Bronze-level articleHypothyroidism

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Suppose a hypothyroid patient is taking a prescription for synthetic T<sub>4</sub>, and her TSH levels are now down within the therapeutic target range.  But, she still feels lethargic, fat, and unhappy.  It ''could'' be because her T<sub>3</sub> levels are inadequate, but it might also be because of factors that have nothing to do with her hypothyroidism.  A good endocrinologist might be willing to test for T<sub>3</sub> levels, or adjust the dose of T<sub>4</sub> to target the low end of the normal TSH range instead of the high end, or even try supplementing the T<sub>4</sub> with a small amount of T<sub>3</sub> &mdash; but (s)he should ''also'' be wary of overmedicating his/her patient all the way into the ''hyperthyroid'' range.<ref>Technically, it's only called hyperthyroidism if the patient's own thyroid produces the excessive hormones. The clinical term for excessive thyroid hormone levels due to oversupplementation is ''thyrotoxicosis.'' Symptoms of thyrotoxicosis include nervousness, irritability, increased perspiration, heart racing, hand tremors, anxiety, difficulty sleeping, thinning of the skin, fine brittle hair, and muscular weakness—especially in the upper arms and thighs.</ref>
 
Suppose a hypothyroid patient is taking a prescription for synthetic T<sub>4</sub>, and her TSH levels are now down within the therapeutic target range.  But, she still feels lethargic, fat, and unhappy.  It ''could'' be because her T<sub>3</sub> levels are inadequate, but it might also be because of factors that have nothing to do with her hypothyroidism.  A good endocrinologist might be willing to test for T<sub>3</sub> levels, or adjust the dose of T<sub>4</sub> to target the low end of the normal TSH range instead of the high end, or even try supplementing the T<sub>4</sub> with a small amount of T<sub>3</sub> &mdash; but (s)he should ''also'' be wary of overmedicating his/her patient all the way into the ''hyperthyroid'' range.<ref>Technically, it's only called hyperthyroidism if the patient's own thyroid produces the excessive hormones. The clinical term for excessive thyroid hormone levels due to oversupplementation is ''thyrotoxicosis.'' Symptoms of thyrotoxicosis include nervousness, irritability, increased perspiration, heart racing, hand tremors, anxiety, difficulty sleeping, thinning of the skin, fine brittle hair, and muscular weakness—especially in the upper arms and thighs.</ref>
  
As a result, books like ''[http://www.amazon.com/Stop-Thyroid-Madness-Revolution-Treatment/dp/0615477127 Stop the Thyroid Madness]'' Really will help patients that are not getting anywhere with doctors who will only look as far as the out-dated TSH. I recommend everyone orders themselves a Stop The Thyroid Madness book.
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As a result, books like ''[http://www.amazon.com/Stop-Thyroid-Madness-Revolution-Treatment/dp/0615477127 Stop the Thyroid Madness]'' scream up-and-down about the need to get your doctor to '''LISTEN!!''' to you.  By which they mean, if your doctor isn't giving you exactly the drugs you tell them to, then they are an evil dupe in the hip pocket of Abbot Laboratories and you should keep looking for one until you find one that will rubber-stamp your prescription mandates.  
 +
 
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Online rants, posted by folks who may or may not be readers of the above book, are similar. "Doctors need to LISTEN!" they scream.  "YOU'RE NOT LISTENING!!!  '''LISTEN TO ME RIGHT NOW YOU MOTHERF#$%ING %^&$$%#S OR I'M GOING TO KILL YOU WHERE YOU MOTHERF$%@ING STAND YOU USELESS PILE OF GARBAGE!!!!!!! ''NO ONE UNDERSTANDS WHAT I'M GOING THROUGH!!'''''"
  
 
== T<sub>4</sub> vs. Desiccated Thyroid: A False dichotomy ==  
 
== T<sub>4</sub> vs. Desiccated Thyroid: A False dichotomy ==  
  
Since desiccated thyroid is derived from ground up animal glands, it is therefore "[[appeal to nature|natural]]", and must therefore inherently be better than that wicked, man-made synthetic T<sub>4</sub>.
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Since desiccated thyroid is derived from ground up animal glands, it is therefore "[[appeal to nature|natural]]", and must therefore inherently be better than that wicked, man-made synthetic T<sub>4</sub>.  
 +
 
 +
The book ''Stop the Thyroid Madness,'' by Janie A. Bowthorpe, seems to imply that the only two courses of treatment available to a hypothyroid patient are an evil corporate-sponsored dose of synthetic T<sub>4</sub> and <I>only</I> synthetic T<sub>4</sub>, or the "natural alternative" of desiccated thyroid (which she almost always calls "Armour thyroid").  Almost no mention is made anywhere in the book of the existence of synthetic T<sub>3</sub>.  Nowhere is the suggestion made of asking ones doctor to add synthetic T<sub>3</sub> into the prescription mix, if you're not feeling fully treated on T<sub>4</sub> alone.  The few places that ''do'' mention people who have been prescribed synthetic T<sub>3</sub> are quick to remind the reader: "But Armour Thyroid contains ''everything'', so you should use that instead!"
 +
 
 +
She also claims that "mainstream" endocrinologists are receiving kickbacks from Abbot Laboratories, the makers of Synthroid (the first and most-recognized brand of synthetic T<sub>4</sub>).  It is not known whether Ms. Bowthorpe is receiving kickbacks from Forest Labs.
 +
 
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Bowthorpe's book isn't the only hypothyroidism information source to present this [[false dichotomy]].  [http://thyroid.about.com/b/2009/01/27/the-desiccated-thyroid-controversy-why-endocrinologists-dont-like-armour-thyroid.htm?nl=1 This about.com article], for example, also touts the virtues of desiccated thyroid extract over a regimen of pure synthetic T<sub>4</sub>, while neglecting to mention the synthetic T<sub>3</sub> option except in an off-the-cuff remark about inflexible endocrinologists.
 +
 
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[[Quackwatch]] now recommends that you be wary of doctors who prescribe desiccated thyroid extract.<ref>[http://www.quackwatch.org/01QuackeryRelatedTopics/armour.html Desiccated Thyroid: Be Wary of
 +
Doctors Who Prescribe It], [[Quackwatch]], last revised 10-Sept-2013</ref>
  
 
== Synthetic T<sub>4</sub> shelf life ==
 
== Synthetic T<sub>4</sub> shelf life ==

Revision as of 06:11, 16 February 2014

Hypothyroidism is a condition in which the thyroid gland doesn't produce adequate levels of thyroid hormones, resulting in symptoms such as lethargy and weight gain. It affects perhaps 5% of the adult American population, most of whom are women with subclinical symptoms.

Of course, with so much of the American population overweight and with lethargy having so many possible causes, it was inevitable that some woo meisters would claim that hypothyroidism is an "epidemic" and that you probably have it.[1] Or, if you've been diagnosed with hypothyroidism and you still feel tired and fat on the medication, that your hypothyroidism must not be adequately treated yet.

Contents

What mainstream medicine says

In the ancient past, iodine deficiency was the primary cause of hypothyroidism. In the modern developed world, though, iodine deficiency is very rare, and the primary cause of hypothyroidism is an autoimmune disorder called Hashimoto's thyroiditis[wp].[2] The only treatment is thyroid hormone supplements. The first such treatment was desiccated thyroid extract -- ground up cow and pig thyroid glands, originally sold by the Armour meat packing company (eventually Forest Labs took over the Armour Thyroid brand name). By the 1950s, the individual hormones involved in thyroid function had been identified, and the pharmaceutical industry soon developed synthetic levothyroxine (T4, sold as Synthroid by Abbot Labs) and synthetic triiodothyronine (T3, sold as Cytomel).

The American Association of Clinical Endocrinologists published their most recent guidelines for the diagnosis and treatment of hypothyroidism in November 2012.[3] While these standards are not cut-and-dried absolutes, they basically boil down to this:

  • Hypothyroidism should be diagnosed by measuring the level of Thyroid Stimulating Hormone (TSH) in the blood. If it's above 5 μIU/mL, and symptoms of hypothyroidism are present, the patient is probably hypothyroid.[4]
  • Hypothyroidism should be treated by prescription T4.
  • The dose of T4 should be adjusted until the patient's TSH level is brought down within the therapeutic target range of 0.45 to 3 μIU/mL. (Or a tad lower if the patient is preggers.)

T4, T3, and Reverse T3: Questionable claims

T4 is technically a "prohormone" — it isn't biologically active until it's deiodinated into T3. Two enzymes (D1 and D2) turn T4 into as much T3 as the body thinks it needs; D1 and another enzyme (D3) turn the rest of the T4 into Reverse T3 (rT3), which is inert. Mainstream endocrinologists tend to prefer prescribing synthetic T4 over synthetic T3 or desiccated thyroid extract (which contains some T3) for two reasons: (1) In the vast majority of hypothyroid cases, the only dysfunction is in the production of T4, not in the conversion of T4 to T3; and (2) having too much T4 in your blood isn't nearly as bad as having too much T3.

Unfortunately, treating hypothyroidism won't always get rid of the all the symptoms that can be associated with hypothyroidism — depression, fatigue, weight gain, intolerance of cold, etc.. And that's where the woo peddlers come in.

Claim   Why it's questionable

Your body isn't turning enough T4 into the biologically active T3, or is turning too much T4 into the biologically inactive Reverse T3. Therefore, you should be taking less T4 and more T3.

 

While stress, or at least TNF which can be released by stress, may decrease the conversion of T4 to T3,[5], no conclusive benefit has been shown for adding T3 to an existing T4 regimen in general.[6][7]

Testing your TSH level is misleading, you need to test Free T3 / Total T3 / Reverse T3 / your Free-T3-to-Reverse-T3 ratio.

 

This provides a convenient excuse to recommend a higher prescription dose. Proponents often cite a study on elderly men from 2005,[8] which showed that high T4 and rT3 levels were associated with reduced physical functioning in the test subjects. The problem is, T3 has a rather short half-life in vivo, and serum T3 levels can vary over the course of a day depending on a number of factors. Worse, Reverse T3 has a different half-life in vivo than T3 does, and so the ratio could theoretically vary over the course of a day as T3 is broken down by the liver but Reverse T3 isn't, or vice-versa.

All clinical lab tests for hypothyroidism are flawed, and you need to look exclusively at the patient's symptoms.

 

This is a favorite of the I-don't-feel-adequately-treated online-support-group crowd. It's also potentially dangerous, in that seeking out an alternative medicine practitioner or fast-and-loose endocrinologist who'll up your dose because you're not feeling good can end up overmedicating you, or mask other potential causes for your symptoms.

The pituitary (or the hypothalamus) preferentially senses T4 over T3. This means that your TSH level will go down in response to taking T4, even if inadequate T3 is still being produced. Therefore, you should be taking less T4 and more T3.

 

This claim runs contrary to the evidence. A March 2013 study states: "Given that the TSHB and TRH genes are negatively regulated by T3 (and not T4), it is crucial that T4 be converted to T3 in order to activate the negative feedback mechanism."[9]

Reverse T3 acts as a T3 antagonist, by blocking or "clogging up" the cellular T3 receptors[10], producing "tissue resistance" to T3[11][12] which results in reduced response even when your T3 levels should be adequate. Therefore, you should be taking less T4 and more T3.

 

Of course, still others have claimed the opposite.[13][14][15][16] There is some evidence that rT3 interferes with the conversion of T4 into T3, at least in vitro[17], but probably not in the concentrations found in vivo. This is very different, though, from the claim that Reverse T3 acts as a T3 antagonist by blocking the receptors; if T4 isn't getting converted into T3, you'd expect very different lab results than if T4 is getting converted into T3 but the T3 receptors aren't working. Interestingly, actual receptors for Reverse T3 do exist in rats, but their function is not yet known.[18]

If the evil mainstream medical establishment duped you into taking T4, all that awful Reverse T3 will have to be cleansed from your system. You should take an elevated dose of T3 for some weeks.

 

Even if Reverse T3 does block T3 receptors, Reverse T3 has a half life in vivo of only a few hours.[19]

Desiccated thyroid extract is what we used to use before Big Pharma pushed that awful artificial Synthetic T4 on us, and we should go back to using it.

 

It was abandoned because it came from ground up cow and pig thyroids, which have a different ratio of T3 to T4 than is normal for a human. It also contains T2 and T1, which have never been proven helpful in treating hypothyroidism but which desiccated thyroid proponents claim makes it "better." Also, until the last couple of decades, desiccated thyroid preparations had an alarming variation in dose from one batch to the other; and even with tightened USP requirements, the FDA issued a recall of over half a million bottles of desiccated thyroid in 2005 due to unstable concentrations of thyroid hormones.[20]

T4 causes lung cancer![21]

 

The study in question, an abstract of which can be found here, is a population study. It looks at 18 different regions in Italy and tries to see of there's any correlation between sales of levothyroxine and various types of cancer. It happened to find one such correlation with lung cancer, but failed to find any correlation with breast, colorectal or gastric cancers. You know what they say about stopped clocks....

T3's antidepressant properties

The questionable push for T3 over T4 may be related to the fact that T3 has had some benefit in treating depression. Some depression sufferers that don't respond well enough to conventional antidepressants have shown improvement when T3 was added to their antidepressant regimen.[22][23]. It's possible that many of these hypothyroid patients, who still show symptoms when their TSH levels are brought within the normal range by T4 and who swear up-and-down that they feel better with T3, may in fact be suffering from undiagnosed depression.

Listen, Damn You!

Suppose a hypothyroid patient is taking a prescription for synthetic T4, and her TSH levels are now down within the therapeutic target range. But, she still feels lethargic, fat, and unhappy. It could be because her T3 levels are inadequate, but it might also be because of factors that have nothing to do with her hypothyroidism. A good endocrinologist might be willing to test for T3 levels, or adjust the dose of T4 to target the low end of the normal TSH range instead of the high end, or even try supplementing the T4 with a small amount of T3 — but (s)he should also be wary of overmedicating his/her patient all the way into the hyperthyroid range.[24]

As a result, books like Stop the Thyroid Madness scream up-and-down about the need to get your doctor to LISTEN!! to you. By which they mean, if your doctor isn't giving you exactly the drugs you tell them to, then they are an evil dupe in the hip pocket of Abbot Laboratories and you should keep looking for one until you find one that will rubber-stamp your prescription mandates.

Online rants, posted by folks who may or may not be readers of the above book, are similar. "Doctors need to LISTEN!" they scream. "YOU'RE NOT LISTENING!!! LISTEN TO ME RIGHT NOW YOU MOTHERF#$%ING %^&$$%#S OR I'M GOING TO KILL YOU WHERE YOU MOTHERF$%@ING STAND YOU USELESS PILE OF GARBAGE!!!!!!! NO ONE UNDERSTANDS WHAT I'M GOING THROUGH!!"

T4 vs. Desiccated Thyroid: A False dichotomy

Since desiccated thyroid is derived from ground up animal glands, it is therefore "natural", and must therefore inherently be better than that wicked, man-made synthetic T4.

The book Stop the Thyroid Madness, by Janie A. Bowthorpe, seems to imply that the only two courses of treatment available to a hypothyroid patient are an evil corporate-sponsored dose of synthetic T4 and only synthetic T4, or the "natural alternative" of desiccated thyroid (which she almost always calls "Armour thyroid"). Almost no mention is made anywhere in the book of the existence of synthetic T3. Nowhere is the suggestion made of asking ones doctor to add synthetic T3 into the prescription mix, if you're not feeling fully treated on T4 alone. The few places that do mention people who have been prescribed synthetic T3 are quick to remind the reader: "But Armour Thyroid contains everything, so you should use that instead!"

She also claims that "mainstream" endocrinologists are receiving kickbacks from Abbot Laboratories, the makers of Synthroid (the first and most-recognized brand of synthetic T4). It is not known whether Ms. Bowthorpe is receiving kickbacks from Forest Labs.

Bowthorpe's book isn't the only hypothyroidism information source to present this false dichotomy. This about.com article, for example, also touts the virtues of desiccated thyroid extract over a regimen of pure synthetic T4, while neglecting to mention the synthetic T3 option except in an off-the-cuff remark about inflexible endocrinologists.

Quackwatch now recommends that you be wary of doctors who prescribe desiccated thyroid extract.[25]

Synthetic T4 shelf life

According to an FDA press release from 2007[26], synthetic T4 can break down if stored in a hot or humid environment (like, say, a bathroom with a working tub or shower).

As of 2008, the FDA[27] and USP[28] now mandate that synthetic T4 must meet a 95%-105% potency specification throughout its shelf life. All formulations sold by pharmacies since that time are required to meet these standards against degradation.

To desiccated thyroid proponents, such degradation with storage time was one more reason not to trust synthetic T4. To more sane individuals, though, it brings up the question of whether the natural T4 in desiccated thyroid doesn't also break down if stored in a hot or humid environment.

Wilson's Syndrome

Wilson's Temperature Syndrome, more commonly known as Wilson's Syndrome (and not to be confused with Wilson's disease), is a commonly pushed for thyroid diagnosis in the alternative medicine community,[29] although it has never been recognized as a valid diagnosis within the established medical community.[30][31][32] Originally proposed in 1990 by Dr. E. Denis Wilson (the syndrome's namesake), the premise of the Wilson's pushers is that, if you have non-specific symptoms similar to hypothyroidism, you must have hypothyroidism regardless of what the blood tests say your thyroid count is. Among the nonspecific symptoms seen as "definitive" for hypothyroidism is a body temperature below 98.6°F, so apparently the Wilson's folks feel that playing in the snow will make you hypothyroid.

Even more dangerously, the cranks who support treating Wilson's Syndrome often prescribe T3 as its treatment. Unsurprisingly, it was treating a phony diagnosis with T3 that led to a patient dying of a heart attack and to the subsequent disciplinary actions against Dr. Wilson by the Florida Board of Medicine.[33]

Hypothyroid diet

Not content with a choice between modern synthetic treatments that have been proven to work, and the older ground-up-thyroid gland that was also proven to work in its own time, various woo peddlers have chimed in with the claim that you can cure your hypothyroidism by diet.

There are some legitimate dietary concerns if you have hypothyroidism:

  • There are some foods known to be goitrogenic[wp], such as soybean protein and cauliflower; these foods contain isoflavones that can interfere with thyroid peroxidase (TPO), thereby reducing the thyroid gland's ability to manufacture T4 -- but only in cases of iodine deficiency.[34] A reasonable recommendation would be to limit your intake of goitrogenic foodstuffs.
  • In patients with Hashimoto's thyroiditis, there's some evidence that increasing your iodine intake can sometimes make the condition worse,[35] perhaps because it can result in elevated levels of TPO (which the Hashimoto's patient's anti-TPO antibodies attack). A reasonable recommendation would be to ensure that your iodine intake is appropriate and not excessive. (Remembering to take the amount of iodine in your thyroid hormone drugs into account.)
  • Conversion of T4 to T3 may be impaired in cases of selenium deficiency.[36] A reasonable recommendation would be to ensure that your selenium level is adequate.
  • People with Hashimoto's thyroiditis have a greater incidence of celiac disease than the general population.[37] A reasonable recommendation would be to get checked for subclinical celiac disease.

However, the diet woo meisters go far beyond these reasonable recommendations.[38][39][40][41][42][43] You'll see claims that you need to completely avoid all foods that might be goitrogenic, completely avoid all foods that have so much as a milligram of iodine in them (including iodized salt), go gluten-free, and (of course) try their new and improved diet program guaranteed to make you feel less hypothyroid in just 21 days or your money back.

The Mayo Clinic says there's no evidence for dietary control of hypothyroidism, outside of ensuring that the patient doesn't eat certain foodstuffs too soon after taking hormone supplements.[44]

Hypothyroidism treatments as weight loss gimmicks

One of the possible symptoms of hypothyroidism is weight gain. One of the possible symptoms of hyperthyroidism is weight loss. It didn't take long for those desperate to find an easy weight loss gimmick to think of deliberately taking thyroid hormones even when thyroid function is normal.

The American Thyroid Association has this to say about the subject:

Thyroid hormones have been used as a weight loss tool in the past. Many studies have shown that excess thyroid hormone treatment can help produce more weight loss than can be achieved by dieting alone. However, once the excess thyroid hormone is stopped, the excess weight loss is usually regained. Furthermore, there may be significant negative consequences from the use of thyroid hormone to help with weight loss, such as the loss of muscle protein in addition to any loss of body fat. Pushing the thyroid hormone dose to cause thyroid hormone levels to be elevated is unlikely to significantly change weight and may result in other metabolic problems.
Thyroid and Weight (PDF), American Thyroid Association

Dietary supplements used to be sold which contained actual thyroid hormones. Today, however, legal access to these drugs is impossible without a prescription. That hasn't stopped certain unscrupulous manufacturers from giving "thyroidally suggestive" names to their dietary supplements, like "T-3"[45], even though they contain no triiodothyronine.

Fluoride

Flouride was used as an effective means of therapy for hyperthyroidism. It is recommended hypothyroid patients avoid it.


http://articles.mercola.com/sites/articles/archive/2011/08/13/fluoride-and-thyroid-dysfunction.aspx

External links

http://www.webmd.com/a-to-z-guides/hypothyroidism-topic-overview

Footnotes

  1. Quackwatch lists hypothyroidism among the Fad Diagnoses prevalent in the past.
  2. Other common causes of hypothyroidism include pregnancy, and getting your thyroid gland surgically removed or destroyed due to cancer. In Hashimoto's thyroiditis, the patient creates antibodies that attack her own thyroid peroxidase (TPO) enzymes; it can be tested for by looking for anti-TPO antibodies in the patient's blood, but since not all people with Hashimoto's thyroiditis develop hypothyroidism, such a test isn't definitive for diagnosing hypothyroidism.
  3. American Association of Clinical Endocrinologists (November/December 2012). "Clinical Practice Guidelines for Hypothyroidism in Adults" (PDF). Endocrine Practice 18 (6): 988-1028. https://www.aace.com/files/final-file-hypo-guidelines.pdf. 
  4. A test for the anti-TPO antibodies caused by Hashimoto's Thyroiditis is also recommended in pregnant patients with a history of Graves’ disease who were treated with radioactive iodine or thyroidectomy prior to pregnancy. (c.f. Recommendation 5 in the PDF file)
  5. Ongphiphadhanakul, B; Fang, SL; Tang, KT; Patwardhan, NA; Braverman, LE (1994). "Tumor necrosis factor-alpha decreases thyrotropin-induced 5'-deiodinase activity in FRTL-5 thyroid cells". European journal of endocrinology 130 (5): 502–7. PMID 8180680. 
  6. Escobar-Morreale, H. F.; Botella-Carretero, JI; Escobar Del Rey, F; Morreale De Escobar, G (2005). "Treatment of Hypothyroidism with Combinations of Levothyroxine plus Liothyronine". Journal of Clinical Endocrinology & Metabolism 90 (8): 4946–54. PMID 15928247. 
  7. Joffe, R. T.; Brimacombe, M.; Levitt, A. J.; Stagnaro-Green, A. (2007). "Treatment of Clinical Hypothyroidism With Thyroxine and Triiodothyronine: A Literature Review and Metaanalysis". Psychosomatics 48 (5): 379–84. PMID 17878495. 
  8. van den Beld et al., Thyroid Hormone Concentrations, Disease, Physical Function, and Mortality in Elderly Men, The Journal of Clinical Endocrinology & Metabolism, vol. 90 no. 12 (1-Dec-2005), pp. 6403-6409
  9. Fonseca et al., Coordination of hypothalamic and pituitary T3 production regulates TSH expression, The Journal of Clinical Investigation, vol. 123 no. 4 (1-April-2013), pp. 1492–1500
  10. The Role of Reverse T3 Testing in Thyroid Treatment, by Mary Shomon on about.com
  11. http://www.thyroid-rt3.com/whatdo.htm
  12. http://nahypothyroidism.org/deiodinases/ , section "Deiodinase type III (D3)"
  13. http://tiredthyroid.com/rt3.html
  14. Nicod et al., The Failure of Physiologic Doses of Reverse T3 to Effect Thyroid-Pituitary Function in Man, Journal of Clinical Endocrinology & Metabolism. 43 (2): 478 (1976)
  15. Venkatraman, Lefebvre. Multiple thyroid hormone binding sites on male rat liver nuclear matrices, Biochemical and Biophysical Research Communications, Volume 148, Issue 3, 13 November 1987, Pages 1496–1502
  16. Wiersinga WM, Chopra IJ, Solomon DH, Specific nuclear binding sites of triiodothyronine and reverse triiodothyronine in rat and pork liver: similarities and discrepancies, Endocrinology. 1982 Jun;110(6):2052-8
  17. Han et al., 3,3',5'-Triiodothyronine inhibits iodothyronine-5'-deiodinating activity induced by 3,5,3'-triiodothyronine at equimolar concentrations in cultured fetal mouse liver, Endocrinology, vol. 119 no. 3 (Sept. 1986), pp. 1076-82
  18. Specific 3,3',5'-triiodothyronine (reverse T3) binding sites on rat liver plasma membranes: comparison with thyroxine (T4) binding sites, Journal of Receptor Research, vol. 3 no. 3 (1983), pp. 393-407
  19. Peeters et al., Serum 3,3′,5′-Triiodothyronine (rT3) and 3,5,3′-Triiodothyronine/rT3 Are Prognostic Markers in Critically Ill Patients and Are Associated with Postmortem Tissue Deiodinase Activities, Journal of Clinical Endocrinology & Metabolism, vol. 90, issue 8, page 4559 (August 2005)
  20. Enforcement Report for May 11, 2005, from the FDA's site. Note that this page lists all recalls issued on 11-May-2005, not just those recalls issued for desiccated thyroid extract. Note also that the Class II recall of desiccated thyroid shown at the top was later downgraded to a Class III recall.
  21. More BAD news if you are on T4-only like Synthroid?: it can cause Lung Cancer, says a study!, stopthethyroidmadness.com, 12-Aug-2013
  22. The Treatment of Depression with T3, Evolutionary Psychiatry, Feb. 2012
  23. Abraham et al., T3 augmentation of SSRI resistant depression, Journal of Affective Disorders, April 2006
  24. Technically, it's only called hyperthyroidism if the patient's own thyroid produces the excessive hormones. The clinical term for excessive thyroid hormone levels due to oversupplementation is thyrotoxicosis. Symptoms of thyrotoxicosis include nervousness, irritability, increased perspiration, heart racing, hand tremors, anxiety, difficulty sleeping, thinning of the skin, fine brittle hair, and muscular weakness—especially in the upper arms and thighs.
  25. [http://www.quackwatch.org/01QuackeryRelatedTopics/armour.html Desiccated Thyroid: Be Wary of Doctors Who Prescribe It], Quackwatch, last revised 10-Sept-2013
  26. Thyroid Drug Potency is Being Tightened: FDA Changes Specs for Levothyroxine
  27. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm161266.htm
  28. http://www.usp.org/usp-nf/notices/retired-compendial-notices/usp-announces-revised-monograph-levothyroxine-sodium-tablets
  29. [1], a major Wilson's crankery website
  30. Is Wilson's syndrome a legitimate ailment?, From the Mayo Clinic
  31. The American Thyroid Association's Statement on “Wilson’s Syndrome”
  32. Wilson's Syndrome also appears on Quackwatch's list of fad diagnoses.
  33. Doctor's syndrome a sham, board says
  34. Doerge DR, Sheehan DM (June 2002). "Goitrogenic and estrogenic activity of soy isoflavones". Environ. Health Perspect. 110 Suppl 3: 349–53. PMC 1241182. PMID 12060828. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1241182. 
  35. Effect of small doses of iodine on thyroid function in patients with Hashimoto's thyroiditis residing in an area of mild iodine deficiency, European Journal of Endocrinology, vol. 139 no. 1 (July 1998), pp. 23-28
  36. Type I iodothyronine deiodinase is a selenocysteine-containing enzyme, Nature, vol. 349, pp. 438-440 (31 January 1991)
  37. Akçay et al., The presence of the antigliadin antibodies in autoimmune thyroid diseases, Hepato-gastroenterology, 2003 Dec; 50 Suppl 2: cclxxix-cclxxx
  38. Smart Foods For Hypothyroidism
  39. LiveStrong hypothyroidism diet -- at least this one doesn't recommend you use a diet instead of taking thyroid hormone medications.
  40. The HypoThyroid Diet: Lose Weight and Beat Fatigue in 21 Days
  41. The Thyroid Diet: Manage Your Metabolism for Lasting Weight Loss; some sound advice mixed in with herbal supplement woo
  42. The Gluten-Thyroid Connection
  43. Midlife plight: my thyroid or my teeth?, by Jennifer Berman, writer and sign language interpreter
  44. Is there any truth to the hypothyroidism diet? Can certain foods increase thyroid function?
  45. S.A.N. T-3
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