Suggestions for an Approach to the Management of Thyroid Deficiency

http://thyroid-disease.org.uk/index.php?option=com_content&task=view&id=18&Itemid=31

SUGGESTIONS FOR AN APPROACH TO THE MANAGEMENT OF THYROID DEFICIENCY

by Dr Barry J Durrant-Peatfield M.B., B.S., LR.C.P., M.RCS. Approved Civil Aviation Medical Examiner

From the article:
"The clinical syndrome of thyroid deficiency is very much more common than is generally realized; (Dr. Broda) Barnes, in several publications, drew attention to this in the last two decades, as has the present writer more recently. One reason for this, is a tendency to think of hypothyroidism and myxoedema as one of the same thing, when this is quite wrong. Myxoedema, as doctors were taught in medical school, is the end result of a progressive disease process resulting in more or less total absence of thyroid hormone; whose symptoms and signs are no doubt perfectly familiar. But this state of deficiency has to start somewhere, winding down over a variable period to the terminal state of myxoedema. Symptoms and signs will naturally vary according to the extent of the level of deficiency reached. Clearly, a 10% loss may have little to show for it; whereas a 25% loss may have several very definite symptoms and signs; and a 40% loss even more so. Furthermore, patients show very individual response to any given level of dysfunction; while one may complain of excessive fatigue and weight gain, another may be more troubled by depression and menstrual problems.

That the diagnosis is all too frequently missed, is an inevitable result of this fundamental misunderstanding, and is commonly the result of an incomplete clinical appraisal in favor of the standard thyroid function tests. These tests are the real problem in diagnostic failure since there are inherent problems in interpreting blood levels of thyroxine and/or thyroid stimulating hormone (TSH) when blood levels may differ widely from tissue blood levels. Since the diagnosis may very properly, and easily, be made clinically, unreliable blood levels should NOT take precedence over clinical judgment.

Equally unsatisfactory is the acceptance by doctors and patients alike of poor response to thyroid replacement.

The present writer has been constantly alarmed and dismayed by hypothyroid patients who for years, all too often, have been obliged to accept a much less than satisfactory amelioration of their illness, being taught to expect no more than some improvement. It is perfectly possible that complete and long lasting remission should be obtained, and neither doctor nor patient should accept anything less. Further, the response should be monitored, not just by the doctor, but by the patients themselves. Since there often is a dynamic situation, the patients should be educated and taught to monitor themselves, making their own adjustments to dosage. In this connection, frequent monitoring by blood tests may be quite misleading and unhelpful. Surely it must be more satisfactory for the physician to ask the patients how they feel; and guide the informed patient in establishing the right dosage levels of replacement therapy."

We are sure Dr. Osler would agree. But if our physician does not listen but instead turns us out of his office after a woefully inadequate fifteen-minute appointment, and our lives are ruined as a result, what then?