TSH TRENDING FOR OPTIMAL TREATMENT OF THYROID DISORDERS

Many patients consult me for a diagnostic quandary concerning the thyroid gland. They are not well, often tired, may have gained weight or developed other symptoms commonly associated with thyroid disorders (listed at the end). They suspect that a problem with the thyroid gland may be at the root of their health issues. However, their thyroid laboratory test results are considered normal by their doctors.

TSH Problems

"TSH problems" usually develop in one of the following ways:

1. Rising TSH levels that are still within the normal laboratory reference range.
2. Rising TSH levels that are minimally above the normal laboratory reference range but are associated with the normal results of other thyroid tests, and so are considered clinically insignificant.
3. Falling TSH levels that are still within the normal range.
4. Falling TSH levels that are minimally below the normal laboratory reference range but are associated with the normal results of other thyroid tests, and so are considered clinically insignificant.
5. Falling TSH levels that fall below the normal range.

Rising TSH Levels Within Normal Range
A 57-year-old woman consulted me for lethargy, weight gain of 14 pounds in four months, and headaches. She saw an endocrinologist who found the thyroid laboratory tests to be normal. I included a small dose of (60 mg) of natural thyroid in her integrative program. She responded well. About a year later, she returned with a relapse of her symptoms. I learned that she had discontinued thyroid supplementation on the advice of her endocrinologist. I restarted natural thyroid and the integrative program. Again she responded well. A year passed and she returned with another relapse. Her endocrinologist had again discontinued the thyroid medication. She laughed and said,

"I learned my lesson. I will not stop taking thyroid until you tell me to do so, but I'm curious. My endocrinologist is a good doctor. Every time I see him he does thyroid testing and tells me the results are normal. I want to know why you disagree with him."

"I use my clinical judgement and he does his," I replied.

"But it doesn't make sense to me," she protested. "My endocrinologist is on the staff of university."

"Evidently our experience is different from his," I tried to reassure her.

"I wish I understood," she countered.

"Let's see if there is a simple explanation," I replied, thumbing through her lab reports.

I pulled the sequential TSH values, noted a pattern of consistent rises, and then plotted them in a simple graph showing the limits of the normal laboratory range of 1.5 to 4.5 units. Her TSH values were as follows: 1.1, 2.3, 3.9, and 4.2. The rising TSH values, I explained, were unequivocal evidence that her thyroid was underactive even though the highest TSH value never went above the upper limit of the laboratory range.

I might point out that the T4 test range of many laboratory test extends from 4.5 to 12.5 ug/dL. That means a woman with a normal value of 11 ug could drop her blood T4 thyroid hormone level value by fifty percent and still be considered "normal." So, it can be a serious mistake to dismiss the lab values just because they are in an arbitrarily defined "normal" range. It is useful to trend the results of T4 and T3 thyroid tests. However, in my experience TSH trending is far more valuable than T4 and T3 trending.

Falling TSH Levels Within Normal Range
The TSH values are also crucial in assessing the results of treatment plans for patients with overactive and underactive thyroid glands. When the TSH values are abnormally high, the patient clearly requires an upward adjustment of the thyroid medication dose. However, the falling TSH values do not indicate overdosing in all cases. The assessment of this issue requires two additional items: (1) the patient's own sense of well-being or lack of it; and (2) the doctor's clinical sense of the case based on his holistic evaluation.

TSH Levels Minimally Above or Below the Range
It should be self-evident from the above discussion that the concept of ignoring "minimally abnormal" laboratory thyroid test results is not valid. Such results are usually highly significant, both in the initial determination of the thyroid function and for the assessment of response to thyroid medication.

Common Clinical Features of Thyroid Disorders
Lethargy
Fatigue
Irritability
Difficulties of mood, memory, and mentation
Temperature dysregulation
Headaches
Heart palpitation
Weight gain or loss
Hair loss
Menstrual and sexual abnormalities

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