Jan 26, 2010

TSH Range - The Saga

How hard can it possibly be to diagnose hypothyroidism? Let me share with you my journey...

Primary Care Physician:
1. Patient books appointment with family doctor to discuss weight gain, heart palpitations & fatigue.
2. Doctor orders TSH test
3. Doctor tells patient that their TSH is within the "normal range" of 0.5 - 5.0 (no mention that TSH has changed from 1.9 to 4.8 since last test
Opinion: advises another TSH test in three months to monitor.

Cranky Internal Medicine Specialist:
1. Meet with patient, treat with skepticism.
2. Decide that a patient with a diagnosis of depression cannot have anything else wrong with them.
3. Note that lab results of TSH at 6.2 are "slightly elevated", but no cause for concern.
Opinion: Patient has history of depression. Depression causes fatigue and weight gain. Refer back to referring psychiatrist.

Private Health Care Physician:
1. Patient presents with weight gain, relentless fatigue, feels lousy.
2. Doctor orders TSH test.
3. Doctor notes that TSH is 8.3
Opinion: Notes that new TSH range is 0.3 to 3.0 - treat immediately, ideal is to be as close to 1.0 as possible

Specialist (Psychiatry)
1. Reviews lab results from Private Doctor
2. Disagrees with the new TSH reference range, but notes that people with depression seem particularly sensitive to thyroid fluctuations.
Opinion: Treat - but not as aggressively as suggested by Private Physician.

Much Nicer Internal Medicine Specialist
1. Reviews previous lab tests.
2. Asks why previous Internist didn't treat thyroid.
3. Suggests that reference ranges are not particularly meaningful, and that one should treat the patient, not the lab result.
Opinion: Thyroid fluctuation could have been my issue long before my TSH started to change. Thyroid is under-diagnosed. Treat aggressively.

Five doctors, four perspectives, two reference ranges, two "wait & see", three "treat", two "aggressively", one "conservatively".

This just shouldn't have been so difficult.


  1. Well that story is just depressing.

  2. Good God. This is just ridiculous.

  3. I take levothyroxine myself and self prescribe to a goal TSH of around one. Even at a TSH of 5, which is close to normal I can tell I'm under dosed. A rough rule of thumb is 1.6mcg per kilogram of weight. For me it took almost 18 months to pin my TSH down just right with 3 months of consecutive stable values around one. It's nice for me since I just write myself a script and head to the lab and they fax the result to my home where I can simply call the pharmacy to order my new four dollar script from walmart. I wish it were so easy for patients in this world of over regulated American medicine

  4. HH - Glad to hear that you have managed to get your thyroid under control! It sounds like you were able to do it fast and efficiently. Looks like I should have gone to med school.

    My next medical saga will be about my ANA levels. At 1:320 I've had four different opinions on what that means as well...

  5. Here's my non medical opinion, since I'm not your doctor.

    It's not normal. In my practice, anything greater than 1:80 is abnormal and deserves further evaluation for the cause. I consider it autoimmune until otherwise proven. If a differentiated ANA titer (it gives you multiple connective tissue disorder titers) and a double stranded DNA antibody (highly specific for lupus) hasn't already been done, in my practice it would have been the next day. Along with an ESR value (erythrocyte sedimentation rate) to look for signs of vasculitis. I would also do a urinalysis to check for protein in the urine which can often be a sign of autoimmune dysfunction affecting the kidneys. Of course, I assume all the basic CBC and complete metabolic profile have already been done to look for anemia, low platelets, renal failure protein levels etc...

  6. HH - what you are saying only bolsters my view that the Canadian health care system has its flaws.

    If your family physician does not take your concerns seriously, you are out of luck unless you can find a new PCP (good luck).

    If your specialist is dismissive, the only way back to another specialist for a second opinion is through another PCP referral (see above).

    Sometimes, grateful as I am to have our health system, I just want to go out and BUY a medical opinion without having to wait 6 months for a referral.

    I suppose my American neighbours also feel constraints with their HMOs, but at least you have the option to pay.