This is a good example of what present accepted... - Thyroid UK

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This is a good example of what present accepted assumptions are regarding T4 treatment, combination therapy re control by TSH levels

diogenes profile image

You naughty people: dosing by how you are feeling. TSH, TSH hear me, is the test that defines right or wrong dosing. Don't let me see you arguing that you are best when TSH is below the normal range.

Recent evidence sets therapeutic targets for levothyroxine-treated patients with primary hypothyroidism based on risk of death

December 2020

European Journal of Endocrinology 184(2)

DOI: 10.1530/EJE-20-1229

Petros Perros, Krishnarajah Nirantharakumar , Laszlo Hegedus


Since the introduction of sensitive assays for serum thyroid stimulating hormone (TSH) clinicians have advised hypothyroid patients to adjust the dose of levothyroxine (L-T4) in order to achieve a normal serum TSH. A minority of patients are dissatisfied with this treatment strategy and experience symptoms. Some indirect evidence suggests that a normal serum TSH may not necessarily reflect euthyroidism at tissue level in patients treated with L-T4. Increasingly hypothyroid patients demand higher doses of L-T4 or liothyronine (L-T3) or animal thyroid extract, often purchased online, and titrate the dose against symptoms, although ample evidence suggests that combination treatment (L-T4 with L-T3) is no more effective than L-T4 alone. Community surveys show that up to 53% of treated hypothyroid patients at any time have a serum TSH outside the normal range. The recommendation by guidelines that the upper limit of the normal range for serum TSH should not be exceeded is supported by robust evidence and is generally accepted by clinicians and patients. However, until recently the lower limit of serum TSH for optimal L-T4 replacement has been controversial. New evidence obtained by two independent large population studies over the past two years has shown that mortality of hypothyroid patients treated with levothyroxine is increased when the serum TSH exceeds or is reduced outside the normal reference range. It is estimated that implementation of a policy of normalising serum TSH in hypothyroid patients will reduce the risk of death of 28.3 million people in the USA and Europe alone.

78 Replies

And, moreover they can make you immortal. The risk of death is 100%, but they have a magic method to prevent it.

penny profile image
penny in reply to diogenes


helvella profile image

The highlighting that TSH assays are sensitive seems bizarre. The rest of the paper only demands that TSH is within the normal range (as they call it). Which does not require any special sensitivity.

It is extremely low TSH levels which have become measurable as sensitivity has increased.

Purchasing online is a scientific and medical way of classifying treatment? I don’t think I have seen any trials which show that buying online in itself does anything.

Buying online is not equivalent to buying without prescription. And what of patients advised by their consultants to purchase online? That is to a very considerable extent a direct result of the inability of purchasing systems to set acceptable prices.

“Patients with low or suppressed TSH, as a result of overtreatment, had an 18% increased risk of mortality for every 6 months of low or suppressed TSH.”

They very nicely point out that mortality rate but ignore the under-treated:

A protective effect for heart failure was seen at low TSH concentrations (hazard ratio 0.79 (0.64 to 0.99; P=0.04) for TSH <0.1 mIU/L and 0.76 (0.62 to 0.92; P=0.006) for 0.1-0.4 mIU/L).

An increase in the risk of fragility fractures was observed in patients in the highest TSH category (>10 mIU/L) (hazard ratio 1.15 (1.01 to 1.31; P=0.03)).

Whereas they try to blame patients for demanding and purchasing thyroid hormone online, under-treatment would, I suggest, be almost entirely at the hands of trained doctors.

It is fatuous to claim: “It is estimated that implementation of a policy of normalising serum TSH in hypothyroid patients will reduce the risk of death of 28.3 million people in the USA and Europe alone.” – without stating what the change in risk is, and over what time.

A one in 100,000,000 per year reduction would be smaller than statistical noise. A 50% reduction every six months would most likely end up self-correcting – they would all die in next to no time.

shaws profile image
shawsAdministrator in reply to helvella

The 'professionals' have to cover themselves so that they will not be blamed for early death - such as some people who've taken their own lives because they could no longer go on being very unwell and told their 'numbers' are fine and they don't need i.e. a T4/T3 combination or T3 alone.

tattybogle profile image
tattybogle in reply to helvella

"Patients with low or suppressed TSH, as a result of overtreatment, had an 18% increased risk of mortality for every 6 months of low or suppressed TSH.”

Oh dear . just checked.... i've had low TSH for 29 periods of 6 months, so perhaps you'd better discount my other reply since there's a 522% chance that i'm actually dead already .

LAHs profile image
LAHs in reply to tattybogle

Yes, me too! ~15 years of low TSH and I'm still alive.

When they first started measuring my TSH their machines couldn't detect anything that low. Their machines are now better so they can tell me it's .001 (sorry, don't have the units to hand).

Ditto!!! 😂😂😂

TSH sensitive??? I changed dose from 175mcg to 100mcg over a period of time and my TSH never moved!


LAHs profile image
LAHs in reply to klr31

Actually that is very interesting, you went from what would be considered overdosed to a ~ starter dose. I wonder how your T3 changed during that transition. And how about that TSH, was it fixed at high, low or "normal"? You would think an endocrinologist would grasp at that data and publish a paper on it, it sure is unusual. But no, thyroid is too hard.

tattybogle profile image
tattybogle in reply to LAHs

my TSH got 'stuck' too......good job they didn't use TSH to decide my initial dose..

when diagnosed..................... TSH 6.8 (TT4 29%)

7 weeks on 50mcg ............... TSH 2.9 (TT4 52%)

5 months on 100mcg .......... TSH 2.5 (TT4 68%)

10 weeks on 150mcg .......... TSH 2.7 (TT4 71%)

about a year later i tried a bit extra for a few weeks (maybe 175 ? can't remember ) , had a test and TSH was 0.001 with over range fT4.

Reduced back to 150mcg and TSH came back to 0.09 ... (which was 'in range' back in 2005 when lab used [0.02 -6] for TSH !)

klr31 profile image
klr31 in reply to LAHs

I have never seen an endocrinologist apart from when I paid privately in 2005. I had been kept on too low a dose of thyroxine for four years after diagnosis in 2001 (50mcg). He put me on T3 as well as increasing T4. I did have to come off the T3 a few years later but was ok on the higher dose of T4 by then. My TSH was very low which, of course, doctors don't like. I would have to check my results for T3 figures but I believe they were always within range. I only eventually reduced my T4 after menopause when I could feel I was becoming over-medicated and my T4 by thus time was above range.


LAHs profile image
LAHs in reply to klr31

Yes, before I "wised up" I had a (stupid) endo. My GP and I had worked out over months that 150 mcg of Levo (T4) got me feeling well because at that level I was generating T3. He then retired! and I reverted to (stupid) endo. who decided that 150mcg of Levo was too high because it made my TSH too low (same old stupid story). Because I was not too well educated on the subject I trusted her and she plunged me back into debilitating hypothyroidism. I struggled for about 2 years with this idiot until I searched and searched for another Endo who prescribed me NDT, and the rest is history (and posted on this site - a number of times).

klr31 profile image
klr31 in reply to LAHs

It's astonishing to me how little some doctors and even some endos know about thyroid problems.


Does the study look at free T3 and free T4 when classifying people as ‘overtreated’ or just the TSH?

diogenes profile image
diogenes in reply to Hoxo

Nobody like these thinks of FT3 except for diagnosing hyperthyroidism.

Will have a read of this.

Graham Leese has done some good studies on TSH in treated patients. This one shows how an elevated TSH carries far more risk than a low TSH (see Fig. 2). We should bear in mind that subjects in these studies have generally been diagnosed on the basis of an elevated TSH, usually > 10. Patients who present with signs and symptoms of hypothroidism and a non-elevated, or mildly elevated TSH are not studied. This latter group is the cohort who need T3 therapy, that's my observation.

One for diogenes . TSH has various isoforms of varying bioactivity and when TSH is low it has a greater proportion of TSH molecules with low bioactivity. Thus, the lower the TSH the greater proportion of TSH isomers with low bioactivity. As a more sensitive TSH assay has to be more sensitive to isomers with low bioactivity. Ideally we want to measure the sum total of TSH bioactivity not the quantity of TSH. Since more sensitive assays detect more TSH with low bioactivity they will give a less accurate picture than older less sensitive assays. Does this look right? There seems to be an attitude that the more sensitive a TSH assay is the better care patients receive - I don't agree.

diogenes profile image
diogenes in reply to jimh111

Nor do I.

TaraJR profile image
TaraJR in reply to jimh111

Your link doesn't seem to the right one for the Leese TSH paper?

jimh111 profile image
jimh111 in reply to TaraJR

Should be this one . Thanks for pointing out.

TaraJR profile image
TaraJR in reply to jimh111

Ah yes, thank you.

FancyPants54 profile image
FancyPants54 in reply to jimh111

"Patients who present with signs and symptoms of hypothroidism and a non-elevated, or mildly elevated TSH are not studied. This latter group is the cohort who need T3 therapy, that's my observation."

That's interesting. That's me. My TSH never got over 7.3, but I had signs and symptoms when it was still in range (still do). Levo has never made me well. I have been adding T3 since Christmas. That hasn't made me well either yet!

jimh111 profile image
jimh111 in reply to FancyPants54

A brief comment so I don't hijack this thread. When TSH fails to rise as fT3, fT4 start to fall it suggests the pituitary is under-responding. This not only affects the stimulation of the thyroid but also reduces stimulation of deiodinase (T4 to T3 conversion). In this case just restoring blood levels of fT3 is not enough because it doesn't do much to rectify the reduced T4 to T3 conversion in tissues such as the brain. I find I need higher doses of L-T3 (e.g. 30 - 40 mcg instead of 5 - 10 mcg).

FancyPants54 profile image
FancyPants54 in reply to jimh111

Thank you. That's valuable to me. I'm on 20mcg T3 with Levo and feel worse with worse blood results so far. My conversion is very poor.

Can the TSH be within range with T3 medication? I thought that if you took T3, the TSH would be automatically suppressed...

TSH110 profile image
TSH110 in reply to Hypomadness80

Only if it’s not enough T3?

vocalEK profile image
vocalEK in reply to TSH110

diogenes - Is this true? Might my TSH "improve" from <0.01 (0.3-4.2), if I took more T3? FT4 is 1.3 (0.9-1.7) and FT3 is 3.4 (2.0 - 4.4). So FT4 is 50% through range and FT3 is 58% through range. I take 25 mcg of Cytomel and was taking 125 mcg of levo. I suggested we raise my levo back up to 150 (where it was before I began taking T3) and my doctor agreed. So far she has been a gem in terms of working with me. Several of my hypo symptoms have improved since I began taking T3. My FT3 was below range before I convinced her to prescribe Cytomel.

diogenes profile image
diogenes in reply to vocalEK

No, the more T3 the lower the TSH. It's difficult to avoid suppressed TSH when on T3, because of its stronger effects at the hypothalamus than T4 or a combination.

See . I suspect that divided doses have less effect on TSh than a single dose daily, that TSH may tend to respond to peak T3 levels. This is pure guesswork on my part, just a hunch.

I’d rather have a life on NDT and die young than live forever in the pergatory of T4 monotherapy - so they can put their paper in their pipe and smoke it. It’s a load of baloney in my opinion.

Musicmonkey profile image
Musicmonkey in reply to TSH110

I'm with you on that one, although in my case it's combination therapy.

amala57 profile image
amala57 in reply to TSH110

I totally agree.

LAHs profile image
LAHs in reply to TSH110

That's my philosophy too. I'd rather die a bit earlier than spend a slightly longer time in a constant state of hypothyroidism. But try telling your (under educated on the topic) Thyroid doc that. If they spent even one day with hypo, they would understand.

LAHs profile image
LAHs in reply to TSH110

Oh, and btw, you won't "die young", you will probably die at 90 instead of 95. And that's after 20 or more years in a state of hypothyroidism oblivion.

TSH110 profile image
TSH110 in reply to LAHs

I don’t rate my chances of making 90! 80 possibly.

What about risk of severe depression and other mental health conditions including suicide in those not adequately treated. Until I was treated with Liothyronine and Thyroxine I had a worsening quality of life and even considered having to go into residential care.

TSH110 profile image
TSH110 in reply to Slug_hater

That was me on T4 monotherapy very fat, extremely depressed and suicidal. It wasn’t living it was being a shadowy “thing”

Slug_hater profile image
Slug_hater in reply to TSH110


TSH110 profile image
TSH110 in reply to Slug_hater

As soon as I started on just 1/4 of a grain of NDT it was as if the part of me that was missing suddenly, like the last piece in a jigsaw puzzle, went back into place and made me whole again. Colour returned and I felt three dimensional not the 2D nonentity with zero personality I had become on Levothyroxine. It got better and better as I titrated up until I felt well again. It was like a miracle.

Slug_hater profile image
Slug_hater in reply to TSH110

So pleased to hear that. Luckily I found a good NHS endocrinologist who put me on Liothyronine as well as Thyroxine and is happy for me to stay on it so luckily I get it free as live in England. He told me if GP insists on blood test they must refer results to him and they have a letter to that effect. He said GPs just go on TSH which is no good.

CaroleM-A profile image
CaroleM-A in reply to Slug_hater

Where are you in the UK? It’s become almost unheard of to get Liothyronine on the nhs now

Slug_hater profile image
Slug_hater in reply to CaroleM-A

Am in Yorkshire and saw endocrinologist in York. Been on T3 since Feb 2020. I realise I’m extremely lucky. He said he was allowed to put me on a 3 month trial as I fitted the criteria (don’t know what the are though). Blood tests after 9 months instead of 3 because of pandemic and was told they were spot on so could continue.

CaroleM-A profile image
CaroleM-A in reply to Slug_hater

I’m very happy for you. One of the lucky ones!

TSH110 profile image
TSH110 in reply to Slug_hater

I Lucky you. Just saw the endo location, I regret leaving York even more now!

FancyPants54 profile image
FancyPants54 in reply to TSH110

God yes, colour has become invisible or dull. I spend so much free time using coloured pencils or paint trying to put some colour back into my life. It only works on the paper in front of me. I can fail to notice the most beautiful of blue sky or green fields. I used to glory in them. I can't cope with dull days at all.

I'm so fat and full of water and misery. My life was so different before this.

Link for this paper :

It can be downloaded as a PDF file.

I looked up Petros Perros and found this link :

A comment from that link :

I got inspired into medicine through observing the impact of successful treatments on people’s lives and the misery brought onto those who are incurable.

So, witnessing misery from incurable illnesses encouraged him to go into medicine. But when he is the direct cause of misery by not trusting his hypothyroid patients to know what is best for them this is absolutely fine.

Hypothyroidism is incurable in a majority of cases (I think - I have no idea how many pregnant women develop hypothyroidism and recover from it after birth) - and yet he doesn't appear to trust the patients when they say they still have symptoms and want higher doses of thyroid hormone.

Another comment from the same link :

Are there any controversies in your practice area?

Some decades ago, we thought that we had solved the problem of thyroid hormone replacement. Yet, some patients remain dissatisfied, seek alternatives, and have recently launched a war against “conventional” endocrinologists. Unfortunately this is exacerbated by self-appointed experts from the dark alleys of alternative medicine, who exploit human suffering and desperation. However, on the bright side of things, this controversy has raised some valid research questions that are answerable by scientific investigation, and the new knowledge gained from it will help resolve some of these issues.

I'm shocked that he thought thyroid hormone replacement was "solved" some decades ago. The only reason (that I can think of) that he can have thought that is because women were told things in the consulting room (e.g. this is normal, nobody else has any problems with Levo, no there aren't any other treatments other than Levo...) that made them believe that they were the only person suffering. With the advent of the internet and forums like this one those huge lies doctors told patients were revealed, and doctors don't like it.

Endocrinologists and doctors dish out insulin to diabetics for them to use as and when they need it. Insulin can be deadly if misused. But thyroid hormones aren't deadly based on data from the Yellow Card system in the UK.

I wonder how he copes with patients with central hypothyroidism? I doubt he can diagnose it, given his above opinion, or he will massively under-prescribe for it.

What I also wonder about is what these people with thyroid disease and a below range TSH (that he has studied) actually die of.

According to the Yellow Card system maintained by the MHRA :

There have been 21 deaths blamed on Levothyroxine since the yellow card system started in 1967. That is roughly one every two and a half years.

There have been zero deaths attributed to liothyronine since 1967.

There have been zero deaths attributed to NDT since 1967.

So where has he got his death info from?

TSH110 profile image
TSH110 in reply to humanbean

He’s a psychopath and a control freak. Perhaps he refers to a time when NDT was the only treatment and dosage was done on lack of symptoms when he says it was solved. It’s gone rapidly downhill since then for at least 30% of us! They die happy I’d say. That’s very interesting about the different thyroid hormones and the deaths they have caused - it really doesn’t tally with his claims of them killing 28 millions of people.

Heart patients who need new valve aortas etc can choose between synthetic and pig parts but we are denied NDT the closest thing we can get to what our own thyroid once made and forced on to just one hormone the thyroid makes - how could any intelligent person think it better to underdose on just one thyroid hormone? He needs his head examining and should be banned from pedalling that pseudo scientific clap trap dressed up as quality research - it’s a load of prejudiced garbage

LindaC profile image
LindaC in reply to TSH110

I've tried to load my gallery of non-thyroid and hypothyroid photos... will keep on trying - they're in a different format...

Despite, 2003 TSH @ 4.56 (0.14 within 4.7 range) + 2007 @ 4.59 (0.11) respectively + heart/weight issues, ill + several GP visits, I was not informed of those #’s. TV's Dr Chris made clear that we must keep on pushing if x, y + z symptoms... I did, only to be Written off 2008/09 by two local #s-led endos (TSH 2.8, then 3.8... hmm - If you saw what I looked like at that time!). Finally diagnosed Feb 2010, by a virologist, MD [Cum Laude], DSc, FRCOG, FRCPath, using clinical judgement/history/exam + 2009 TSH 3.8 accounted for. Dx again, May 2010, Guys MD, studied under/followed ‘Hypothyroid Luminaries’ said, “Need T3 for life” and provided source. (No doubt of Dr S dx, I was looking to reduce my years of supplements accrued to try to 'fix myself',in the absence of no medical relief! Dr P added two more :-) )

GP readily accepted Feb 2010 dx. Levo made me ill = clearly not in need of much > T4. After private ‘trial’, NHS funded imported Armour IRO 5+ years. So after doing well on NDT (T4 effects tolerated for what was gotten from T3) in 2011/2012, began using small doses of Liothyronine [T3], long advised by Dr P, then over time increasing it, I did well on both NDT, then much more on T3. Jan 2015: freezing shins/punch drunk/uncoordinated/ worst fatigue ever, so v ill; the being the only reason for wanting to see an endo.

Mid-2015 saw another endo, lauding himself on the EU stage said I’d “NEVER BEEN HYPOTHYROID, to reduce NDT/T3 + then stop altogether. Foolishly, but so ill, I tried until low HR was again jerking me out of sleep. Endo said, “Try Neurology”! Challenging his attitudes (after a 70 min. gaslighting call to my home to ‘talk me round’) and writing to express my disgust at his conduct, I was then faced with disparaging GP referrals. Medics were being told that I had, “Self-diagnosed + self-medicated” because I, of course, continued with the advice from Dr P; the accepted Dr S diagnosis + NHS funding of NDT is clearly there in my M Records in B/W!? Growing health issues since then, not really taken seriously. These people simply don't give x2 F's, not sure where I'd be without Dr S and Dr P - wouldn't give 10 cents for the rest of this lot combined. I certainly know who has exploited me!

TSH110 profile image
TSH110 in reply to LindaC

That’s awful. Have you read any of Dr Tanya Smith’s blog posts? She had awful trouble getting a diagnosis and ended up having to take T3 only as nothing else restored her health. I am lucky NDT suits me.

LindaC profile image
LindaC in reply to TSH110

Yes, I have read some - dreadful, disguised [or not so] misogyny at its worst. Yes, despite the predominant T4, I did so well on Armour... needed to up, brick wall from medicine. Great that it suits you :-)

And what about those patients who simply 'believe' them... accept what they're saying? Met someone a few years back, coming under the elderly classification, who was having Levo removed DUE TO AGE, when surely to function it's needed all the more. All this lady wanted to do was to be able to 'care for her ailing husband', let alone herself.

TSH110 profile image
TSH110 in reply to LindaC

This is what I fear that they will remove thyroid hormone therapy simply on the grounds of age it’s nothing short of eugenics. That poor woman I hope she fought the attempt off and got the medication she needed.

LindaC profile image
LindaC in reply to TSH110

I don't think she did. And yes, nothing short of eugenics... oh this has been mooted for a while, even saying it could be dangerous for the elderly! Alas, many elder people [and younger] fear 'authority', whereas I had a grandmother who 'feared no one and certainly no man' 😅... best legacy I could ever have dreamed of (strength of an ox + the b*lls of a lion). A price is generally paid for that but nothing is more significant in this life than 'owning yourself'.

Owning self, well as far as possible, eh?
TSH110 profile image
TSH110 in reply to LindaC

Your mum sounds amazing. I’m not one to be cowed so I would certainly refuse to go along with what she had done to her. I presume it probably killed her

LindaC profile image
LindaC in reply to TSH110

No, it was it my Grandmother - my mother pretty much [not wholly] went along with expectation... never my paternal G'mother. What a woman! No, you don't seem as if you are one to be cowed. Yes, she may well have gone by now or be in a very bad way. 😓

TSH110 profile image
TSH110 in reply to LindaC

Sorry I should have read your comments more carefully! I think jumping to conclusions goes with the territory of hypothyroidism 🙄 they say my paternal grandma was a formidable woman I am supposed to look just like her, my maternal grandma was pretty scary she was only 4 foot 8 but could put the fear of god into anyone she had a firey temper. It’s through her that the multitude of thyroid problems that have afflicted my generation, came.

That poor woman. Criminal.

LindaC profile image
LindaC in reply to TSH110

Hey, that's fine, easy to do - yes, your grandma sounds formidable! Suppose they had to be in those times, unless prepared to put up with...

Hypothyroidism in family - my paternal G'mother was certainly hypothyroid - as were her sisters - and there's a strange metabolic issue with most family members... it escaped me, until it didn't! I've beaten in now though! Their mother [my GG-mother] died around 60 yrs old, treated as if she had dementia yet was filled with fluid and it took a two-seater sofa to sit her - no ££ in war-time for excessive eating! 😓😪 Likely myxedema madness (first described in the literature in1949) poor woman died in 1950, before I was born. Dreadful but we're going back and back and... unless someone stops 'them'. 👺👽💩

LindaC profile image
LindaC in reply to humanbean

Totally agree with your post - this is utter madness.

2016 Letterhead to endo... because this is what we're increasingly faced with.
TSH110 profile image
TSH110 in reply to LindaC

Very good but scary as it’s too close to the truth.

I saw Dr Perros privately 15 years ago really struggling with my previous year’s hypothyroid diagnosis: on 150 levo a TSH of 1.2, FT4 55% in range and FT3 3.81% in range. I had had to go on sick leave for 3 months, then give up a teaching career as just couldn’t cope mentally or physically anymore. Yet all that was said to be wrong might have been diabetic or sleep apnoea related not hypothyroid! 12 years later still with problems and mounting history of ailments that have a high degree of relationship to hypothyroidism ( from 6 months without sense of smell, bile duct stones, fibromyalgia, never mind hair loss, brain fog, gaining weight etc) I felt obliged to go down DIY route with use of T3, meanwhile GPs ( more noticeably this last year or so) insist that TSH is too low, totally ignoring that FT3 is low too and I have much pain etc!

LindaC profile image
LindaC in reply to Judithdalston

That sounds dreadful. :-( Were you helped at all?

With a Free T3 less than 4% of the way through the range this is what one would expect. You should have been given some T3 in addition to your Levo.

LindaC profile image
LindaC in reply to humanbean

Oh, he's certainly not into T3 or NDT...

TSH110 profile image
TSH110 in reply to Judithdalston

He’s as bad in practice as he is in theory then. What a monster.

As for the assertion "ample evidence suggests that combination treatment (L-T4 with L-T3) is no more effective than L-T4 alone," I have learned that you can "prove" anything you want by manipulating the parameters of your study. Example: You want to assert that a treatment is ineffective, so you make sure the dosage is too low. Or you are not wise enough to realize the dosage you are giving is too low and come to an inaccurate conclusion. Another way to manipulate is via how you select your study subjects. Example: Include lots of people who are good converters and then point out that they had no improvement in their health.

LindaC profile image
LindaC in reply to vocalEK

Snake oil has moved on... don't you know, to smoke and mirrors!

Occam would slit them with his razor... lunacy! Still, this has long been on the cards... along with their NDT and T3 shenanigans... 👺☠️

"New evidence obtained by two independent large population studies over the past two years has shown ...."

So ...This paper cherry pick's it's evidence from 2 recent papers.

Well, two can play at that game ..and i used to drive a 'cherry-picker' here are some things i cherry picked from one of papers they refer to ;

actually shows a higher risk of mortality when TSH is between 4 and 10, (hazard ratio 1.29)

than it does when TSH is below 0.1, (hazard ratio 1.18)

So if (according to current NICE guidelines) it's perfectly acceptable to leave people with a death risk of 1.29 while their TSH is 5/6/7/8/9 for MANY YEARS before treating them ... then what EXACTLY is their problem with leaving people with a lower death risk of 1.18 if their TSH goes below 0.1 while on treatment ?

"RESULTS 162 369 patients with hypothyroidism and 863 072 TSH measurements were included in the analysis. Compared with the reference TSH category (2-2.5 mIU/L), risk of ischaemic heart disease and heart failure increased at high TSH concentrations (>10 mIU/L) (hazard ratio 1.18 (~) and 1.42 (~) respectively).

A protective effect for heart failure was seen at low TSH concentrations (hazard ratio 0.79 (~) for TSH <0.1 mIU/L and 0.76 (~) for 0.1-0.4 mIU/L).

Increased mortality was observed in both the lowest and highest TSH categories

(hazard ratio 1.18 (~) ,..................... 1.29 (~) ,......... and 2.21 (~)

........ for TSH <0.1 mIU/L, (~) 4-10 mIU/L, (~) and >10 mIU/L.

An increase in the risk of fragility fractures was observed in patients in the highest TSH category (>10 mIU/L) hazard ratio 1.15 (~)

CONCLUSIONS In patients with a diagnosis of hypothyroidism, no evidence was found to suggest a clinically meaningful difference in the pattern of long term health outcomes (all cause mortality, atrial fibrillation, ischaemic heart disease, heart failure, stroke/transient ischaemic attack, fractures) when TSH concentrations were within recommended normal limits. Evidence was found for adverse health outcomes when TSH concentration is outside this range, particularly above the upper reference value."

It also says...

" At low TSH concentrations (<0.4 mIU/L), no association with ischaemic heart disease or stroke/transient ischaemic attack was present, but we observed a protective effect for heart failure (hazard ratio 0.79 (..) for TSH <0.1 mIU/L and 0.76 ( ..) for 0.1-0.4 mIU/L)."

"In the adjusted model, we observed no association between risk of atrial fibrillation and the lowest or highest TSH categories. However, we found a marginal protective effect at TSH concentrations of 0.1-0.4 mIU/L (hazard ratio 0.86"

"TSH below 0.4 mIU/L was protective for atrial fibrillation in women, and TSH 0.1-0.4 mIU/L was protective for atrial fibrillation in patients aged 65 years or under."

"In the adjusted model, we found no association between low or high TSH and risk of all fractures; however, we observed an increase in risk of fragility fractures at TSH concentrations above 10 mIU/L "

So... Mr's Perros, Nirantharakumar & Hegedus..... MY paper reviewing these results, would say

.... " New evidence obtained by two independent large population studies over the past two years has shown that mortality risk for hypothyroid patients is greater if left untreated until TSH reaches 10, than it is if TSH falls below 0.1 on treatment,

This, combined with the protective effects (from heart failure) found at TSH <0.1 , and the protective effects (from heart failure AND atrial fibrillation) found at TSH 0.1 - 0.4 , suggests that we should consider limiting the amount of years spent at TSH between 4-10, in order to reduce unnecessary DEATHS, and we should reconsider our current advice about "risks of below range TSH" if the patient reports quality of LIFE is improved at this level."

.....and who's to say MY chosen 'bowl of cherries' is any less truthful than yours ?

(And as for the introduction of "very sensitive assay's for measuring TSH".. well, it might be "very sensitive" .... i could give any idiot a set of feeler gauges to measure the gap in my spark plugs... but if he doesn't understand how to adjust the gap to make MY engine run better, then it really doesn't matter how accurate the feeler gauges are......)

TSH110 profile image
TSH110 in reply to tattybogle

👏🏽👏🏽👏🏽 Brilliantly said tatt! Their cherries are darn sour but yours are the sweetest of the sweet. I bet you drove that cherry picker second to none they are a serious bit of kit


I’d like to know where they get this “ample evidence that combination of T4/T3 is no more effective than T4 alone” Did they test 7 very elderly people in a nursing home like the NICE Committee did for their “evidence” for the new NICE Guidelines ?

also ... since when was "ample" a suitably scientific term for describing the quality of evidence included in 'evidence based medicine' ?

Surly 'ample' is more suited to discussing the size of portions of pudding.

TSH110 profile image
TSH110 in reply to tattybogle

Spotted dicks?

Are you familiar with Lorraine Cleaver's Thyroid Petition? The medics provided "evidence" of the papers they thought supported their position on T3 in a letter in response to the petition. You can read that letter in the second link I gave in this post :

The link to the "evidence" is :

Just keep scrolling to see the abstracts of the papers.

Diogenes wrote a reply just after mine (the healthunlocked link above) which explains more of what is going on.

Thanks for the links- I’ll take a look

LindaC profile image
LindaC in reply to humanbean

Dr John Lowe sent rebuttal papers - excellent - to the 'UK Thyroid Boys' - ignored!

SlowDragon profile image

Or you read other research which says something entirely different, patients with a serum TSH below the reference range, but not suppressed (0.04–0.4 mU/liter), had no increased risk of cardiovascular disease, dysrhythmias, or fractures. It is unfortunate that we did not have access to serum free T4 concentrations in these patients to ascertain whether they were above or within the laboratory reference range. However, our data indicate that it may be safe for patients to be on a dose of T4 that results in a low serum TSH concentration, as long as it is not suppressed at less than 0.03 mU/liter. Many patients report that they prefer such T4 doses (9, 10). Figure 2 indicates that the best outcomes appear to be associated with having a TSH within the lower end of the reference range.

Over replacement with thyroxine?

There is some concern that administering thyroxine in a dose which suppresses serum TSH may provoke significant cardiovascular problems, including abnormal ventricular diastolic relaxation, a reduced exercise capacity, an increase in mean basal heart rate, and atrial premature contractions.12 Apart from an increase in left ventricular mass index within the normal range, these observations have not been verified.13 Moreover, there is no evidence, despite the findings of the Framingham study, that a suppressed serum TSH concentration in a patient taking thyroxine in whom serum T3 is unequivocally normal is a risk factor for atrial fibrillation.

Low TSH no heart issues

In summary, patients on long-term T4 with either an increased serum TSH (>4 mU/liter) or a suppressed TSH (<0.03 mU/liter) have an increased risk of cardiovascular disease, dysrhythmias, and fractures when compared with patients with a TSH within the laboratory reference range. Patients with a low, but not suppressed, TSH (0.04–0.4 mU/liter) had no increased risk of these outcomes in this study.

I suppose I should ask why, if some patients find combination therapy or T3 better than T4 alone, this phenomenon is not real, but in their eyes, a placebo effect. The logic of the paper is completely unclear, when they admit some patients don't like T4 only but don't supply a sensible reason other than the above.

How about they consider even economic 'Value of Life' stood up against this!?

Thanks for the information.

I managed to find a female GP who has underactive thyroid too so she has been very helpful.

I'm interested to know if anyone has elevated cholesterol or cardio issues with this disease?

How are the risks of mortality increased do they suggest? My levels have been mostly on the lower side of the normal range but occasionally for about 6 months my levels drop for no reason. then return to normal... for no reason. Strange these hormones

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