PREAMBLE to HYPOTHYROIDISM

 PREAMBLE to HYPOTHYROIDISM

"Important things you may not know about hypothyroidism or things your doctor might not be telling you or even know about thyroid".

 

How did I get interested in the thyroid?

When in 1975 I began to study rheumatology in Paris at the Lariboisière Hospital and doing my internship at the Foundation A. Rothschild in the department of rheumatology of Dr. Yves Chaouat, I found that many patients who consulted hospital had an undefined condition involving muscle and tendon widespread pain and extreme fatigue. Whether they were labeled as suffering from polyentesopathia, fibrositis, muscular rheumatism, or diffuse idiopathic polyalgic syndrome, the common denominator was that these patients were mainly women between 20 and 50 years, the troubles were daily, installed from several months, and respond poorly to conventional analgesics and anti-inflammatory drugs. Given this context and the mysterious origin of this disease, it appeared to be psychosomatic in nature and these patients were receiving antidepressant treatment orally or of repeated intravenous infusions rounds.

In 1980 appeared in the medical world two diagnoses that did not exist before, fibromyalgia and chronic fatigue. Those were the diagnostic labels that suited to these patients, fibromyalgia when the pain took the front of the clinical presentation, chronic fatigue when fatigue predominated. But that did not change the management of these patients. 

I continued to attend the rheumatology department at the Foundation A. Rothschild, and this until 1989. I wrote a thesis of rheumatology (Click Here). But in the meantime, in 1981, I had settled in Paris as general practitioner (Click Here). In interesting me closer to this type of patients who wanted to follow me in the private, I noticed that the majority of them also showed thyroid function disorders, whether the musculoskeletal presentation (FMS) was dominant or the fatigue (CFS). Having done a 6-month internship in an endocrinology department some years before, I was well aware of all aspects of clinical hypothyroidism. In 1981, the TSH test already existed. 

Since the early twentieth century had succeeded tests and each new test that was declared reliable to tell if a person was hypothyroid or hyperthyroid ultimately proved not to be compatible with clinical data (Click Here). Finally, the TSH test was discovered and touted as the final answer. The thyroid stimulating hormone is part of the pituitary feedback mechanism that controls the thyroid gland. The consensus of thyroidologists decided in 1973 that the TSH blood test was that they had sought throughout these years. TSH was not only able to deliver all of the thyroid diagnoses but it could also be used as well for monitoring treatment. Since then, and until nowadays, almost every conventional discussion of thyroid diseases is focus almost exclusively on the use of TSH as the "gold standard" for diagnosing and treating thyroid diseases, and often regardless of symptoms. Typically, if the TSH is higher than the normal value, a patient is diagnosed with hypothyroidism, and TSH levels below normal are interpreted as hyperthyroidism. Over time the TSH test was made more and more sensitive and because of these improvements it was even more thought that it was the total answer for thyroid diagnosis and it was increasingly seen as the perfect answer for the diagnosis and monitoring of thyroid treatment. Knowledge on thyroid metabolism evolved as well. 

So getting back to my patients suffering from fibromyalgia and chronic fatigue syndrome, in 1981, when I moved into the private, I was able to rely on the TSH test to support my findings on the signs and symptoms of hypothyroidism that the majority had, in addition to their musculoskeletal pain and fatigue. I was aware that the pain and the fatigue could fit with the diagnosis of hypothyroidism, that is to say, they were described in the semiology of thyroid insufficiency. Some had high TSH, confirming my diagnosis of hypothyroidism, but for others, the majority, although the symptoms of hypothyroidism were old, the TSH was normal, that means into the reference values. Moreover, and this is what I have found over the years, many people developed signs and classic symptoms of hypothyroidism, but the TSH was still too slow to become abnormal and rise to confirm clinical diagnosis. Sometimes it never did. 

In any case, in 1981, the TSH being high or not, I began to treat these patients with thyroid hormone in the normal way that I was taught in the Faculty. For those who had normal TSH, I saw no reason to wait until the TSH rises to start treating. I was always interested in medical research, and here I could bring my own contribution. I decided to entrust any of my patients to an endocrinologist for two reasons. First because none would agree to treat patients with a normal TSH, and secondly because the consensus among endocrinologists was to begin to treat patients once their TSH greater than 10 mIU/L, ie well beyond the norm, regardless of the symptoms, and that I did not accept it. I soon became convinced that TSH can lag a long way behind the appearance of low thyroid symptoms. There was no relationship between TSH and how people felt. This has been proven true throughout my career. The value of TSH has no clinical correlation except the absolute extreme with severe symptoms or signs. The reasons for this are complex and I will give explanations later in this presentation. 

The results were spectacular. The vast majority of patients I treated with thyroid hormone saw their symptoms of fibromyalgia and CFS disappear - or almost all. Some require a larger dose than others. If the treatment was stopped for whatever reason, the symptoms began to return slowly over the following months. Nevertheless, I did not stop asking TSH dosages, because I was curious to know where they stood face to patients with a clear clinical diagnosis of hypothyroidism. 

So, where did the two "new" diseases, FMS and CFS, come from? As soon as I started to get interested, from a research in library I found out that in the medical literature in the 1930s the symptoms and signs of these two diseases, that were not identified then, were described as possible expressions of hypothyroidism. It was not surprising to me. Earlier treated, they were corrected by adequate doses of thyroid hormone. Clinicians had already noticed that if such patients had thyroid hypo-function during too long, all signs and symptoms, regardless of what they were, were more difficult to reverse. The clinicians of the past, during decades (before the TSH) were astute and very observant and were able to diagnose and treat hypothyroidism correctly without the TSH - why do we need it now? Anyway, to focus excessively on the biological tests, doctors nowadays give less weight to the clinical manifestations. 

Thus, it confirmed what I suspected already heavily, fibromyalgia and chronic fatigue were both hypothyroid conditions. This has been demonstrated by the work of Dr. John C. Lowe, Director of Research for the Fibromyalgia Research Foundation and one of the innovators in the diagnosis and treatment of hypothyroidism, work that I relate in this study. Clinicians of the past would surely be aghast at the total missing of appreciation by doctors nowadays for clinical evidence of thyroid hypo-function that complain so many patients with chronic fatigue and fibromyalgia. Because of the fact that the TSH is mostly in the standard in these patients, it does not encourage them. And because their TSH is in the standard, the under-lying cause of their disorder is not taken into account. This applies to all primary hypothyroidism, which form the most common being Hashimoto's disease and whose diagnosis is too often delayed or neglected, sometimes for years, due to a so-called TSH in the standard, leaving patients suffer needlessly and treated with symptomatic drugs, antidepressants, analgesics, vitamins, and others, all ineffective on the original cause undiagnosed, hypothyroidism. (Click Here).

Dr. Anthony Toft, endocrinologist and President of the British Thyroid Association, wrote in the Bible of thyroidology Werner and Inghar, "The Thyroid", published in 1991, that the measurement of serum TSH alone may not always reflect thyroid status, and that a TSH in the standard does not disqualify a thyroid condition. So, is this the standard reference TSH a problem? I will discuss later. Does the diagnosis of thyroid disease should be based primarily on this one test? Some experts say no,  a view I share.  In any case, it is imperative  that physicians  return to  "their classics", namely semiology of hypothyroidism, its signs and symptoms, even in its early stage, and also, and this is the essential, they should be listening to their patients. As for treatment, they insist on a test track, trying to normalize, while there is no correlation with the clinical presentation. 

I have had a lot of pleasant surprises of people badly disabled by fibromyalgia or chronic fatigue for years who slowly saw their symptoms disappear. Of course it is a pleasure to see that happen. 

That's how I got interested in the thyroid, its physiology and treatment. Then came to see me thyroid patients without fibromyalgia or chronic fatigue syndrome, or apparently. They were inadequately treated hypothyroid patients as they had remaining signs and symptoms of the disease, sometimes even disabling, while their doctors seemed quite satisfied with a TSH returned to the "norm". If all of them did not meet all the diagnostic criteria for fibromyalgia established by the American College of Rheumatology, some had the entire list. Hashimoto's disease, which most physicians treat, wrongly, in the same way as any hypothyroidism, has occupied much of my time. The fact that whole families are affected is not trivial. Then I refined my treatment of fibromyalgia and chronic fatigue syndrome, having found in the Guaifenesin great interest, together with the management of hypothyroidism as small it is clinically. Finally, the discovery that fibromyalgia and chronic fatigue syndrome are autoimmune diseases, just as Hashimoto's disease, encouraged me to involve an immune stimulating treatment with impressive success. Ultimately, the three diseases may be, in fact, varying clinical manifestations of the same underlying autoimmune problem.

 

norkurld@zahav.net.il
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