Recently it was reported that a common anti-inflammatory medication (Aleve) caused an increase in heart problems or stroke in patients being studied to see if it helped Alzheimer’s risk. Another common medication, Vioxx, was taken off the market after studies showed that long term use increased risk of heart problems. A major problem is that the FDA over emphasizes short term studies and the wealth of clinical experience is not systematically monitored. The media contributes to the problem. Medications that help people feel better or raise their quality of life don’t make news. That wouldn’t increase ratings. It’s the juicy stories that get the press.

Last year, a report on a study of hormone treatment in menopausal women claimed that hormone therapy causes increased heart problems, strokes, and cancer. On the Today Show an author was interviewed saying basically that pharmaceutical companies have misled doctors and the public. The author further stated that they have profited by misrepresenting the benefits of hormones and failed to report dangerous complications. The interviewer’s response was "a lot of us women are mad that we have been so deceived." The truth of the matter is that less than half of menopausal women were on hormones at the time and up to half of the ones that were on hormones stopped them after the report came out. Insurance companies fearing an avalanche of law suits, put pressure on physicians. Some insurance companies told gynecologists they wouldn’t cover complications of hormone treatment other than short term use. For this and other reasons many doctors advise their patients to get off hormones. My knowledge of the limitations of studies and more importantly my clinical experience all lead me to believe at this time the benefits both short term and long term (especially for the brain) outweigh the risks for most menopausal women taking hormones.

Another example of media impact is that of Michael Moore. He is currently working on an expose of the pharmaceutical industry. He is allegedly paying physicians, pharmaceutical reps and others to provide the "inside scoop" on the workings of the pharmaceutical industry. On a recent Today Show he described the pharmaceutical industry as evil. Katie Couric’s attempt to get him to admit that the industry does provide us with new and better treatment was met with sarcasm and contempt. He gave an example that Eli Lilly had known for years but kept secret that Prozac, a popular treatment for depression and anxiety, increased the risk of suicide 12 times. My reply to this is, "do you think it would still be on the market if it was that dangerous?" He made his statement as if it were fact. A lot of people see him as a folk hero. I like that in America we are free to say what we believe. I’m exercising the right of free speech now. What I don’t believe in is the right to present opinions and distorted information out of context, and quote uninformed sources as though they are well researched fact. Satire should not be presented as a documentary. It does a lot of harm. But it gets the ratings and makes the money, and after all this is America.

What role has managed care (more honestly, managed cost), played in changing the way medical care is provided? The idea of a system that improves the quality of medical care is a good one. But over the past two decades I believe the result has been more the opposite. When I first started treating patients in the private sector, (early 70’s), decisions about medical tests, hospitalization, and treatment were made between the patient and doctor. Insurance would help with the cost depending upon the specifics of the policy or health care program. Medications were mostly generic. As health care costs escalated, insurance company profits began to shrink and the cost to employers was increasing at an alarming rate. Thus, the managed care system was born.

Managed care now monitors care and has the right to approve or not approve tests, hospitalization, or treatment. The decisions about care were gradually taken away from the patient and the doctor. Of course, the patient is always free to pay for healthcare themselves, but the costs are usually prohibitive.

The managed care companies became a fourth player in this process. They justified their existence by reducing the amount of dollars insurance companies had to pay - the managed care company would then get part of the savings for their profit and cost of doing business. So, in effect, the insurance companies would sometimes save 30% (20% of which would go to the management company). The insurance companies were happy, the employers were happier because they had more cost containment, the management companies were happy they had a job, BUT the poor patient now has about 30% less help with care and mainly has been out of the loop. In addition, the management companies contract with certain physicians who help "contain costs". This would insure that the physician gets a certain volume of patients with guaranteed but reduced payment for their services.

So how does this change the way physicians provide care? Almost always it means less time for the patient. The visit is shorter, and maybe less frequent, and tests are harder to get approved. Certain medications (cheaper generics) are more likely to get approved. Although I stopped accepting insurance (control) for my services a few years ago, I must still get involved frequently with having to request approval for medications that I feel are the best for the patient. Recently, I asked an insurance company to approve Provigil, a medication that increases alertness, and is also used for narcolepsy, shift work, and many other causes of excessive sleepiness. This was the only medication that I could find that one of my patients could take that would allow her to stay awake at work and not cause any side effects. After two letters pleading our case we were still denied. Why? COST. The insurance company felt that the drug was too expensive so the patient was "out of luck".

I am a bibliophile, or a person who loves books. My friends and family would probably say I am more a hoarder of books, journals, magazines and notes. (More about what causes hoarding later) I love going to book stores and I always see what they have on medicine and neuroscience. I don’t think it’s a coincidence that there are more books on thyroid than any other subject. I believe the reason is low thyroid is an extremely common, fixable problem that may be more frequently mismanaged than any other medical condition. Proper treatment improves fitness and quality of life but most doctors don’t get it. There are two maladies that I have noted in some physicians, PRE EXTRACTION DISORDER and MILK OF MAGNESIA DEFICIENCY. In the first condition they lack important information or don’t understand key principles because their head is somewhere in their sigmoid colon. In milk of magnesia deficiency, they believe things that are sometimes creative or at one time believed, but unfortunately not true - ergo they are full of crap. You may think this point of view is unkind, and you’re right. I believe that as an ADHD person I was put on earth to stir things up and challenge the system, so I won’t apologize for being at times “tacky”.

Why are there so many books about thyroid? I believe when a doctor “gets it” and starts treating low thyroid effectively, they realize how often it is mistreated and how many patients suffer the consequences. I could regale you with case after case of examples, but suffice it to say, I too feel compelled to try and educate the public and my physician peers about the physiology of thyroid hormones.

The thyroid gland in the neck secretes two primary hormones, the more abundant T4 and the more active T3. Most of our T3 is made in other parts of the body by converting T4 to T3. I am working on a thyroid article that will go into detail about all the important nuances, but the key points are:

• Thyroid regulates the activity of every cell in the body.
• Many people, for various reasons, are low in T4 and/or T3.
• Most doctors will order only part of the tests needed for accurate diagnosis (the TSH).
• Total T4 and T3 uptake and a multiple called T7 or free thyroid index (FTI).

The FTI is preferred by insurance companies because it’s cheap, not because it’s adequate. This test is unreliable according to many reputable texts, so I consider it to be useless. The most important test is the Free T4 and sometimes the Free T3. Even when the Free T4 is within normal range, it may be too low for the individual. It would be analogous to giving you an IQ test in which you scored 90, and I told you this range was normal. The normal average range of IQ is 90-110, but what if you said “my IQ used to be 130”? … Something’s wrong. That may be the case with your thyroid.

One reason that this is missed is that most doctors don’t ask about thyroid symptoms (or a lot of other symptoms for that matter). But if you have fatigue or easy fatigueability you need to review all the possible symptoms:

Dry skin, hair loss, sensitivity to cold, constipation, swelling, decreased memory, depression, or mood sensitivity, weight gain, difficulty losing weight, and infertility.

Even when low thyroid is treated, it usually is undertreated. The main medication used is Synthroid (the generic is especially unreliable). Many patients also need T3, either Cytomel, or in combination Armour or Thyrolar.

In the past 2 years I have attended two lectures by different Endocrinologists who talked about treating low thyroid. They talked about TSH, estimated Free T4 and treatment with Synthroid. No discussion of secondary hypothyroidism (low thyroid) which means due to causes other than an underfunctioning of the thyroid gland. Neither presenter talked about the role of T3 or use of T3 in treatment.
The books on medicine and endocrinology all say that for secondary hypothyroidism the TSH is useless, and yet, that is frequently the only test they get. At the second talk I asked if they believed that the soul was in the pituitary. This is the gland that helps regulate thyroid by monitoring levels and secreting TSH. But the problem is the pituitary (the master gland just outside the brain) is regulated by the hypothalamus in the brain.

Years ago a study found that if post menopausal women not on estrogen were treated with too much thyroid it could worsen osteoporosis. Ever since there is a fear of causing bone loss, and the result has been a lot of undertreatment. The problem is over reliance on the TSH and fear of osteoporosis, “osteophobia.”

In secondary hypothyroidism the thermostat for body temperature and the set point for basal metabolic rate is set too low. I believe a common cause is “hibernation”. Many of us are mostly indoors and some are mostly sedentary. But we adapted over 1000’s of years to being outside all day and physically active. Our energy and sleep were regulated by the bright outside light. Even on a cloudy day it is 10x’s brighter outside than inside. If our brain thinks we are hibernating, and especially if we have cultural heritage from the northern countries, then we compensate by reducing our metabolism until the weather permits productive outside activity. By reducing our temperature and metabolism we conserve energy (stored as fat). This is also why it’s very difficult to lose weight.

If our hypothalamus is set too low the pituitary will read our level as too high when we take an adequate healthy amount of thyroid medicine. The TSH will then be below the normal range - this is fine. But most doctors overreact and lower the thyroid medicine. Now the patient feels terrible, but their TSH comes up and the doctor is happy - pre-extraction disorder. Most doctors are conscientious. They want to do what’s best for their patients, but in the case of thyroid, they mostly don’t get it.

Low thyroid can cause or worsen depression. In women it is:

It’s like for your car you have to have gas, oil, and water. You can’t compensate for no gas with more water. You can’t compensate for low thyroid with an SSRI (antidepressant such as Lexapro). In men testosterone is more important than estrogen. The brain converts testosterone to estrogen in men and women. Older men have more brain estrogen than older women (who are not taking estrogen). Older men have half as much Alzheimers - the only common cause of premature death more common in women.

In bipolar disorder Synthroid or T4 needs to be in the upper part of normal range to help stabilize mood. T3 is more of an antidepressant but obsession by “osteophobic” physicians results in inadequate treatment doses to help with mood. “The operation was a success (we kept the TSH up) but the patient died.”

I will cover osteoporosis n detail later but just a note - adequate estrogen/testosterone/DHEA, weight bearing exercise, and adequate calcium is the prevention/treatment.

Other than that I have no opinions.

“I know I feel stressed most of the time. I know I am not as happy as I should/could be. I certainly don’t function at my full potential. My energy, sleep, sex life, etc., leave a lot to be desired. How do I make things better? Where should I start? If I decide to try medication, what kind of medication should I take?”

These are the underlying questions usually not in full conscious awareness that most people have when they go to see their doctor. Ted Mitchell, M.D., director of Wellness Programs for the Cooper Clinic in Dallas, says that 75-90% of all doctors visits are stress related. Stress overload and poor health habits are far and away the main cause of not only shortened life span but reduced quality of life.

Most individuals have at least one area in their life where they need help. Emerson’s advice is, “first be a good animal.”

Be physically fit. This includes keeping your blood pressure at 130/80 or better. Many people have high blood pressure or hypertension. Unfortunately, the majority don’t know it. If caught early blood pressure can be brought down to normal range.

This is especially true along with weight loss, added calcium, general stress management, relaxation, aerobic exercise, and muscle toning. But most of these changes take time and meanwhile high blood pressure is pounding the arteries in your heart, brain, and kidneys. Since your kidney’s monitor blood pressure and release hormones to increase it when it’s low, once high pressure damages your kidneys you will have chronic hypertension. Your kidneys will under read your pressure and constantly release hormones to raise it. To prevent these damaging effects of elevated pressure, you need to take medication, (usually starting with a diuretic and/or ace inhibitor). If adequate life style changes are made then medication can be phased out. But if they are not, or you waited too long you will need to be on medication for life.

Since blood pressure is easily measure and monitored it serves as a good model for physical health systems. The same principles apply to stress disorders - if you catch them early and make life style changes you may be able to fix the problem without medication or at least only need medication for a limited time. But just as high blood pressure damages the body, clinical depression and other major mental health disorders damage the brain. This may mean you will have to take medication indefinitely … or not … You of course have the right to choose an unhappy or unfulfilling, shortened life.