The Thyroid Paradox

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The Thyroid Paradox
By James K. Rone M.D.



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Dr. James K. Rone M.D. Homepage

About the Author: James K. Rone, M.D., is a writer and private-practice endocrinologist in Murfreesboro, Tennessee. He is a former military physician, a member of the American Thyroid Association and the Endocrine Society and has been awarded fellowship in both the American College of Physicians and the American College of Endocrinology. Thyroid disease - in particular hypothyroidism - has been his focus of clinical interest for nearly twenty years, and he is a thyroid patient himself, giving him a unique empathy for those struggling with thyroid disorders. He lives with his wife Susan on their farm outside Nashville.

CONTENTS

• Introduction

- Hypothyroidism is underdiagnosed
- My Experience as Both, Physician and Patient
- Irreconcilable Differences
- Specialist Versus Generalist
- Mainstreamist Versus Reformist
- Origins of What We Know or Think We Know
- Cookbook Medicine
- An Open-Minded Approach

• Acknowledgments

CHAPTER 1

• Thyroid Boot Camp

- Thyroid Anatomy and Physiology
- Thyroid Hormones
- Why Is Thyroid Important?
- Control of the Thyroid System

CHAPTER 2

• When to Think Low Thyroid

- The Zulewski List
- Fatigue
- Weight Gain
- Other Clues to Hypothyroidism
- Who Needs Thyroid Testing?
- My Criteria for Thyroid Testing

CHAPTER 3

• Low-Thyroid Diagnosis

- Radiology
- Basal Body Temperature
- Tribute to a Forgotten Pioneer
- Thyroid Blood Tests
- Thyrotropin og Thyroid-Stimulating Hormone (TSH) Test
- Normal and Abnormal TSH Levels
- The Problem of Central Hypothyroidism
- Free Thyroxine / Free T4 Test
- Total Thyroxine / Total T4 Test
- T3-Resin Uptake
- Free Thyroxine Index
- Total and Free Triiodothyronine (T3)
- Thyroid Antibody Testing
- TRH Stimulation Test
- Current Mainstream Standards

CHAPTER 4

• Human Error in Thyroid Testing

- Six Common Blunders
- History of Exam Ignored in Favor of Test Results
- TSH Test Is Not Done
- Failure to Treat a High TSH Simply Because T4 or T3 Test Are Normal
- Blowing Off a TSH of 5.0-10.0 mU/L as Insignificant or Not Warranting Therapy
- Failure to Retest Borderline Results
- Failure to Consider Central Hypothyroidism
- Failure og Interpretation
- Is It Always Normal to Be Normal?
- Shades of Normal
- The Individual versus the Population
- Statistically versus Physiologically Normal
- Redefining Normal TSH
- How Much Hypothyroidism Is Missed
- What's the Solution?

CHAPTER 5

• Atypical Hypothyroidism: Central Defects

- Murphy's Law of the Thyroid
- Points 1 and 2 - Brain and Pituitary Problems
- Occult Central Hypothyroidism (OCH)
- Post-Hyerthyroid OCH (Occult Central Hypothyroidism)
- Jessica's Fall into Thyroid Purgatory
- Steroid-Induced OCH (Occult Central Hypothyroidism)
- Stress, Depression, and Steroids
- The Stress-Steroid Connection

CHAPTER 6

• Atypical Hypothyroidism: Peripheral Defects

- Point 3 - Making and Secreting T4 and T3
- Point 4 - Transport Proteins
- Points 5 and 7 - Entry of T4 and T3 Into Cells and Cell Nuclei
- Point 6 - Conversion of T4 to T3
- Point 8 and 9 - Thyroid Hormone Receptors
- Hormone Resistance
- Thyroid Hormone Resistance
- Central versus Peripherial RTH (Resistance to Thyroid Hormones)
- Point 10 - The Balancing Act

CHAPTER 7

• Thyroid Replacement 101

- Branded versus Generic Drugs
- Synthetic versus Natural
- T4 versus T3
- The Pros and Cons of Differing Thyroid Replacement Strategies
- T4 Only
- T3 Only
- T4 / T3 Cocktail
- Basic of Thyroid Replacement Therapy
- A Field Guide to Thyroid Pills
- How to take It
- Monkey Wrenches
- Thyroid Replacement and the Heart
- Duration of Thyroid Replacement Therapy
- Cost of Thyroid Replacement Therapy

CHAPTER 8

• Monitoring and Troubleshooting Thyroid Replacement

- TSH Testing
- The Problem of Low TSH
- Testing Frequency
- Full Replacement or Less?
- When Good Labs Lie
- Thyroid Replacement After Hyperthyroidism
- Wright
- Post-Hyperthyroid Central Hypothyroidism
- Persistent TSIs (antibodies called thyroid-stimulating immuniglobulins)
- Adverse Effects of Thyroid Replacement

- Overdosing
- Hyperthyroidism
- HPT (hypothalamic–pituitary–thyroid) Axix Suppression

- Unmasking
- Troubleshooting Thyroid Replacement
- Recipe for Succes
- Starting Therapy
- Monitoring and Adjusting Therapy
- Follow-up

CHAPTER 9

• Escaping the Paradox

- Cooking Soufflès in an Easy-Bake Oven
- Why Evidence-Based Medicne?
- Time
- Knowledge
- Cost
- Physician Extenders
- You Can Escape the Paradox
- Conclusion

• Epilogue
• Glossary
• References
• Index
• About the Author

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