In this lecture, the 2nd of 4 delivered at the Integrated Medicine and Mental Health Conference in San Antonio, TX, Dr. Cady carefully reviews the literature regarding thyroid status and optimization. Multiple citations from the peer-reviewed medical literature are referenced and cited. At the conclusion of viewing this presentation, the viewer should be able to recognize the absolute fallacy of checking just TSH, and recognize the necessity of looking at the entire thyroid axis in terms of diagnosis and treatment. Relevant in depression and cognition are reviewed.

1. THYROID
On My Mind
LLoouuiiss BB.. CCaaddyy,, MMDD –– CCEEOO &&
FFoouunnddeerr –– CCaaddyy WWeellllnneessss
IInnssttiittuuttee
Child, Adolescent, Adult,
Functional Neuropsychiatry –
Evansville, Indiana
5tth Annual IMMH CONFERENCE –
San Antonio, TX
Saturday, September 20, 2014

2. Continuing Medical Education Commercial Disclosure Requirement
I, Louis B. Cady, M.D., have the following commercial relationships
to disclose:
• Speaker faculties: Forest Pharmaceuticals, Sunovion, Shionogi,
Takeda-Lundbeck
•Testing laboratories: Immunolaboratories, Great Plains Diagnostic
Labs, LABRIX
•Commercial endeavors: Pharmanex distributor
•Historical honoraria, speaking: Bristol-Myers Squibb, Celltech,
Cephalon, Eli Lilly, Glaxo Smith Kline, Janssen, McNeil,),Pfizer-
Roerig, Sanofi~aventis, Searle, Sepracor, Shire, McNeil, Takeda,
WorldLink Medical, Wyeth-Ayerst

3. “Truth is a constant
variable.”
– William Mayo, MD. “Dr. Will”
Gonda extension, Mayo Clinic Building
2004. © Louis B. Cady, M.D.

4. Onn myy iiPPhhoonnee –– 99//1199//001133

5. www.slideshare.net/lcadymd

6. Purpose of this talk (& challenges):
• Real-world integration of
endocrine concepts.
• “Bridging the gap” between
historical uses of thyroid meds
and enlightened practice.
• Understanding relevance of
thyroid hormone in affective and
cognitive dysfunction
• Review of laboratory testing and
rationale
• Discussion of rational risk-balancing
& integrated treatment
Limitations:
•Only 1 hour!!
•Limited
epidemiology
•No in-depth
focus on
supplements or
iodine deficiency
(or testing or
treatment)

7. How to get the MOST out of this presentation:

8. My bias: whatever works for the
patient; whatever it takes.

11. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS
MEDICAL GUIDELINES FOR CLINICAL PRACTICE
FOR THE EVALUATION AND TREATMENT OF
HYPERTHYROIDISM AND HYPOTHYROIDISM
AACE Thyroid Task Force
Chairman
H. Jack Baskin, MD, MACE
Committee Members
Rhoda H. Cobin, MD, FACE
Daniel S. Duick, MD, FACE
Hossein Gharib, MD, FACE
Richard B. Guttler, MD, FACE
Michael M. Kaplan, MD, FACE
Robert L. Segal, MD, FACE
Reviewers
Jeffrey R. Garber, MD, FACE
Carlos R. Hamilton, Jr., MD, FACE
Yehuda Handelsman, MD, FACP, FACE
Richard Hellman, MD, FACP, FACE
John S. Kukora, MD, FACS, FACE
Philip Levy, MD, FACE
Pasquale J. Palumbo, MD, MACE
Steven M. Petak, MD, JD, FACE
Herbert I. Rettinger, MD, MBA, FACE
Helena W. Rodbard, MD, FACE
F. John Service, MD, PhD, FACE, FACP, FRCPC
Talla P. Shankar, MD, FACE
Sheldon S. Stoffer, MD, FACE
John B. Tourtelot, MD, FACE, CDR, USN
2006 AMENDED VERSION
This amended version reflects a clarification to specify pertechnetate as the
compound attached to 99mTc.
ENDOCRINE PRACTICE Vol 8 No. 6 November/December 2002 457

13. • “Thyrotropin (Thyroid-Stimulating Hormone or
TSH). Measuring TSH is the most sensitive
indicator of hypothyroidism.” (hunh?!) –
accessed 9/5/2011
• “…blood tests for measuring levels of
TSH and free thyroxine (T4) are the only
definitive way to diagnose
hypothyroidism” – 10/6/2012
http://www.umm.edu/patiented/articles/how_serious_hypothyroidism_

14. http://umm.edu/health/medical/ency/articles/thyroid-accessed 8/2/2013

15. 4

16. Releasing
Factors
Releasing
Factors
Brain
HHyyppootthhaallaammuuss
ACTH LH & FSH Prolactin GH TSH
Adrenal
Gland TTeessttiicclleess OOvvaarireiess LLiivveerr TThhyyrrooiidd
Adrenal
Gland
Cortisol Testosterone Estrogen
DHEA Progesterone
T3 & T4
IGF-1
Pituitary
DHEA

17. What are the TYPES of
hypothyroidism (from the top down)?
• Tertiary hypothyroidism – deficiency in
hypothalamus – not enough TRH
• Secondary hypothyroidism –pituitary
isn’t kicking out enough TSH “your
thyroid labs are ‘just fine’”
• PRIMARY hypothyroidism – where
thyroid gland can’t make thyroid
hormone
– This is the only one that high TSH is good
for diagnosing!!
TSH levels
•Low TSH
•Low TSH
Your doc is
happy!! 
•HIGH TSH
(finally!)

18. Iodine
required
(65% of T4)
Selenium
required!
“the foot soldier” “the evil twin”
FEEDBACK
INHIBITION
CORTISOL
80% of T4
converted in the
liver

19. Selenium
required!
CORTISOL
Conventional medical practice:
-Only TSH is typically considered.
-You get T4 if you’re lucky.
-Ill-considered: “the foot soldier” “T7”, “Total the evil T4, twin”
Total T3,
%T3 uptake
80% of T4
-You DON’T get Free T3 or Rev T3
converted in the
liver

20. Must have iodine to make T4!
Source: Office of Dietary Supplements, NIH accessed 8/11/2013
http://ods.od.nih.gov/factsheets/Iodine-QuickFacts/

21. Sources/locations of deficiency:
• Chlorinated or fluorinated drinking water
• Not using iodized salt
• Consumption of NaCL in processed foods
• Consumption of soy & “goitrogens” -
cabbage, broccoli, cauliflower and Brussels
sprouts
• Being pregnant
• People living with iodine deficient soils
eating local foods

22. % Mineral depletion from the soil
during the past 100 years, by continent
North America 85%
South America 76%
Asia 76%
Africa 74%
Europe 72%
Australia 55%
Source: UN Earth Summit Report 1992

23. - Selenium is one of the factors that may affect the risk of cognitive
decline. In selenium deficiency the brain remains selenium replete the
longest suggesting that Se plays an important role in brain functions.
- Results from this study: “Low Se status is a risk factor for cognitive
decline even after taking into account vascular risk factors.”

24. SELENIUM DEFICIENCY in FASEB:
• “Adaptive dysfunction of
selenoproteins from the
perspective of the ‘triage’
theory: why modest
selenium deficiency
may increase risk
of diseases of
aging.”
Foundation of American
Societies for Experimental
Biology
McCann, J, Ames BM. FASEB J.
2011 Jun;25(6):1793-814.

25. “But the doctor told me my thyroid
was fine.”
• Can be “wnl” but suboptimal.
• TSH frequently only thing checked.
• Nothing known about Free T4 or Free
T3.
• Free T4 can be converted to Reverse T3 under
stress (cortisol)
• Free T4 can be underconverted to T3 (Se def).
• Can have normal levels (or slightly elevated
levels) of everything and have auto-immune
thyroid disease.

26. (permission granted to use photos & data)

27. • Early 20’s college student
• Weight gain, fatigue, brain fog
• Saw “numerous” MD’s asking for help
• Told “nothing is wrong with your thyroid;
your labs are fine.”
(permission granted to use photos & data)

28. (permission granted to use photos & data)

29. A physician’s wife. “Fatigued”
“No sex drive.”
(c) 2013 Louis B. Cady, M.D. - all
rights reserved

30. Review of all hypothyroid patients in a
private practice in Belgium between
May 1984 and July1997
• 24 hour urine Free T3 correlates better with
clinical status of hypothyroid patients, and
even better than T4 by RIA.
• Conclusions: In this study symptoms of
hypothyroidism correlate best with 24 h
urine free T3.
Baisier WV et al. 2000, Vol. 10, No. 2 , Pages 105-113

31. Selenium
required!
“the foot soldier”
FEEDBACK
INHIBITION
CORTISOL
80% of T4
converted in the
liver
“the evil twin =
REVERSE T3”

32. Why Reverse T3?
• Hibernating bears can:
–Lower temperature 9 – 11
degrees Farenheit
–Reduce their metabolism by
75%
–Drop heart rate from 55 to 9 bpm
• Rev T3 thought to “hibernate”
humans

33. What causes elevation in Rev T3?
• High Cortisol (emotional stress) or high
copper
• Heavy metal toxicity – mercury, lead,
cadmium
• Nutritional starvation
• Selenium or Zinc deficiency
• And high dose of thyroxine
(T4 – a pro-hormone) (!!!)

34. Increased T4 and Rev T3, with dec. Free T3
associated with hypothyroidism at the
TISSUE LEVEL
Notion of “Reverse T3 ratio”
FT3 (pg/dL)
Rev T3 (ng/dL)
>20:1 = optimal
Calculator: http://www.stopthethyroidmadness.com/rt3-ratio/
Van den Beld, AW, et al. Journ Clin Endo Metab. 2005; 90(12):6403-6409

35. Useful Target Symptoms in
Major Depression
¨ Depressed mood 100%
¨ Reduced energy: 97%3
¨ Fatigue or loss of energy: 94%2
¨ Impaired concentration: 84%3
¨ Tiredness: 73%1
¨ Hypersomnia: 10%–16%4 (Insomnia)
1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J Gen
Pract 1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath et
al. J Affect Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.

36. A FEW common symptoms of
hypothyroidism (adapted from multiple sources)
• Depression, fatigue
• Cold intolerance
• Concentration problems
• Weight gain
• Poor cognitive
• Slowed relaxation
performance
phase of DTR’s
• Lack of motivation
• Brittle hair/fingernails
• Reduced libido
• Decreasing eyebrows
• Psychosis – “myxedema
• HIGH blood pressure
madness”
• Constipation
• Exacerbation of bipolar
symptoms

37. 1149 women - mean 69 years of age.
Definition of SCH: THS >4.0mU/L and normal
Free T4 (0.9 0 1.9 ng/dL) (Annals, 2000)
“Subclinical hypothyroidism is a strong indicator of
risk for atherosclerosis and myocardial infarction in
elderly women.”

38. Multiple study review
“normal FT4 and elevated TSH”Definition of SCH:
THS >4.0mU/L and normal Free T4 (0.9 0 1.9
ng/dL) (Annals, 2000)
“The treatment of subclinical hypothyroidism is
seldom necessary”
o Recommendation: onnllyy ttrreeaatt iiff TSH >1100

39. “Data supporting associations of subclinical thyroid
disease with symptoms or adverse clinical
outcomes or benefits of treatment are few.” (JAMA
2004)

40. How much subclinical
hypothyroidism?
• 4 – 8.5% of US population (for TSH> 5.1!!)
– Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T4
and thyroid autoantibodies in the United States population (1988–
1994): National Health and Nutrition Examination Survey (NHANES
III) J Clin Endocrinol Metab. 2002;87:489–99.
– Canaris GJ, Manowitz NR, Mayor G, et al. The Colorado Thyroid
Disease Prevalence Study. Arch Int Med. 2000;160:526–3
• UK study (2011): 8% of women over 50 and
men over 65 have under-active thyroid and
100,000 could benefit from treatment
– BBC News 2011 - January 24

41. More studies
• 24.2% of an adult female population in
Puerto Rico = hypothyroid
– Vonzales-Rodriguez LA, et al. Thyroid dysfunction in an adult female
population: A population-based study of Latin American Vertebral
Osteoporosis Study (LAVOS) - Puerto Rico site. P R Health Sci J. 2013
Jun; 32(2):57-62.

42. Modern Medicine’s Paradigm:
Two Standard Deviations – “if you are not
sick, then you must be well.”
“NORMAL”
OPTIMAL?
OPTIMAL
TSH = 0.45 4.12 source:
Percentile (2.5th% 97.5th% NHANES III

43. Average (normal) or optimal?
• Would you like an normal wife (husband) or
an optimal one?
• Would you like a “normal” marriage or an
exciting and optimal one?
• Would you like a “normal” medical practice
or an incredible, exciting, and (optimal!!)
stimulating one?
• Would you like “normal” thyroid
labs or OPTIMAL ones?

44. Definition of “normal labs”:
“When your lab
values are as
crappy as
everyone else’s.”
- Neal Rouzier,
MD (World Link Medical Seminar II
– Spring 2011)

45. So what are people doing
out there?
What does the literature say?

46. Serum concentrations of Free T3, Free T4, morning cortisol,
afternoon cortisol and change in cortisol concentrations.
Adjustments for: age, sex, body mass index, hypertension, previous
MI, heart failure, diabetes, NY Heart Assn. functional class,
depressive symptoms and anxiety symptoms.
Lower Free T3 = more physical fatigue
Lower Free T4 = more exertional fatigue
Lower morning cortisol and change in cortisol concentration = more
mental fatigue.

47. Aim: evaluate biological factors assoc. with suicide attempts in
naturalistic sample
439 patients with major depression, bipolar and psychotic
disorders consecutively assessed in the ER of an Italian Hospital
(Jan 2008-Dec 2009)
Suicide attempters were 2.27 times less likely to have
higher Free T3 values than non-attempters (odds ratio =
0.44; 95% CI; p=0.01) (prolactin level differences failed to reach
significance)

48. Treatment resistant depression is a common challenge.
Best augmenting strategies available:
-Lithium
-Thyroid hormone
-Anti-anxiety medications
-Atypical antipsychotics.

49. LEVEL III RESULTS:
Per HDRS – 17, remission in:
15.9% on Li
24.7% on T3
Per QIDS-SR16, remission in:
13.2% on Li
24.7% for T3 *
* Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial,
Medscape Psychiatry

50. 63 patients with “subclinical hypothyroidism”
HAM-D and MADRS scales with serum TSH Free T4, free T3
TPO AB and Tg-AB levels
Prevalence of depressive symptoms in this
population was 63.5%
“This study suggests the importance of a psychiatric
evaluation in patients affected by subclinical
hypothyroidism.”
Hunh?

51. Aim: Evaluate relationship of subclinical hypothyroidism and
cognition in the elderly.
- 337 outpatients; {177 = men; 160 = women}
MMSE scores were SIGNIFICANTLY lower in
subclinical hypothyroid patients compared to
euthyroid (p<0.03)
“Patients with subclinical hypothyroidism had a
probability about 2 times greater (RR = 2.028, p<0.05) of
developing cognitive impairment.”

52. An opposing view:
• “Thus, any abnormal thyroid function tests
in psychiatric patients should be viewed with
skepticism. Given the fact that thyroid
function test abnormalities seen in non-thyroidal
illness usually resolve
spontaneously, treatment is generally
unnecessary, and may even be potentially
harmful.”
• Dicerman AL, Barnhill JW. Abnormal thyroid
function tests in psychiatric patients: a red
herring? Am J Psychiatry. 2012 Feb;169(2):127-33

53. “Subtle deficits in specific cognitive domains
(primarily working memory and executive
function) likely exist in subclinical hypothyroidism
and thyrotoxicosis, but these are unlike to cause
major problems in most patients.” (Endocrinol
Metab Clin Noprth Am. 2014 Jun)
“Patients with mild thyroid disease and
significant distress related to mood or cognition
most likely (??) have independent diagnoses that
should be evaluated and treated separately.”

54. The Glamorous Grandmother
• 4/8/11 – 80 yo returned to practice. No real
complaints. History of depression. On des-methylvenlafaxine.
– Daughter “handling her finances”
• 5/2/11 – “doing terrible.”
– TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4
– Fasting BS 120; HgBA1C 6.5%
– Fasting insulin 36 (!!!) {3 – 25}
– Progesterone – 0.2 {0.2 – 1.4 follicular}
– Total testosterone 11
– DHEA-S = 25 MICROgrams/dL (!!)
• Age adjusted {10 – 90} . Optimal = {c. 350-500}
• Rouzier = {300 –females, 600 males}

55. G.G. - interventions 5/2/11 & Follow-up
• Interventions:
– RAISE T4 from 50 to 75 MICROgrams
– DHEA – 25 mg SR q a.m.
– Progesterone 50 mg then 100 mg HS, transdermal.
– Testosterone – 2 mg for one week, then 4 mg
transdermal
– Referred to better MD for intervention with AODM.
• 6/13/2011 – improvement in fatigue. Labs
rechecked.
• 7/11/2011 – “feeling wonderful”
• 2012 – 2014 – N.P. meddled with thyroid Rx;
began declining; returned back to baseline Rx.

56. G.G. – labs before and after
` 4/11/11 interventions 7/11/11 changes
TSH 3.84 Raise T4 from
50 – 75 ug
0.01 (L) none
FT4 1.16 “ 1.24 “
FT3 2.8 “ 3.3 “
Progesterone <0.2 100mg topical
HS
0.9 None
Testosterone 11 4mg topical 15 4 mg LABIAL
DHEA-S 25 25 mg SR n/a continue

57. The glamorous grandmother – post tune-up:
DHEA, thyroid, testosterone, progesterone
Photos removed for web posting
9/28/2011 (permission granted to use photos & data) 01/26/2012

58. Photo removed for web posting
October 12, 2012 – used with permission

59. July 29, 2014 – used with permission
• 85 years old – living
independently
• Reading books
• Driving car
• Dating nice man from
church
• Thyroid RX:
– T4 – 75 ug
– T3 – 5 ug 2x/d
• Hormones:
– DHEA 50 SR, Biest,
Progesterone,
Testosterone
Photo removed for web
posting

60. G.G. – interventions & labs
` 4/11/11 Interventions,
current
6/9/2014 Ref range
TSH 3.84 Raise T4 from 50 –
75 MICROgrams,
add 10
MICROgrams T3
0.02 (L) {0.45-4.5}
FT4 1.16 “ 1.07 {0.80-1.76}
FT3 2.8 “ 4.0  {2.3 – 4.2}
Estradiol 0.4 mg E2 SL 20 {27-122}
Progesterone <0.2 10 mg SL HS 1.5 {0.2 – 1.4 =
follicular}
Testosterone 11 2 mg topical (wrists) 235(H) {5-32}
DHEA-S 25 50 mg SR 463 (“H”) {“10 – 90”}
NTX 19!!  {17 – 94 –
premenopausal}

61. Health Status, Mood, and Cognition in
Experimentally Induced Subclinical
THYROTOXICOSIS [emphasis Cady]
Samuel MH et al. J Clin Endocrinol Metab May 2008, 3(5):1730-1736
• 33 hypothyroid subjects receiving T4
• Double blind, randomized, cross-over study
of usual dose T4 or higher dose T4
• Mean TSH levels decreased from 2.15 to
0.17 mU/L on “subclinical thyrotoxicosis”
arm (p<0.0001) with NORMAL FREE T4
AND FREE T3 LEVELS.
• So what happened???

62. Health Status, Mood, and Cognition in
Experimentally Induced Subclinical
THYROTOXICOSIS [emphasis Cady]
Samuel MH et al. J Clin Endocrinol Metab May 2008, 3(5):1730-1736
• POMS (Profile of Mood States) confusion,
depression, and tension subscales IMPROVED.
• Motor learning was better
• “These findings suggest that thyroid
hormone directly affects brain areas
responsible for affect and motor
function.”
• Question to ponder: were they really
“thyrotoxic”? Or were they OPTIMIZED?

63. Association of thyroid dysfunction with
depression in a teaching hospital
Ojha SO et al. J Nepal Health Res Counc. 2013 Jan;11(23):30-4
• 70 patients diagnosed with first episode
depression - selected by random sampling
– 21% found to have thyroid dysfunction of some
type
–11% were found to have
SUBCLINICAL HYPOTHYROIDISM
• Conclusions: “…thyroid dysfunction is
common in depressed patients…”

64. Low mood and response to levothyroxine treatment in
Indian patients with subclinical hypothyroidism [Visnoi
G et al. Asian J Psychiatr. 2014 Apr; 8:89-93]
• 300 patients with SCH vs. sex matched controls
• HAM-D significantly higher for SCH
• Positive correlation between Hamilton scores and
serum TSH
R(2)0.87, p = 0.00
“Levothyroxine treatment
resulted in a significant decrease
in TSH levels and
Hamilton scores.”
April 2014

65. August
2014

66. Demartini B, et al, cont. J Nerv Ment Dis 2014 Aug
• 123 consecutive outpatient’s with SCH vs
control group w/o thyroid disease
• Psychiatric interview, HAM-D, MADRS
• TSH, Free F4, Free T3
• Scales:
– HAM-D 63.4% vs. 27.6%
– MADRS 64.2% vs. 29.3%
– DX of patients 17 vs. 7
• “The prevalence of depressive
symptoms between these two groups
was statistically significant.”

67. Thyrotopin Levels and Risk of Fatal
Coronary Heart Disease….or
“what they don’t teach you in medical
school or residency”
• The HUNT study – Asvold, BO et al. Arch
Intern Med.2008; 1678(8):855-860
• METHODS: 17,311 women and 8,002 men
with no known thyroid, cardiovascular
disease, or diabetes mellitus at baseline.
• OUTCOME MEASURE: Association
between TSH and fatal CHD

68. The HUNT study – Asvold, BO et al. Arch Intern
Med.2008; 1678(8):855-860 – cont.
• Median follow up of 8.3 years
– 228 women & 182 men died of CHD
• TSH levels of those that DIED:
– 0.50 – 3.5 mIU/L
• 192 women
• 164 men
• “Thyrotropin levels within the reference
range were positively associated with CHD
mortality (in women, but not men).”

69. OK – but what about HEART DISEASE
risk?
• Citation: Subclinical hypothyroidism and the risk of
coronary heart disease: a meta-analysis.
Rodondi N et al. Amer. Jour of Med. July 2006,
119, 541-551. (meta-analysis)
• Medline search from 1966- April 2005
– 14 observational studies met criteria
• Subclinical hypothyroidism (elevated TSH, normal
T4) increased odds ratio of CHD to 2.38
(CI 1.53-3.69) after adjusting for risk factors

70. “Subclinical hypothyroidism vs.
euthryoidism was associated with
greater mortality in those with CHF
but not in those without.” [Adj. hazard
ratio = 1.44X, CI = 95%]
Rhee CM et al. J Clin Endocrinol Metab. 2013 Jun; 98(6):2326-36.

71. Want to place your
bets??
The higher you go
(w/TSH), the higher your
risk.
• Reference range 0.50 – 1.4 mIU/L
= RR of 1
• {1.5 – 2.4 mIU/L} = RR of 1.41
• {2.5 – 3.5 mIU/L} = RR of 1.69 Asvold, BO et al
“Wheels of Fortune” – Las Vegas. © Louis B. Cady, MD

72. So what does the American Association of
Clinical Endocrinologists (ACEE) say?
• “The upper limit of TSH
should remain at 4.5
mIU/L, rather than 3.0-3.5 as
some other organizations have
suggested.”
– https://www.aace.com/files/position-statements/
subclinical.pdf retrieved
August 25, 2014

73. Lab values – one more time…”4.5” is where the
American Assn. of Clin. Endocrinologists want
the highest level of TSH
4.5 is the
upper limit
they want –
this is at c.
the 99th%
TSH = 0.45 4.12 source:
Percentile (2.5th% 97.5th% NHANES III

74. The perils of pharmacology
• “Too much… of
a good thing… is
WONDERFUL.”
– Mae West

75. A word of caution, and a reflection on the
Glamorous Grandmother
• OPUS (Osteoporosis & Ultrasound Study) - 2,940
POST-menopausal women 6 year prospective
study
– 1,278 healthy euthyroid average 68yo women
selected
19 yrs post-menopausal who did not take any
medication that might affect their bones.
• The higher one's FT3 and/or FT4, the lower one's
BMD and the greater one's risk of non-vertebral
fracture. FT4 <0.88ng/dL had better outcomes than
those Source: Mu rpwhy/ FE,T et4 a l.> T1hy.r1oi2d nfugnc/tdioLn w. ithin the upper normal range is associated with
reduced bone mineral density and an increased risk of nonvertebral fractures in healthy
euthyroid postmenopausal women. J Clin Endocrinol Metabl. 2010 Jul;95(7):3173-81. with
commentary adapted from Alvin Lin, MD Las Vegas, NV.

76. Does Grandma have to pick between
optimally euthyroid or osteoporotic?
• 57 yo MWF transferred to me - 11/19/2009
– On Prometrium, Androgel (??? Tiny dose), Bi-est,
Estriol pV, and Norditropin (which was
subsequently able to be tapered with DHEA)
– Armour thyroid – 30 mg
• PMH
– TSH of 6.89 in June 2007
– Bone densitometry – within normal limits
• PE – hint of thyromegaly.
– Neuro – normal DTR’s, normal exam

77. Case study – a woman with her TSH
“suppressed” from 1.19 to 0.10 (L)
` 1/4/11 3/1811 5/16/11 11/14/2012
Thyroid Rx 75ug T4 /
15 ug T3
75ug T4 /
10 ug T3
100 ug T4/ 5
ug T3 bid
100 ug T4/ 5 ug T3
bid
TSH {0.34-
4.72}
???????
0.12 1.19 0.06 (L) 0.10 (L)
FT4 {0.6 – 1.8} 0.5 (L) 0.5 (L) 0.9 0.6 (L)
FT3 {2.0 – 4.4} 2.8 3.2 3.7 3.4
Rev T3 Within
normal
limits
Within
normal
limits
Within
normal limits
NORMAL
Within normal limits

78. Case study – a woman with her TSH
“suppressed” “The Rest of the Story”
` 1/4/11 3/18/11 5/16/11 11/14/2012
Estradiol
{12.5-166.3}
On triple Hormone RX, DHEA, Vit D & MVI
0.12 21.2 53.3 15.1
Progesterone 1.9 2.0 2.4 2.0
Testosterone,
50 41 118 (H) 60
total
LH/FSH 53.9/86.4 59.6/94.9
DHEA-S 314.2 363.8 573.1 (draw
after Rx)
481.1 (H)
25-OH Vit D 53.7
NTx-
Telopep
7.5 {6.2-
19.0}
Bone loss of a teen – 20 yo

79. Thyroid treatment riffs:
• “Compounded slow-release T3 has been
suggested for use in combination with T4,
which proponents argue will mitigate many
of the symptoms of functional
hypothyroidism and improve quality of life.
This is still controversial and is rejected by
the conventional medical establishment.”
– Todd, C H (2010). "Management of thyroid
disorders in primary care: challenges and
controversies". Postgraduate Medical Journal
85 (2010): 655–9.

80. Rx controversies:
• “As of 2012 there are no controlled trials
supporting the preferred use of desiccated
thyroid hormone over synthetic L-thyroxine
in the treatment of hypothyroidism or any
other thyroid disease.”
– American Thyroid Association
– Garber, Jeffrey R., et al. “Clinical practice guidelines for
hypothyroidism in adults: cosponsored by the American
Association of Clinical Endocrinologists and the American Thyroid
Association.” Endocrine Practice 18.6 (2012): 988-1028.

81. 70 patients- ages 18-65 years of age. w/ primary hypothyroidism on
stable T4 for 6 months.
Randomized to either dessicated thyroid extract (DTE) or T4 for 16
months, then crossed over for another 16 months.
RESULTS:
- “No differences in symptoms” and neurocognitive measures.
BUT:
-DTE patients lost 3 lbs!
-48.6% of patients (n=34) PREFERRED DTE.
-Those patients preferring DTE lost 4 lbs during the DTE treatment
and subjective symptoms were all significantly better
while taking DTE as per general health questionnaire-12
and thyroid symptom questionnaire.

82. “Conclusions”:
- DTE therapy did not result in a significant improvement in quality of
life; however, DTE caused modest weight loss and nearly half (46.8%)
of the study patients expressed preference for DTE over L-T4.
DTE therapy may be relevant for some
hypothyroid patients.” [Can you believe it????]

83. So what the
heck am I
supposed to
do with this
stuff?

84. Framework:
• Decide where in the literature you
want to be.
• Do you want to practice the way
things “used to be” or do you want
to practice evidence based
medicine?
–[or just blindly listen to the specialty
societies who parrot from the past?]

85. • Synthroid ® (levothyroxine)
• Cytomel ®
Rx:
(Tri-iodothyronine – “T3”)
– Instant release (cheap!)
– Compounded in SR capsule
(easier dosing)
• Armour® thyroid (brand or
generic) = T4 + T3
• Naturethroid = T4 + T3 –
better tolerated in some

86. Holistic Rx: • Background:
– There are 4 molecules of iodine on T4
(thyroxine = thyroid hormone) and 3
molecules of iodine on T3, active thyroid
hormone.
– T4 is made up of 63% iodine.
– How can we make them if we don’t have
enough iodine?
• Filter your drinking water.
• Iodine supplementation as needed after
testing

87. Dx:
• TSH
• Free T4
• Free T3
• Reverse T3
• If indicated:
– Anti-thyroid antibodies (anti-
TPO)
– Anti-thyroglobulin antibodies
– Thyrotropin receptor
antibodies (TRAb’s)
• We typically do not do:
– Total T4, Total T3, or thyroid
reuptake
Test! Test! Test!

88. Thyroid “by the numbers.”
1. Review this lecture.
2. Go get good training. (Neal Rouzier, MD)
3. PSYCHIATRISTS! Acknowledge that “T3 augmentation” is
in your literature and it is your RIGHT TO PRACTICE IT.
4. Therapists/other practitioners: wake up! Don’t fall into trap
of “blaming” the functionally hypothyroid patient. REFER!
5. Start LOW.
6. Go SLOW.
7. Test test test test test.
– MUST GET BASELINE (which typically hasn’t been done).
– If you are unsure or nervous, TEST.
– MONITOR THE THERAPY.
1. Explain “Goldilocks and the Three Bears” to your patients
and start LOW, giving them some flexibility.

89. Two books:

90. “Sit down before fact as
a little child,
be prepared to give up
every preconceived
notion,
follow humbly wherever
… nature leads,
or you shall learn
nothing.”
- Thomas H. Huxley

91. Contact information:
Louis B. Cady, M.D.
www.cadywellness.com
http://www.tms-relief.com
Office: 812-429-0772
E-mail: lcady@cadywellness.com
4727 Rosebud Lane – Suite F
Interstate Office Park
Newburgh, IN 47630 (USA)