—some people erroneously think that TSH normally should be underneath 2.5, which is incorrect, but even if you were going to that standard—this patient was still in the normal range. Now the free T4 was 0.94. The normal range is 0.7 to 1.9, so 0.7 to 1.9 and this patient was 0.94. This provider wrote in “should be over 1.1.” This was the lab finding that substantiated putting this person on a prescription thyroid hormone medication, trying medication after medication, numerous different medications and doses, this patient feeling poorly all the while.
Here’s what makes this even more unbelievable. Her chief complaints: gas, bloating, fatigue, constipation, and diarrhea. Also a little bit of insomnia and some cramping during her menstrual cycle. It should be somewhat clear here that the majority of her symptoms, really, are gastrointestinal. So how is it a provider sees the symptomatic complaints, majority digestive, and combines that with a normal thyroid lab finding, and says, “Aha, we should now use thyroid medication!” baffles me.
Now, I want to also be careful to say there may be something that I’m unaware of, in terms of other therapies that this provider used. But as I’ll share with you in a moment here, it was pretty darn easy to obtain good results in this case using basic gut therapies. So I don’t think we can really let this provider off the hook. It’s not like I had to reach deep into the available therapeutic toolkit to help this patient get better. Maybe we could let this slide if that were the case.
Basic Gut Therapies Healed the Patient
But in this case, basic gut therapies (we’ll detail them in a second) got this patient to a point where she had no more symptoms. Yet, this patient was given numerous thyroid medications and she had no lab evidence to substantiate that.
I also share in this case study that one of the first things I did was just recheck her thyroid. And just like her last test—the one that “diagnosed” her hypothyroid—was normal, so were the tests that I ordered. So, our first visit in my office is where we do all the data gathering, examine history. At the second visit we present my plan. And at the third visit we follow up after someone’s been on that plan for a number of weeks. At her third visit, pretty much six weeks in, bloating improved, gas greatly improved, food intolerances improved, constipation improved, insomnia improved.
I didn’t ask her if her fatigue had improved, but I’m assuming it did, given that everything else had improved. Especially when insomnia improves, oftentimes fatigue improves because a person’s sleeping better. One complaint was worse, and it was that she had a little bit of diarrhea because she was taking a bit too high a dose of vitamin C, which went right away when she brought the dose down.
So in roughly six weeks, this patient was unburdened from a diagnosis that was incorrect, thinking that she had a thyroid disease when she did not. And she saw all of her symptoms improve. In this case study, I write up exactly what we did. But again, spoiler, it’s not complicated. She came in previously on a diet that was keto, paleo, and low FODMAP, which is a fairly restrictive diet. Thankfully we were able to improve her food intolerances so she could expand her diet.
She came in already on that diet, so I didn’t feel the need to push her into any more restrictive of a diet. So we left diet the same. There were no lifestyle recommendations. We had her use a B complex, vitamin C, vitamin D with K, and then our three probiotics, our Lacto-Bifido blend, our Saccharomyces boulardii, and our soil-based probiotic, plus magnesium citrate. This is all that was needed to get this patient healthy.
So I think it’s really important, again, for me to say that oftentimes providers are led to believe that to help patients they have to have this deep understanding, do these elaborate lab assays, and go through all this extensive treatment. And if keto, paleo, low FODMAP didn’t work, we better add in autoimmune paleo, and if this one thyroid marker’s a little off, we better put you on medication… And this is just out of control. It’s so hyperbolic.
Literally half the game in functional medicine is just not getting pulled into all the nonsense, and just focusing on, “Here are the symptoms. Here is the system of the body that these symptoms are likely coming from. In this case, obviously the gut. And now let’s start working through the available gut therapies in a logical sequence.” And what do you know, in many cases, this is all that needs to be done. At the very least, in many cases, they will at least see a measurable improvement. You might have to dig a little deeper for complete improvement in some of the more complex cases, but they will at least be moving in the right direction and happy about that.
Now, one of the things that can also thwart optimal outcomes in functional medicine is false positives on lab tests. And this is the double-edged sword of some of the more progressive and sensitive functional medicine tests. Yes, they may not miss something that is there, but they may actually show you a false positive for something that’s not there.
Comparison of Two DNA-Based Stool Tests
Let me take a step back. There’s a specific case study I want to share in a second here. But let me take a step back to what we shared in another issue of the Future of Functional Medicine Review. This was entitled “Dr. Ruscio’s Comparison of Two Popular DNA-based Stool Tests.”
Now, whether you’re a patient or a provider, you’ve likely become confused regarding what functional medicine stool test is the best. And there are pros and cons to many tests. But if you weigh out all the pros and cons, two tests really look to be the best. Now I detail these two tests. Essentially we’re looking at the Doctor’s Data Parasitology x3 with H. pylori versus the GI-MAP. And both of these labs make claims that are not fully supported but they also have viability. The challenge with DNA testing is it suffers from false positives.
Let me zoom out even further for a second here, just to clarify something that might be confusing. There are two tests that we’re comparing here. There’s the GI-MAP test, which is DNA-based. Then there’s Doctor’s Data which offers both DNA-based and non-DNA based tests. So I provide the specific tests that you should use.
Essentially what we come down to comparing, when we get some of the initial details out of the way, is the non-DNA test, which is the Doctor’s Data Stool with Parasitology x3, compared to the GI-MAP. The Doctor’s Data profile uses a culture technique known as MALDI-TOF. The GI-MAP uses a DNA-based analysis. For our lay audience here, I apologize for the details. We’ll get to some more simplified take-homes in just one second. Bear with me here for a moment.
So the challenge with the DNA testing, while it may purportedly (not substantiated) detect pathogens that stool culture does not detect, it also suffers from false positives. Meaning you don’t actually have X, but the lab says that you do. That’s not the only thing that some of these functional medicine tests suffer from false positives regarding. False positives on calprotectin are also fairly routinely seen. What is calprotectin? Calprotectin is an inflammatory marker that’s part of what is used to diagnose inflammatory bowel disease. This leads to the case study I wanted to share with you.
Be Mindful of False Positives
In the August 2019 case study, I detail a case that had a false positive for calprotectin and for H. pylori via the GI-MAP. But when we compared this to the calprotectin on a LabCorp profile, we saw the LabCorp stool for H. pylori and the LabCorp breath test for H. pylori come back negative for H. pylori, and calprotectin was normal.
Now, the GI-MAP is a good test and it’s one that I routinely use. But you can see false positives for organisms like H. pylori. I detailed—and this is a really important insight in the newsletter—that it seems that many functional medicine labs, also including Doctor’s Data, suffer from false positives on the calprotectin. That is important because you want to identify if someone has inflammatory bowel disease and make sure they have a followup with their gastroenterologist if so. In this case it was easy to be able to see that this patient did not have any of the signs or symptoms of inflammatory bowel disease.
I have been chronicling various case studies in the newsletter for a while now, commenting, “Here’s another case of what appears to be a false positive in calprotectin.” A few months later, “Here is another case of what appears to be a false positive calprotectin.” So we’ve seen enough case studies in the newsletter now that we can fairly confidently affirm that the functional medicine tests oftentimes suffer from false positives for calprotectin also.
Hey everyone. I’d like to thank Aerodiagnostics, my favorite SIBO lab, for making this podcast possible.
Again, Aerodiagnostics is the SIBO lab I use in my clinic. They have impeccable organization, customer service, test quality, and support. Regarding support, if you’re not highly proficient in reading SIBO labs, Gary definitely offers the best clinical support I’ve ever come across. He goes over labs in detail and offers insight analysis and really goes above and beyond.
Aerodiagnostics offers cash pay and insurance billing options, and they do a terrific job of keeping costs low and billing easy. They are for accounts for clinicians and direct-to-consumer testing and Aerodiagnostics, again, is my go-to SIBO lab.
If you’re wondering about how hydrogen sulfide ties into traditional testing of hydrogen and methane, please check out our recent podcast with Gary from Aero. Essentially, we’ve developed a simple questionnaire that will allow you to hone in on hydrogen sulfide SIBO, without needing additional testing or cost. Aerodiagnostics, check them out.
One other take-home from this review of two of the best functional medicine stool tests is that mapping the microbiota is not clinically actionable. This is probably the millionth time that I’ve said this on the podcast. But I just outline that and reaffirm why we should be cautious. We really shouldn’t be looking at the microbiota-mapping aspects of these tests.
It boils down really to two tests. I provide you with the details of those tests. Essentially we’re looking at GI-MAP compared to Doctor’s Data Parasitology x3 with H. pylori. So those are the two tests that I advocate. We also go through some of the pros and cons. The main con to be aware of is this somewhat high tendency towards false positives. That’s okay, you just have to understand that that is a false positive and not be too quick to proclaim, “Oh, you have this infection and inflammatory bowel disease,” when there’s really no supporting evidence for that.
Substantiate Treatment & Avoid Excesses
This is one of the reasons why I say that lab testing is only a third or a fourth of the needed information to make a decision clinically, which is why I am not a huge advocate of lab-centered treatment programs for patients. As much as someone will say, “Oh, it’s scientific,” it’s only scientific if the science is solid. Unfortunately in some of these tests, the science still isn’t solid. We have to do the best we can and make sure we’re weighing all these things appropriately. So you have about a third to a fourth of the data you need to make a decision when you have these stool testing results back.
Okay. So that brings us full circle to a really sad case study where someone saw a provider who you would think could do a solid job with a thyroid case, and actually turned a non-thyroid case into a thyroid case. The old adage of, “All you have is a hammer. Everything looks like a nail,” seemed to really be true in this case. Then, some insights on the two likely best functional medicine stool tests, how to use them, and a few cautions for not getting tripped up into false positives.
All of this, again, has been summarized in various issues of the Future of Functional Medicine Review Clinical Newsletter. I really hope you’ll head over to drruscio.com/review, pay $1 to have a full month of access and read, read, read, read. Learn as much as you can.
And if this seems to be something that can help you get the optimal results like Dr. Mather, like Dr. Abbott, then I hope you’ll sign up and join us. Because we want as many people—I want as many people—who understand this new paradigm in functional medicine out there as possible, because there’s so much help we can offer patients.
As great as functional medicine is, there’s a lot of good and there’s a lot of bad. That bad is waste, excess, fear, superfluousness. So we can do a lot better than that, if we can leave that out and focus on the things that work. We come away with this fantastically beneficial modality, not only for the patient, but also for you as a provider. If you help patients that build your practice—and we all want to have safe, secure practices—this is a nice tool to help you towards that endpoint.
So head over to drruscio.com/review. Sign up for a dollar. Have a look around. If you like what you read, I hope you will stay on board with us and join our cohort of people who are trying to improve functional medicine. All righty, guys, we will talk to you next time.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.