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From: Kevin G. Rhoads on 30 Sep 2005 08:49
>Have you read "Thyroid Disease Manager" and www.thyroidmanager.org?
I have a hardcopy of an earlier version of the deGroot, Larsen, Stansibury (?sp) & Retifcoff (?sp)
text; I have perma-links to the site and I have downloaded PDFs for the on-line version of the
edition. I also picked up a few other hardcopy books about thyroid and about more general
endocrine issues. I haven't read through everything, but I have read through portions of several
and often more than once.

>I think you'd be impressed with the treatment section of Chapter 9.
>
>"Therapy should be monitored with TSH measurements (using an immunometric
>assay) and estimates of free T4.
followed by much good stuff not quoted.

The problem isn't what the textbooks say to do, it is that, as far as I can tell, the MDs nowadays
aren't being educated to do that and when they start practicising, there is pressure to do TSH
only -- whether from HMOs and insurance reimbursers or from peer pressure or administrators in
large hospitals or whatever.

An example, for about 20 years we went to a Family Practice doctor in the Boston area. He first
diagnosed Nora's hypo-thryoidism. When that happened, he checked the books and asked some local
endocrinologists about this. He was told, and repeated to us, "that treatment was easy, you Rx
synthroid and test TSH, increase synthroid Rx until TSH is in range, it's easy". He wasn't
told about measuring T4 as well as TSH, he wasn't told that titrating the dose had potential
problems -- HE WAS TOLD, REPEATEDLY FROM SEVERAL SOURCES: IT IS EASY.

If the "gold standard" of practice were what the deGroot &al book says, any edition, we wouldn't
have the mess we have. But the "gold standard" of practice is something similar but much simplified --
simplified to the point of error as far as I can tell. The thyroid textbooks warn about TSH not
indicating properly due to other things -- the practice is to blindly believe TSH even in spite of
contradictory evidence, just as one example where it has been simplified to death.

But I think that the treatment recommendations even of the deGroot &al could be better. They did
the best they could with what they knew, and I respect that. But several bits of the TSH vs. T3/T4
as means of monitoring adequacy of dose are based on ASSUMPTIONS. Plausible assumptions I will grant,
but assumptions that are testable and as far as I can tell have never been tested. I don't like
when people assume they know the answer. They did that with estrogen replacement, and when they finally
tested, they found out that their assumptions, which experts felt were plausible, were really wrong.

The questions below are all ones that have an "answer" derived from plausible assumptions, but have not
been tested in ways that allow a definitive answer from experiment (at least as far as I can find).
But present "gold standards" for diagnosis, testing and monitoring of hypo-thyroid are predicated upon
the ASSUMED answers. If those assumptions are false, or even not completely true, then the diagnosis,
treatment and monitoring standards presently used could be fundamentally flawed.
1) Does TSH under adequate hormone replacement fall into that same ranges as TSH in normal populations?
2) How does the range of normalcy for TSH relate to the "normal", i.e., two-sigma from assumed Gaussian, range?
3) How much variation is their in normal levels from individual to individual?
4) Is once a day dosing of T4 meds really adequate? Particularly with a few hours absorption time constant,
rather than just looking at the long time constants of other parts of this system.
5) How often do the TRH, TSH production and release remain intact and unimpaired in people with autoimmune
thyroid issues?
6) If the TRH, TSH subsystems are affected:
a) what percentage of the population?
b) to what degrees?
c) with what results?
7) Is impairment of peripheral T4 -> T3 conversion truly rare? Or does this occur, at least partially, more
commonly?
8) The intact gland releases T3 as well as T4 (and possibly other things not identified as hormones), so how
do we know that T4-only is adequate? And is that definition of "adequate" one of restoration to full functioning
or just keeping the person from getting ill and dying?

Finally, the phlogiston theory is often discussed in chemistry classes to indicate what people believed for a
while. Prior to testing, the phlogiston theory WAS PLAUSIBLE. That was early chemistry not alchemy. They weren't
making sh*t up, they tried to find plausible explanations for the facts they did know -- and the phlogiston theory
plausibly explained all known facts at the time it was developed and promulgated. Further facts derived from
testing showed that the phlogiston theory was NOT TRUE. It is that last step that is science. Any idiot can
make up theories. With a modicum of smarts, one can make up plausible theories. TESTING THOSE THEORIES IS
WHERE THE ESSENCE OF SCIENCE HAPPENS. SO why is this CRITICAL scientific step absent from "scientific" medicine
at least as applied to management of hypo-thryoidism. THEIR THEORIES ARE PLAUSIBLE -- SO WAS PHLOGISTON. Phlogiston
theory failed when tested -- why haven't the plausible theories underlying hypothyroid management been tested?

Until they test these theories, they are NOT doing "scientific" medicine -- what they are doing is no different
than driving out devils. 'Cause if you believe that maladies are caused by devils getting into people, and that
dancing around the sick person, waving feathered sticks can drive the devils out -- guess what, much of the time
you try it, it seems to work! The person gets better! Occasionally they die, because the devils were too strong!
(UGGH need more feathers. These very stong devils! UGGH dance all night! Son better in morning, UGGH say.)

And the poor tribesman who observes that out on the hunting trail, people got well even without UGGH dancing
around waving feathered sticks had better keep his mouth shut. (UGGH big man in tribe. Lowly hunter get kicked
out of tribe if not smart.)

Wearing a white lab coat and waving test numbers around instead of a grass skirt and feather sticks -- without
testing the testable assumptions, however plausible those assumptions may be, THERE IS NO SCIENCE TO IT.

Personally at least UGGH is likely an honest charlatan, he knows that what he does is magic. The MDs are practicing
magic, at least someof the time, but are deluded into thinking it is science.
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