Treat the patient--not the blood tests!
How many of us believe that something must be so if we see it in print? Do you take for granted what the newspaper tells you? If so, you are a fool! If we believe that everything is fine because the blood tests are normal, then I suspect we are even bigger fools.
How many of us were taught what the normal range actually meant during our training? Although nobody came right out and said it, I was given the strong presumption in medical school that the normal range was derived by scholars who pored over the scientific literature, determining what was healthy enough to allow us to safety presume that there was no problem. It therefore came as quite a shock to me when I looked up the national guidelines for laboratories to see how these normal ranges were derived. For a very large percent of tests, the normal range is simply based on two standard deviations! Let's see how this works using thyroid problems as an example.
The normal range for Free T4 thyroid hormone levels in the past has been based on statistical norms (called two standard deviations). This means that out of every 100 people, those with the two highest and lowest scores are defined as abnormal, and everyone else is arbitrarily considered to be normal. That means if a problem affects over two percent of the population (as many as 24% of women over 60 are hypothyroid, and 12% of the population have abnormal antibodies attacking their thyroid), then our testing system will miss most of them. In addition, our testing system does not take biological individuality into account. To translate how poorly this "two percent equals abnormal" system works, consider this: if we applied this approach to getting you a pair of shoes, any size between a 4 and 13 would be "medically normal." If a man was accidentally given a size 5 shoe or a woman a size 12, the doctor would say the shoe sizes they were given are "normal," and that no problem existed! This is pretty close to an exact analogy for what happens when we overly rely on blood tests' normal ranges.
Even for test that have normal ranges based on physiologic function, major problems occur. Over the last two decades, for example, the acceptable upper limit for a TSH thyroid test has dropped from over 12 to less than three. That means that anyone who had a TSH level between 3 and 12 had been told they were normal despite actually being hypothyroid. Even worse, they were often told they were essentially crazy because the test showed no abnormalities, and so they were inappropriately treated with antidepressants.
Again, using TSH has an example, other factors also play a role in decreasing its reliability. For example, if the thyroid is underactive because the hypothalamus is suppressed (as is common in fibromyalgia and/or chronic pain), the TSH test, which is the most often used to evaluate thyroid function, may appear to be normal or even suggest an overactive thyroid. In fact, it is well-known among lab experts (but not physicians) that in hypothalamic hypothyroidism, the TSH can be high, low, or normal! Do you still want to rely on only blood testing to determine if the patient needs thyroid hormone?
To give you an idea of the problem's scope even when only looking at thyroid conditions, let's look at the situation further. Hypothyroidism, like most other illnesses that predominantly affect women, has been dramatically under-diagnosed. The American Academy of Clinical Endocrinologists (AACE), the nation's largest organization of thyroid specialists, has now confirmed this. After a 2002 meeting, the normal range for thyroid tests was dramatically narrowed. As noted in the AACE press release:
Until November 2002, doctors had relied on a normal TSH level ranging from 0.5 to 5.0 to diagnose and treat patients with a thyroid disorder who tested outside the boundaries of that range. Now the AACE encourages doctors to consider treatment for patients who test outside the boundaries of a narrower margin based on a target TSH level of 0.3 to 3.0 AACE believes the new range will result in proper diagnosis for millions of Americans who suffer from a mild thyroid disorder, but have gone untreated until now. "The prevalence of undiagnosed thyroid disease in the United States is shockingly high--particularly since it is a condition that is easy to diagnose and treat," said Hossein Gharib, MD, FACE, and president of AACE. "The new TSH range from the AACE guidelines gives physicians the information they need to diagnose mild thyroid disease before it can lead to more serious effects on a patient's health, such as elevated colesterol, heart disease, osteoporosis, infertility, and depression."
Now, years after the new directives have been given, doctors are still largely unaware of these new lab guidelines for diagnosis and treatment. Even the major labs doing thyroid testing have not bothered to change the now-incorrect normal ranges for both diagnosis and treatment of thyroid disorders.
Simply changing the normal range for the TSH test to "less than 3" increased the number of Americans with thyroid illness from 13 million to approximately 27 million. Unfortunately, over 13 million Americans with thyroid disease remain undiagnosed, and the majority of those receiving treatment are hot being dosed appropriately. Doctors do not know that they have not been adequately trained in the proper diagnosis or treatment of hypothyroidism, and the cost in human life and devastating illness is enormous. What makes this especially tragic is how easy treatment is if doctors are given the correct information. Even these new guidelines miss millions who suffer from hypothyroidism.
Let's See What Happens When You Treat the Patient and Not the Blood Tests!
In two studies done by Dr. G.R. Skinner and his associates in the United Kingdom, patients who were felt to have hypothyroidism (an under-active thyroid), because of their symptoms (including pain), had their blood levels of thyroid hormone checked. The vast majority of subjects had technically normal thyroid blood tests. This data was published in the British Medical Journal. Since that time, Dr. Skinner has done another study in which the patients with normal blood tests who had symptoms of an underactive thyroid-those whom most physicians would likely say had a normal thyroid hormone. A remarkable thing happened-well. maybe it wasn't that surprising! The large majority of patients, despite being considered to have a normal thyroid, found their symptoms improved upon taking thyroid hormone (Synthroid[R]), at an average dosage of 100 to 120 micrograms a day.
These two studies--plus another, which indicated that thyroid blood tests are only low in about three percent of patients whose doctors sent in blood tests (and this at an HMO where the doctor really suspected that the patient had thyroid problems)-confirm what I have been saying all along. Our current thyroid testing will miss most patients with an underactive thyroid. Once again, doctors of decades ago were on target when they knew that one has to treat the patient and not the blood test.
If I Can't Trust Blood Tests, How Can I Know How to Treat Patients?
Discovering how to treat a patient is why we went into the ART of medicine instead of simply becoming a technician. Simply recall the symptoms of hypothyroidism. If the patient has chronic pain, fatigue, heavy periods, constipation, easy weight gain, cold intolerance, dry skin, thin hair, and/or a body temperature that tends to be on the low side of normal, you should consider giving them a therapeutic trial of a low dose of thyroid hormone. As long as the patient does not have underlying angina/heart disease and you follow up with a blood test to make sure that the Free T4 (do not use TSH) thyroid levels are in a safe range (going above the upper limit of normal may aggravate osteoporosis), a trial of low-dose thyroid hormone treatment is usually safe and may be dramatically beneficial. If the symptoms of low thyroid improved on thyroid hormone, it is fair to suspect that the patient has an underactive thyroid. The questions to ask to determine if a problem is present despite normal lab tests are, "Does the patients have symptoms and/or findings on examination suggestive of the illness, and do they respond to treatment?" It is that simple but don't forget to look for accompanying problems.
For example, in another study, 152 women who had symptoms of an underactive thyroid despite normal blood tests were evaluated. In the first phase of the study, 49 women were given a high-protein, low-carbohydrate diet that eliminated sugar, wheat, and dairy for one month. This group experienced an 18% decrease in joint pain and a 14% decrease in muscle pain, combined with a 21% decrease in fatigue. All 152 patients were then given 22 days of thyroid therapy using T3, the active form of thyroid hormone. They were given 7.5 micrograms twice a day, slowly increased to 37.5 micrograms twice a day and then tapered off. After 22 days, all of their symptoms decreased by an average of 39%. One week later, they were switched to Armour Thyroid 60 mg twice a day for three more months. Fatigue decreased by 60%, headaches by 63%, depression by 73%, insomnia by 69%, joint pain by 58%, and muscle pain by 58%.
Do Faulty Lab Tests Only Apply to Thyroid Hormone Problems?
Of course not! Let's use Cortisol testing for adrenal insufficiency as another example. The normal range for a morning Cortisol is 6-24 mcg/dl. This range was actually based on an assessment determining when Cortisol deficiency should be considered a problem, and an "officially" low Cortisol is probably found in less than one out of 100,000 people. In my experience, most healthy people have a morning Cortisol between 18-24 mcg/dl. Nonetheless, a level of 12, 8, and even 6 is considered absolutely and totally normal and healthy. A level of 5.9 however is considered life-threatening: 5.9 is life-threatening, but 6.1 is totally healthy. What makes this concept even scarier is that the machine is only accurate within two points! People do not go from totally healthy to near death based on .1 mcg/dl difference in Cortisol levels. Yet, this is how almost every endocrinologist in the country practices, so it is not surprising that they miss most cases of inadequate/suboptimal adrenal function that are not life-threatening.
So How Do I Tell if a Person Needs Adrenal Support?
Going back to what we said before, to determine if a patient needs adrenal support, look for the symptoms of an underactive adrenal. In fact, I suspect that many people suffer exhaustion of their adrenal glands. With the kinds of stresses common in modern society, a person's adrenal test may initially show hormonal levels that are actually higher than usual, since the adrenal gland tends to overcompensate to deal with stress. Over time, this may exhaust the adrenal reserve-that is, the adrenal's ability to increase hormone production in response to stress. In endocrinologist Dr. William Jefferies' experience (and in mine as well), people with either low hormone production or a low reserve often respond dramatically to treatment with low doses of adrenal hormones.
Symptoms of Adrenal Insufficiency
If adrenal glands are underactive, what symptoms might the patient experience? Low adrenal function can cause, among other symptoms:
* Pain and fatigue
* Recurrent infections
* "Crashing" during stress
* Hypoglycemia (irritability when hungry)
* Low blood pressure and dizziness upon first standing *
Hypoglycemia deserves special mention. Many people become shaky and nervous, then dizzy, irritable, and fatigued when they get hungry. They then often feel better after they eat sweets, which improves their energy and mood for a short period of time. Because of this, these people often crave sugar, not realizing that it makes their blood sugar level initially shoot back up to normal, which is what makes them feel better, but then eating the sugar makes the blood sugar continue to soar beyond normal. The body responds to this by driving the sugar level back down below normal again. The effect, energy-wise, is like a roller coaster.
Dr. Jefferies has noted--and again, my experience confirms his finding--that most people with hypoglycemia have underactive adrenal glands. This makes sense because the adrenal glands' responsibilities include maintaining blood sugar at an adequate level. Sugar is the only fuel that the brain can use. When a person's blood sugar level drops, he or she feels poorly, and this can flare pain. I recommend diagnosing "hypoglycemia" based on symptoms, and I consider "glucose tolerance tests, other tests of hormonal function, incredibly unreliable and a waste of time.
Treating Adrenal Insufficiency
People with hypoglycemia can treat low blood sugar symptoms by cutting sugar and caffeine out of their diets, having frequent, small meals, and increasing their intake of proteins and vegetables. Fruit--not fruit juices, which contain concentrated sugar--can be taken in moderation, about one to two pieces a day, depending on the amount of sugar in the fruit. Taking 250 micrograms of chromium a day (present in the Energy Revitalization System vitamin powder) for six months often helps smooth out hypoglycemic symptoms.
Treating the underactive adrenal problem usually banishes the symptoms of low blood sugar. You can begin with adrenal glandulars combined with licorice and key nutrients (all present in Adrenal Stress End[R] by Integrative Therapeutics, which I helped to formulate). You may consider using prescription hydrocortisone, such as Cortef[R] in addition. When used in doses of 20 mg or less a day, Cortef is usually quite safe and can result in a dramatic decrease in many symptoms. Dr. Jefferies has found that as long as the adrenal hormone level is kept within the normal range, the main toxicity that a patient might experience is a slight upset stomach due to the body not being used to having the hormone come in through the stomach. If you are uncomfortable with ultra-low dose Cortef, I invite you to read Dr. Jefferies' material on the safety of low-dose cortisone as well as our research. Most patients only need 5 mg to 12% mg a day, equivalent to 1 to 3 mg a day of prednisone (a more dangerous and less effective synthetic form of Cortisol[R]). After feeling well for six to 18 months, most people begin to slowly decrease their adrenal hormone dosage, eventually discontinuing the treatment entirely.
Although we used thyroid and adrenal insufficiency as models for the problems inherent in relying on blood tests, these problems occur across the entire spectrum of medicine. I invite you to re-examine your belief that because something is written or based on technology you can trust it more than your own intuition and training. Our insecurity and need for certainty--no matter how fake and flawed the "certainty" is--can be devastating to the patient. It's time to reclaim the art of medicine!
by Jacob Teitelbaum, MD
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|Title Annotation:||Pain Free 1-2-3!|
|Date:||Jan 1, 2009|
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