Improper Termination of Medical Investigation of Symptoms of Hypothyroidism

[Guest guest]

I am putting the following paper (written by our own eric Pritchard (a US Researcher) into our FILES section for those of you who are not being properly diagnosed and told you are "suffering a somatoform disorder" because your thyroid function tests are being returned within the normal reference range yet you are still suffering symptoms of hypothyroidism. Perhaps if you are experiencing this problem, you would like to discuss this paperwith your GP or endocrinologist.

I have sent a copy of the first half of this paper to 541 NHS endocrinologists.

Luv - Sheila

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Improper Termination of Medical Investigation

of the Symptoms of Hypothyroidism

by K. Pritchard

Medical investigations of patients’ woes are often terminated either by declaring a medical mystery or by effectively blaming the patients for imagining too much. A name for a medical mystery is “nonspecific symptoms.” The symptoms do not uniquely point to a particular illness so the medical answer is to quit and let the patient continue to suffer. Blaming the patient is done by diagnosing the patient’s illness as a “functional somatoform disorder,” which is to say that the illness is simply being imagined by the patient. Most generally, in both cases, there are physical reasons for the patients’ woes, although they may require some effort to find them. Although this concept has general application to medicine, it has particular application in diagnosing the symptoms of hypothyroidism.

Providing a “nonspecific symptom” or “functional somatoform disorder” diagnosis prematurely is counter to the modern requirements for valid consent [1] or informed consent [2]. In these cases the patient makes a decision based upon a complete knowledge of the medical facts and risks as well as the physician’s preferred course of action as well as alternatives. Additionally, this position is supported by medical ethics:

“Among the various treatments that are scientifically valid, medically indicated, legal, and offer a reasonable chance of benefit for patients, the decision of which treatment to use should be made between the physician and patient.” American Medical Association Code of Medical Ethics 2004, §8.20(4) [3]

Provide a Good Standard of Practice and Care. Keep Your Professional Knowledge and Skills up to Date. The UK General Medical Council (2006)

The “nonspecific symptom” diagnostic has been promoted by the American Thyroid Association [4] via a supporting study by Barsky and Borus, Functional Somatic Syndromes. [5] That suggests a connection with Weetman’s somatoform disorder allegation. [6] It is supported by Patients’ Perceptions of Medical Explanations for Somatisation Disorders [7] by Salmon, s, and Stanley. But Mayou, et. al., noted in Somatoform Disorders: Time for a New Approach, “The only common feature of somatoform disorders is that they show somatic symptoms without an associated general medical condition.” [8] And Shape, et. al., commented in Unexplained Somatic Symptoms, Functional Syndromes, and Somatization: Do We Need a Paradigm Shift?, “However, the association to a general medical condition depends “on the state of medical science.” [9]

The definition of somatization disorder is one that is believed to have no physical basis. [10] Yet the supporting studies did not screen for any physical basis that might explain the study subjects complaints. [5,7] Thus, the conclusions are not so conclusive and can be considered too extensive. In fact, the existing conclusions are logically suspect because the subjects may have had real physical problems and not imaginary ones. Using real physically produced symptoms to imply imaginary symptoms is not logically correct or proper.

The above quotation by Sharpe, et al., [9] points also to a real problem. The associations of symptoms to somatization disorders are reduced as medical science advances. That is medical science, not merely what medical practice is willing to acknowledge. This leaves three possibilities: true medical mysteries or truly imagined symptoms, known causes without remedy, and known causes with remedies. While medicine can not treat medical mysteries, imagined symptoms, or maladies without remedy, it can treat those that do have remedies providing they are recognized.

The “nonspecific symptoms” or “functional somatoform disorder” diagnostic may not be used until all of the potential causes of the symptoms known to medical science, not merely medical practice, have been exhausted.

The Symptoms of Hypothyroidism

There are three reasons why the symptoms of hypothyroidism may be attributed to somatization, ordered here by simplicity of explanation:

1. The symptoms are mistaken as other conditions.

2. The symptoms are caused by other hormone deficiencies or other abnormalities.

3. The diagnostics for hypothyroidism do not test for all of the causes of the symptoms of hypothyroidism.

First, hypothyroidism may demonstrate itself as muscular and skeletal pains. [11] The scope of the examination for those pains may not include hypothyroidism and consequently be attributed to a medical mystery or the patient’s imagination.

Second, one of the major symptoms of hypothyroidism is fatigue. Fatigue may also be a byproduct of other maladies such as hypogonadism (deficiency in testosterone and/or estrogen) [12,13] or hypoadrenalism. [14]

Another symptom of hypothyroidism is low body temperatures, low basal temperature in particular. [15,16] Unfortunately, the study of body temperatures [17] has the same logical problem, it did not screen out subjects with known physical maladies that alter body temperature, including hypothyroidism. As a low basal temperature can approach hypothermia, its differential diagnostics are quite instructive. [18] It recommends investigations for hypothyroidism [and its mimics], hypoadrenalism, hypopituitarism, hypoglycemia, malnutrition, exposure, etc. Obviously, these demand further investigation. [19, page 844]

Third, the diagnostics for hypothyroidism, per guidelines, [20-27] are as the “-ism” suffix would imply, aimed strictly at the thyroid gland. The thyroid stimulating hormone (TSH) level indicates the demand placed upon the input to the thyroid gland to produce thyroxine (T4). Thus the output of the thyroid gland is measured by the free thyroxine assay (fT4). And the antibodies may be measured for some indiction of the internal operation of the thyroid gland.

While these diagnostics are seemingly adequate for the thyroid gland, they are inadequate for all of the thyroid related causes of the symptoms of hypothyroidism. This can be illustrated in the two prevalent definitions: [28]

1. The clinical consequences of inadequate secretion of hormones by the thyroid. [29]

2. The clinical consequences of inadequate levels of thyroid hormones in the body. [10]

Although these definitions were once believed to be equivalent, circa 1970 scientific discoveries of post-thyroid operations of peripheral metabolism (which converts the output of the thyroid, thyroxine (T4), to triiodothyronine (T3)) and peripheral cellular hormone reception (which accepts T3 for use by the cells’ nuclei) make these definitions different. The first corresponds to deficiencies in the thyroid or earlier. The second corresponds to deficiencies from the hypothalamus through the thyroid to the use by the cells’ nuclei. Deficiencies in this discovered realm, which corresponds to the difference between the definitions above, require a T3 replacement.

Unfortunately, the diagnostics in the guidelines [20-27] do not address any hormone found in the post-thyroid realm. These hormones are triiodothyronine (T3) and reverse T3 (rT3). The therapy considerations do not assay these hormones and do not replace T3.

Conclusion

It is improper to make the “nonspecific symptoms” or “functional somatoform disorder” diagnosis prior to exhausting all potential causes of the symptoms known to medical science.

It is quite improper to dismiss the continuing symptoms of hypothyroidism when the TSH assay is normal, or the entire thyroid panel (TSH, fT4, and antibodies) are normal. There are many other possible causes, both post-thyroid and elsewhere in the endocrine system.

The lament by Toft and Geoffrey Beckett [30] is, then, quite understandable and quite unnecessary:

“It is extraordinary that more than 100 years since the first description of the treatment of hypothyroidism and the current availability of refined diagnostic tests, debate is continuing about its diagnosis and management.”

Endnotes

1. For more information see www.medicalprotection.org/uk/factsheets/consent-basics

2. Matthies v. Mastromonaco (160 NJ 26 and affirmed by the New Jersey Supreme Court)

3. Code of Ethics, Am. Med Assoc., 2004, §8.20(4) pg. 25

4. “’s Syndrome,” American Thyroid Association, Nov 1999 updated May 2005

5. Barsky, AJ, MD and Borus, JF. MD, Functional Somatic Syndromes, Ann Intern Med, June 1999, 130(11): 910-921.

6. Weetman AP, Whose Thyroid Hormone Replacement is it Anyway? Clin Endocrinol, 2006;64(3):231-233

7. Salmon P, s S, Stanley I, Patients’ Perceptions of Medical Explanations for Somatisation Disorders: Qualitative Analysis, BMJ, 1999; 318:372-378

8. Mayou MA, Kirmayer LJ, Simon G, Kroenke K, Sharpe M, Somatoform Disorders: Time for a New Approach in DSM-V, Am J Psychiatry, 2005; 162:847-855

9. Sharpe M, Carson A, “Unexplained Somatic Symptoms, Functional Syndromes, and Somatization: Do We Need a Paradigm Shift?, Ann Intern Med, 2001, 134:926-930

10. Tabor’s Cyclopedic Medical Dictionary, F.A. , 2001

11. Golding DN, Hypothyroidism Presenting with Musculoskeletal Symptoms, ls of Rheumatgic Diseases, 1970, 29(10)

12. Shippen E, Fryer W, Testosterone Syndrome, M. , 2007

13. Starr, Mark MD, Hypothyroidism Type 2, Mark Starr Trust, 2005, pg195-196

14. Ibid., pg 184

15. Ibid., pgs 12-15

16. , B MD, Hypothyroidism: The Unsuspected Illness, Harper & Row, 1976

17. Mackowiak, et al., A Critical Appraisal of 98.6 Degrees F, the Upper Limit of the Normal Body Temperature, and other Legacies of Carl Reinhold August Wunderlich, JAMA, 1992, 268:1578-80

18. Differential Diagnosis of Hypothermia, http://pier.acponline.org/physicians/public/d598/tables/d598-tddx.html

19. Lowe JC, The Metabolic Treatment of Fibromyalgia, McDowell Publishing Company, 2000

20. Baskin, HJ, MD, Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism, Am Assoc Clin Endocrinol, 2002, Rev 2006

21. Levy EG, Ridgway EC, Wartofsky L, Algorithms for Diagnosis and Management of Thyroid Disorders, www.thyroidtoday.com 2004.

22. The American Thyroid Association provides links to several hypothyroidism related guidelines: “Use of Laboratory Tests in Thyroid Disorders,” “Treatment Guidelines for Patients with Hyperthyroidism and Hypothyroidism,” and “Guidelines for Detection of Thyroid Dysfunction.”

23. Levy EG, Hypothyroidism Treatment Failure: Differential Diagnosis, www.thyroidtoday.com 2004.

24. Vanderpump MPJ, Ahlquist JAO, lyn JA, et al., Consensus Statement for Good Practice and Audit Measures in the Management of Hypothyroidism and Hyperthyroidism, BMJ, August 1996

25. Garber JR, Hennessey JV, Lieberman JA, CM, Talbert RI, Managing the Challenges of Hypothyroidism, Supplement to J of Fam Pract, 2006, www.jponline.com

26. Kaplan MM, Clinical Perspectives in the Diagnosis of Thyroid Disease, Clin Chem, 1999, 45:8( 1377-1383

27. UK Guidelines for the Use of Thyroid Function Tests, The Association for Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation, 2006, www.british-thyroid-association.org/guidelines.htm

28. Pritchard EK, “The Linguistic Etiologies of Thyroxine-Resistant Hypothyroidism,” Thyroid Science www.thyroidscience.com – click on “debate.”

29. Hypothyroidism, a publication by the American Association of Clinical Endocrinologists and supported by Abbott Laboratories. 2006 & 2008. www.thyroidawareness.com

30. Toft and Geoffrey Beckett, British Medical Journal 2003 (8 Feb); 326:295-296