if the normal TSH range is 0.4-4.5 why are GP's... - Thyroid UK
if the normal TSH range is 0.4-4.5 why are GP's are not allowed to prescribe until the tests show 10 or over ?
They can prescribe but they usually do another test after at least 6 weeks to make sure that the raised TSH wasn't the result of a viral infection and that it is still raised. Unfortunately many GPs don't treat until it is over 10, but they can.
It is a bit daft really why they don't prescribe.
Carolyn x
>They can prescribe but they usually do another test after at least 6 weeks to make sure that the raised TSH wasn't the result of a viral infection and that it is still raised.
It's definitely a good idea to confirm the raised TSH if the diagnosis is in doubt.
>It is a bit daft really why they don't prescribe.
It depends whether or not the patient is symptomatic, and whether thyroid hormone levels are low. A lot of elderly women in particular have a mildly elevated TSH readings and no symptoms of thyroid disease. Putting them all on levothyroxine would not be necessary.
It certainly is daft when symptomatic patients are denied thyroid hormone replacement because their TSH isn't over 10! This certainly seems to be an issue.
'A lot of elderly women in particular have a mildly elevated TSH readings and no symptoms of thyroid disease'
I dispute that! Given that doctors know nothing about hypo symptoms, how would they know that these women have no symptoms? Are you saying that these elderly women are 100% fit as fiddles and running marathons? Or are you saying that what symptoms they do have are being put down to them being 'elderly'? (What is 'elderly', anyway?) Has anyone ever tried giving them some thyroxine to see if it makes them feel any better? Because I bet it would!
I don't have any statistics to back up my theories, but I bet you don't either! And as an 'elderly' lady, I find your dismissive (doctorly) attitude offensive.
Grey
Indeed. Why would the GP even test TSH if there were no symptoms? I was told that I as always tired by one GP as I was "no longer a young woman". I was 34! (He didn't test TSH or anything else, just told me to go to bed earlier.)
>I was told that I as always tired by one GP as I was "no longer a young woman". I was 34! (He didn't test TSH or anything else, just told me to go to bed earlier.)
How bizarre! Did you report an unusual sleep-wake schedule to prompt this discussion of your bedtime?
Anyway, I should probably go to bed 
Take care.
Good evening,
>Why would the GP even test TSH if there were no symptoms?
>'A lot of elderly women in particular have a mildly elevated TSH readings and no symptoms of thyroid disease'
Such results come from population-based studies of TSH levels, not individual GP's test results.
>Given that doctors know nothing about hypo symptoms....
Goodness me, could that perhaps be an over-generalisation?!
>What is 'elderly', anyway?
No precise definition, but the frequency of mild (sometimes asymptomatic) TSH elevations increases over the age range of 60 to 70 to 80...
The prevalence of subclinical hypothyroidism (TSH above range but less than 10) is 4% to 8% in the general population, but up to 15% to 18% in women who are over 60 years of age.
Interestingly, it has even been suggested that a very slight degree of hypothyroidism might have certain health-related advantages in people over 75 - see the American Journal of Therapeutics (Nov. 2011). Here is a link to the abstract...
ncbi.nlm.nih.gov/pubmed/206...
>Are you saying that these elderly women are 100% fit as fiddles and running marathons?
I suspect relatively few of them, but some nonetheless!
>Has anyone ever tried giving them some thyroxine to see if it makes them feel any better?
Yes, absolutely. A Cochrane review of twelve clinical trials looked to answer this very question back in 2007.
>Because I bet it would! (make them feel better)...
Unfortunately, it didn't. Overall, in the twelve studies analysed, levothyroxine treatment of subclinical hypothyroidism did not improve health-related quality of life, nor did it improve survival. Some evidence suggested a reduction in cholesterol levels, but no resulting reduction in cardiovascular disease was observed.
>I don't have any statistics to back up my theories, but I bet you don't either!
I try my best not to post things which I cannot back up.
>And as an 'elderly' lady, I find your dismissive (doctorly) attitude offensive
At no point have I been dismissive of anyone's ill-health on this forum, or any other forum for that matter. My only suggestion was that mildly elevated TSH results should not automatically result in 'knee jerk' prescribing of thyroid hormones to patients who report feeling well. Presenting symptoms, clinical signs, various other test results and the patient's own preferences should all be taken into account. Not everyone wants to take medication when they are feeling OK, and this should always be respected.
Kind regards,
Bob.
I would also like to point out that in spite of the Cochrane review described above, I do support a trial of levothyroxine treatment for any symptomatic patient who has a TSH of between 4 and 10 (approx).
A 3 to 4 month trial should be enough to determine whether or not the treatment has led to improved well-being. If it is unhelpful it can be tapered off and stopped.
I read with interest your debate.
Like Bob, I personally tend to favour the not 'so easy jump into thyroxine et al'.
As much as the range of FSH, at times, seems a bit broad with an upper limit of 5, as you all know very well it is not the sole measure/indicator that something is terribly going wrong.
Certain deficiencies inhibit the correct conversion from T4 to T3 and increase TSH.
Often with time and gradually when all these deficiencies have been corrected and the bio-chemistry within the body is harmonious and functioning properly symptoms dissipate gradually.
Having said that, when one is suffering much and is desperate to get better, they are ready to take anything to include hormones.
For example, one of the many key factors attributed to hypo are high levels of cholesterol and BP which are also strong markers of magnesium deficiency which often ignored to be perused in favour of borderline TSH treatment, the lack of accurate testing, and/or not so informed GP.
Patients struggle now with both, new treatment and the core of the problems.
Cholesterol levels continue to rise, GPs get alarmed and push for statins which lead to more side effects i.e. further increase in BP and depression and therefore anti-depression drugs are prescribed and the vicious cycle therefore continues.
The same is also applicable when B12 is low too as a huge array of symptoms develop and add further complications to the diagnosis.
Those who were looking for statistics you could have a quick read:
Death by medicine webdc.com/pdfs/deathbymedic...
articles.mercola.com/sites/...
Another book that I read with interest, is Could it be B12
amazon.co.uk/Could-be-B12-E...
As for 'elder women' it is often the case when women approach menopause led by a rocky road of perimenopause, hormones will fluctuate not only a daily basis but within the hour. This impact the thyroid hormones ultimately.
I was stunned to know that in France, and as soon as women reach their late 30s, many doctors start recommending good quality supplementation i.e. magnesium, b6, b12, zinc, etc. as preventative treatment before the bodies that running on empty.
I am not claiming that this is one-fit-for all recipe but I do understand what bob is trying to say.
Doctors are allowed to prescribe whatever the value of TSH. The idea that they cannot prescribe unless TSH hits 10 is widely believed, probably by quite a number of doctors! But that is simply not true, it is not disallowed.
The relevant actual statement in the guidelines which seem to be widely used is this:
There is no evidence to support the benefit of routine early treatment with thyroxine in non-pregnant patients with a serum TSH above the reference range but <10mU/L. Physicians may wish to consider the suitability of a therapeutic trial of thyroxine on an individual patient basis.
acb.org.uk/docs/TFTguidelin...
Which puts the ball directly into the physician’s court to decide. In my view, symptoms are enough to make the situation qualify as not routine and give support to a trial.
In my own case, it was a series of steadily rising TSH results which eventually went just over our local top of range (about 5.1 with top being 4.95, if I remember correctly).
Remember, at the end of the line, the doctor who prescribes,or refuses to prescribe, is responsible for their decision. Although we often get the impression that following guidelines would exonerate them of any blame, that is not the case. Following guidelines alone is not an adequate defence.
Rod
Another thing I found was that the quote from the thyroid foundation stating what you've said was attached to an in range ft4. It later states that a slightly elevated tsh with a low, out of range ft4 could signify secondary hypo, yet most docs (certainly none I know) do further tests when such a result is seen. Most still wait for that golden 10 to happen, which for secondary won't as the tsh will continue to fall, which ironically means that if in range the ft4 won't be checked so cannot be seen to still be right or wrong! The system is seriously flawed.
Additionally, many doctors are under the belief that a patient won't have any signs/symptoms relating to thyroid unless the tsh is above 10. I know that one from personal experience. It's a wonder anyone under 10 ever has any success.
Quite right.
The document I quoted actually says:
It is the responsibility of the requesting physician to provide clinical information to guide the laboratory in the selection of the most appropriate TFT but if clinical details are not available that allow the identification of the above categories of patient, then it may be prudent for laboratories to measure serum TSH and FT4 on all specimens rather than embark on a first-line serum TSH testing strategy followed by a cascade to include FT4 and FT3 if indicated.
Funny how the lab seems to have the upper hand in determining which tests to run these days.
My GP was not entirely convinced that the symptoms I had were thyroid-related. But when, something like two years later, I rather bounced in and looked and felt well, his thinking might have had a nudge in the direction of believing. (Maybe that is wishful thinking? )
If anyone has several TSH results, especially if they are (as mine) clearly rising each time, plot a simple graph. Visual presentation is very powerful.
Rod
Hi Rod
Wise words great mate!
Can I add:
It is important to point out to forum members a few things about the Association of Clinical Biochemistry and their relationship to doctors and patients
The guide was written not by the NHS but by the ACB - a private organisation.
This organisation promotes its own interests i.e. the interests of biochemsits, so it's not surprising that the document "guides" the reader to accept that the lab has the final say.
The lab is not the patients clinician, the doctor is. the lab only looks at samples and does not consider the clinical presentation of the patient. I've never been to the lab for a diagnosis!
The NHS Constitution and Good Medical Practice make it quite clear that any decision about a patient's care has to be taken by the doctor in partnership with the patient. The lab shouldn't (but often does) come in to this picture with regard to discussing treatment.
Labs (and for that matter - guidelines) are there to provide the doctor with another diagnostic tool, not to replace the doctor's skill and experience.
Doctors can prescribe any medicine at any blood hormone level PROVIDED that they can justify their prescribing i.e. it is clinically justified.
I roundly condemn that doctors are supine and let labs dictate to them. (They seem somewhat more assertive about their pay and pensions.)
In my view, every single request that a doctor makes should have a clear response from the lab. Simply not doing it, or a cryptic comment that does not explain, are not enough. It should be a 100% duty of a lab to make such responses - even if they say they won't or can't do a test. (That will inevitably be the case some of the time.)
It should be like accounting - every single widget that comes into the company needs to be accounted for. Even if one gets damaged, thrown away, given as a sample, ...
The only exception is when a lab does a test that was not requested - e.g. an out of range TSH causes then to do an fT4.
Rod
HA!....as if they'd ever use their inittiative and do EXTRA tests!.....I keep asking for FT4 and FT3 tests to be done but to no avail....my doctor requests them, the lab only does TSH....I guess what I'm saying is that I agree with you Rod but don't think the last bit will ever happen unfortunately 
I got the " the lab wont do it" response from my GP. I told her that the lab is not my clinician, she is and the lab should carry out the tests we agreed. She phoned the lab and I now get TSH FT4 and FT3 tested every time.
>HA!....as if they'd ever use their initiative and do EXTRA tests!....
This is actually quite common at some hospitals. For example, a below range TSH can trigger a T3, and an above range TSH can trigger a free T4 measurement.
Well, I guess I live in the wrong catchment area for these sort of tests .....I found out that I had been overdosing on my levo because I had breathing problems for 5 days before going to the doctor......my FT4 was over the range by quite a bit (I got it checked privately)......this would have showed straight away that my dose was too high apparently
>The idea that they cannot prescribe unless TSH hits 10 is widely believed, probably by quite a number of doctors!
I can't imagine they believe it's disallowed, although they might say that to patients. It's more a case that they've been led to believe it's inappropriate.
The antiquated dinosaur of an endo told me that he would not treat me until the TSH level got nearer to 10. I said he wouldnt as I would be dead by then as I feel that ill.
He wouldnt budge for nothing, kept spouting that my bloods were 'within normal levels'.
The GP is exactly the same.
Am trawling round for a GP that is sympathetic to thyroid problems without resorting to waiting until the TSH gets to 10!
Ann xxx
I got thyroxine privately, then, after 4 weeks showing improvement i went to my GP and said "look it works"....told him how and now am being upped and treated on the NHS ...apparently he couldn't deny the fact that I'd improved on the medication....worth a go?
Ann, do keep at it (with a new gp) as it can work. In the end my gp gave me a trial script after I "twisted her arm" as she put it. Once on t4 it seems much easier (or it was for me) to negotiate the dosage as it is a fait accompli and once you've got the accoutrements of uat they are more inclined to treat you as though you have uat instead of arguing that you don't (if that makes any sense).
In the eyes of conventional medicine, a TSH of above 3 to 5 (approx), is mildly elevated. A TSH of above 10 to 12 (approx), is substantially elevated.
>why are GPs are not allowed to prescribe until the tests show 10 or over?
They are allowed, but they often don't - it mainly depends on:
1. Other blood results, especially free T4. If free T4 is normal, many doctors do not prescribe, unless (perhaps) it's right at the bottom of the reference range. If fT4 is below range, prescribing is much more likely, especially if thyroid auto-antibodies are present. In some cases, a subnormal fT4 reading combined with a low, normal or mildly elevated TSH (less than 10) may suggest pituitary gland dysfunction. This is because it is common for TSH to be very elevated (above 10) when T4 is below range. If pituitary dysfunction is suspected, referral to an endocrinologist is recommended. Primary hypothyroidism, on the other hand, is usually treated in general practice.
2. The presence (or absence) of typical hypothyroid signs/symptoms. This can be difficult to assess because symptoms of hypothyroidism are often vague (fatigue etc) and overlap with many other conditions. If thyroid blood tests are borderline, assessment of other potential causes of the patient's symptoms is a good idea.
3. The attitude of the doctor is also important. Your doctor may be following guidelines released by the British Thyroid Association, or advice from the laboratory
When TSH levels are below 10, levels of thyroid hormones (T3 and T4) are often still within the reference range (this is called compensated, 'mild', or subclinical hypothyroidism). This is extremely common in the elderly, in whom it may be 'normal' and asymptomatic. A TSH of between 5 and 10 in a young person is more likely to represent thyroid disease, particularly if thyroid auto-antibodies are present. The decision to prescribe usually depends on fT4 levels and/or symptoms, as described above.
When the TSH is above 10, T4 levels are usually subnormal and the patient clearly symptomatic (this is called overt hypothyroidism). In this situation it is usual to prescribe immediately.
It is sometimes useful if the doctor has old blood results to look back on, from a time before current symptoms were present. This may be the case if your GP has ordered thyroid function tests as part of a general health evaluation in the past (although labs do not usually recommend performing TFTs on asymptomatic patients, unless there is at least some plausible reason to suspect the onset of thyroid disease). Still, some GPs do perform TFTs fairly routinely, and this can provide figures for comparison.
So, if your TSH is between 5 and 10 (approx), you should at a minimum be having blood tests for fT4 AND a careful evaluation of your signs and symptoms. A blood test for thyroid auto-antibodies (thyroid peroxidase/TPO antibodies) may also be useful. Measuring T3 is less likely to be informative in this situation..... partly because it is usually within the reference range (unless you are otherwise seriously unwell), and partly because T4 is the major hormone produced directly by the thyroid gland (T3 is predominantly produced by peripheral conversion of T4 to T3). Although T3 is the biologically active thyroid hormone, the fact that most T3 is produced outside the thyroid gland means that blood levels of T3 are much less representative than T4 of what your thyroid gland is actually doing. Instead, T3 levels are representative of the degree of peripheral conversion. Primary thyroid disease is not known to affect the peripheral conversion of T4 to T3, but conversion may be altered in other non-thyroidal conditions. Because T3 levels can be reduced by most serious non-thyroidal illnesses such as infections, cancer etc. (called the sick euthyroid syndrome), T3 levels are not a good indicator of primary hypothyroidism - which is by far the most common type of hypothyroidism. In addition, debating whether or not your levels are near the bottom of the reference range is not likely to be met with much enthusiasm by your doctor - a substantial proportion of the general population will have levels in the lower part of the reference range; this cannot diagnose anything.
Measuring levels of T3 (preferably free T3; fT3) is useful in specific clinical circumstances:
1. If hyperthyroidism is suspected. Although almost all hyperthyroid patients have elevated fT3 and fT4, a small minority only have elevated fT3 (called T3 toxicosis). TSH is usually suppressed/undetectable.
2. In the treatment of hypothyroidism, if a patient requires a dose of levothyroxine (T4) sufficient to suppress TSH to below the reference range in order to feel well. In this case, fT3 should be measured to ensure that it remains within the normal range.
For patients on liothyronine tablets (T3), fT3 measurements may be difficult to interpret due to significant fluctuations which occur throughout the day when on liothyronine treatment (T3 has a short half-life in the blood). Blood levels could be measured at 'trough' ie. first thing in the morning before a dose of T3 is taken, or at 'peak' after a dose has been absorbed. It is usual to measure at 'trough' but in either case, it is difficult to interpret the results because there is no hard data to tell us what level of fT3 to aim for under these circumstances. The normal range for fT3 was not established for patients taking pharmaceutical T3. Signs and symptoms are therefore very important to take into account, and close monitoring is essential when high doses are prescribed. BTA guidelines recommend using TSH to adjust liothyronine treatment but in practice TSH appears to be more readily suppressed by liothyronine than levothyroxine, thus limiting the use of TSH for these patients. I expect that this is due to high (non-physiological) peaks in T3 levels suppressing pituitary output of TSH. TSH is still a useful blood test for many patients on levothyroxine replacement.
3. fT3 should be measured for patients on amiodarone who present with thyroid illness. Amiodarone has complex effects on the thyroid, but also affects conversion of T4 to T3.
4. fT3 is sometimes measured if a patient's symptoms are not consistent with their blood results. Slow conversion of T4 to T3 theoretically leads to an elevated TSH, high T4 and low T3. The much more common finding of high TSH, low T4 and low T3 simply represents primary hypothyroidism, not a conversion defect.
I've just had a little look into why some labs persist in measuring total T3 and not free T3. I found in the British Medical Journal 'A free T3 assay would be the preferred test over a total T3 assay; however, some commercially available free T3 assays are variable and unreliable.' I suppose this has something to do with it.
Hmm. I think I went a bit off the point. Anyway, I did answer the question somewhere in there
Also, like Rod said, a consistently rising TSH (still below 10) is an important sign.
I realise how lucky I was 18 years ago when I started with Thyroxine as a GP was quite happy to try me on it when I was just considered borderline underactive at 6.52 ( range was 0.35-5.50). Although T4 did the trick for a few years, it has proved not to be the answer long term, but I am grateful for the GP for helping me at the time, and buying me a few years of relative health.
I was previously with a GP who wasn't even prepared to do a blood test for me when I suggested that my fatigue for half of my menstrual cycle could be caused by my thyroid! I was so disgusted by her response that I changed GPs. She told me that it couldn't possibly be my thyroid.
Lol, it is an odd thing, that so many doctors presume that the thyroid cannot possibly be the cause of so many problems yet there is clear proof that it is. Having been told my symptoms cannot possibly be related to mine as I my tsh wasn't high enough (outside range but under 10) it makes things somewhat strained with the doctor/patient relationship. It could be, for you, that the pituitary gland is partially to blame but I would bet that avenue was not explored?
Having read all of the above answers i wonder where we fit in who have in range TSH and T4, but are clearly very ill with all the symptoms of Hypothyroidsim. Is it the opinion of those here that we could not have thyroid disease, or that it is possible to have it with in range bloods? (mine have been variable over the years, but are currently TSH 2.39 and T4 12.6 (with a range of 12 - 21)).
Hi Justy
You will need to ask this as a new question as this will be lost here... I believe it is possible to be hypo with in-range bloods. If you ask a new Q you will get lots of support and answers from those with much more knowledge from me - I fit the high TSH-low T4 profile, so only know a little about this.
I'm sure many on here will know a lot about being hypo with in-range TSH/T4.
Liza
Low TSH with low FT4 is a sign of a pituitary problem. And your FT4 is low. Have you had an antibodies test? Might be worthwhile to see if your body is converting to FT3.
Are your tests always much the same or has there been any significant changes? Has the TSH dropped or the ft4 dropped? Any pattern should show with tests if you've had several.
Check out this link - it reminded me of your question - here the doctor writing this doc states that TSH and T4 tests are 'notoriously' inadequate at diagnosing thyroid issues and are not definitive.
Thank You for all your replies. I have been on levothyroxine for some months now and have seen major improvement (and in some cases disappearance of many symptoms - even though my TSH levels are still high - very weird to suddenly start growing eyebrows again lol). I was simply asking the question because I was informed by my current GP that I have had the symptoms of an underactive thyroid for over 20 years and that my TSH level has NEVER dropped below 8.0 (since 1991 when I was first tested) with the occasional 'spike' of up to 12 and that all the other relevant numbers clearly indicated an underactive thyroid. Five months ago my TSH rose to over 10 and hasn't dropped since (regardless of increasing amounts of levothyroxine - still being regularly tested and dosage adjusted).
I asked my current GP why I had always been told for over 20 years (by five different GP's and an Endocrinologist) that my thyroid was not the root of any of my symptoms - and that everything was in an acceptable range, even though I have every symptom continuously for years. If I had been told my results and that GP's were told not to prescribe, I would have 'gone private' - this is when he said that as far as he could see from my notes - I should have been prescribed years ago, however, GP's are advised very strongly against prescribing as long as TSH remains below 10 - regardless of what the other 'numbers' are.
Well from what I've read, I was led to understand that GP's are guided to treat TSH over 10, when accompanied by symptoms, eg tiredness, etc. I'm in the no man's land of TSH 8 and have had extreme fatigue for over 10 years, which has got considerabley worse the last year. I didn't even know I had over range TSH as blood results were always said to come back 'normal' and only last year got a copy of last 10 years results, showing TSH 7.5, 7 years ago. I should have been helped many years ago as I do have the accompanying symptoms, but GP just thought I was trying it on!!
But as someone with TSH 10 and low T4, assuming you have accompanying symptoms, amazing that you haven't been helped.
A link pointing out the connection between TSH, T4 and T3 and importance of testing all:
//healthunlocked.com/thyroiduk/questions/130774156/why-do-my-doctors-keep-increasing-my-medication-when-i-started-off-as-borderline-why-do-i-feel-must-worst-since-i-started-thyroxine?ref=email_dailyB
That's all very interesting. I have always had a normal TSH reading - around 1.4 but I then developed nodules (TSH still fine) and after a biopsy showing the nodule could be cancerous, my consultant recommended a hemithyroidectomy. I had that done January 2013 - fortunately no cancer - and my consultant was confident my remaining thyroid would kick in and I wouldn't need replacement thyroxin. My TSH gradually went up, however and when it reached 6.5 he put me on 50mcg of thyroxin which brought my TSH back down to around 1.2. I have recently moved to Spain and as my OH and I are pensioners, we are under the care of the Spanish equivalent of the nhs. I had a TSH test done in January and it was 3.74. As my Spanish isn't too good yet, I wasn't able to go into details about my history and anyway the doctor just said my TSH was fine and within range and to come back in a year. I do actually feel fine .................no hypothyroid symptoms, so am unsure what to do. Oh and the test here in Spain was done early morning before food whereas the tests in England were done in the afternoon. I am 'elderly' 67 so maybe it's OK for my TSH to be as it is..............and I have also read that it can be higher in the early morning before thyroxin meds anyway. I am thinking of having tests done privately just to check - I don't think there's any point going back to my Spanish GP at this point. Any advice - should I just leave things as long as I don't have symptoms?
Best written info on why we need FT3/FT4 tests over TSH please?
