My understanding of the thyroid gland has changed dramatically over my twenty years in medicine. As with most physicians, I learned of the symptoms of an underactive thyroid: fatigue, unexplained weight gain, constipation, dry skin, hair loss and others.

Early on in practice, women would come to the office complaining of this cluster of symptoms and my working diagnosis was hypothyroidism. I was trained to order a single thyroid blood test, TSH, and if it came back elevated, the person probably had an under-active thyroid gland. If it came back normal, they didn’t. Period.

For most of these patients with classic signs and symptoms, the TSH came back normal so I told them they had normal thyroid function. I couldn’t easily explain their fatigue and other symptoms.

The next stage in my career, from a thyroid perspective, was characterized by a more profound level of ignorance. Women would come in with the same thyroid-ish grouping of issues and I would tell them that, while it seemed like a thyroid problem may be the cause of their symptoms, I could almost guarantee them it wasn’t.
And I would do the TSH test to prove it.

With the thyroid, we have taken a common problem that requires a sophisticated approach for diagnosis and management and reduced it to a single blood test. At least half of those with a thyroid problem would be missed by using TSH alone.

There are many reasons why a person will not have adequate active thyroid hormone with good action in the cells and tissues of the body. For some, it is the autoimmune process Hashimoto’s thyroiditis and positive antibody tests and/or a classic pattern on thyroid ultrasound can be helpful in diagnosing that.

Some people don’t convert the less active T4 hormone to the more active T3 hormones.

Some shunt too much T4 hormone to the dormant reverse T3 form rather than the active (free) T3 form.

Some have enough circulating free T3, but it’s not utilized adequately in the cells and tissues.

Some are deficient in what the body needs to make thyroid hormone. This would include: iodine, selenium, whole molecule vitamin C (not the ascorbic acid version in most vitamin C supplements) and magnesium.

Some may have adrenal problems from stress, lack of sleep, excessive caffeine and other causes that has to be addressed first before the thyroid can be managed.

I am on my fourth book on the thyroid gland, A Functional Approach to the Thyroid by Kenneth Blanchard, MD, PhD, and it is filling in more gaps in knowledge. I have read innumerable research studies, articles and other sources on thyroid dysfunction. This is a complex topic that requires a complex approach.

From his many years of experience, Dr. Blanchard recommends using a free T3/reverse T3 ratio to determine if the active hormone is being utilized in the cells and tissues. A ratio under 0.2, from his perspective, would be an indicator of this particular problem that would otherwise be unappreciated.

Often, if the primary care provider gets a normal TSH test, they may still entertain the question on whether they have a thyroid issues to explain the patient’s chronic fatigue. The logical next step would for the patient to see an endocrinologist. They should be the expert on this question right?

In my experience, there are few endocrinologists that will go even one step beyond a TSH level. So, where does that leave us? Either the mainstream endocrinologists are correct or David Brownstein, MD, Suzy Cohen, PharmD, Kenneth Blanchard and other practitioners will similar views are correct. But not both.

You may have to become an expert on the thyroid yourself and find an open-minded practitioner willing to explore non-traditional avenues.

The next blog on chronic fatigue will focus on vitamin and mineral deficiencies as potential causes.

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