I'm doing an internship in human rights law and we have the opportunity to write an article to be circulated in the organisation's newsletter. I am thinking of writing an article about the human rights implications of improperly treated hypothyroidism, particularly the lack of access to liothyronine. My initial ideas are to touch upon the following points:
Introduction to the human right to health
Basic overview of thyroid disease, its symptoms, causes and who it affects (mostly women)
How it's diagnosed and problems with standard treatment (levothyroxine)
Why doctors stick to prescribing levothyroxine despite many patients feeling unwell on it (medical and economic justifications)
Why liothyronine is not prescribed (price inflation etc) even when there is an established clinical need
Other schools of thought in treating hypothyroidism and how other countries approach it
How improper diagnosis, treatment and lack of access to liothyronine affects patients, that it disproportionately affects women and how this is a human rights violation
I would massively appreciate if any of you could share any academic papers or information you have on the above topics and whether you think there is anything else I should include. Many thanks!!
Zara
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Zazbag
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You have to open the second link. The part of it that I was interested in was the right hand half of Table 3.
Note that the UK won't diagnose hypothyroidism in many cases until TSH is > 10, and some doctors have been quoted as saying that it shouldn't be diagnosed until TSH is > 20. But as the info on the link to the graph says "The most common value, or Mode, is at 1.25 " and the graph doesn't go above a TSH level of 6.
2) Note that not everyone is able to produce adequate levels of TSH (Thyroid Stimulating Hormone) to stimulate the thyroid, due to problems with their pituitary or (less commonly) with their hypothalamus. This condition is known as Central Hypothyroidism and many doctors refuse to even consider that the condition exists or that the patient sitting in front of them might have it. In fact they probably don't even know what their patients Free T4 and Free T3 are because they are never tested by the labs when the TSH is within range. When someone with this condition is treated they are at risk of being permanently under-treated (if they get treatment at all) due to the reliance on TSH because many doctors don't know that TSH isn't perfect and don't know any other way of managing hypothyroidism other than via TSH.
Personal anecdote : I think I may have this condition. I was first told in the early 1990s by an IVF clinic that my thyroid was "borderline underactive". I was given my first prescription for Levo 23 years later, with great reluctance from the doctor because as far as she was concerned I suffered with subclinical hypothyroidism and it didn't need treating. I have since seen other members quote Free T4 and Free T3 results similar to mine were before treatment and they had a TSH of between 10 and 30. My TSH has never been above about 5.7 or 5.8. An accidental discovery in an MRI scan showed my pituitary is squashed in one direction and stretched in another. (The MRI scan was being used to look for something else.) Note that during the time I was untreated for low levels of thyroid hormones and repeatedly looked for help I was always tarred with the "drug-seeker" label and once labelled, it becomes a life sentence with little or no chance of an appeal succeeding.
3) Why liothyronine is not prescribed (price inflation etc) even when there is an established clinical need
Note that price inflation is exclusively a UK phenomenon. Perfectly good T3 can be bought (in person) from Turkey for 2 or 3 euros for a packet apparently - although I've never tried this, and online can be bought for about £10 - £11 per hundred (although I may be a tad out of date with that - I haven't bought any for quite a while).
Germany and France have their own T3 products which are much cheaper than the ones produced for the UK market, and as far as I know they prescribe them too.
4) Note also that doctors tell patients that wanting T3 is like wanting cocaine, heroin or speed because it gives you more energy to get your housework done (believe it or not - the misogyny is jaw-dropping). They ignore the fact that every human alive has T3 flowing in their veins because it is an essential hormone, but seem not to care whether we have enough of it.
5) There are doctors who think T3 will kill us but this is not true :
7) Doctors appear to much prefer that patients take anti-depressants rather than thyroid hormones for as long as possible because they really do think that thyroid hormones are harmful. However, the risks associated with anti-depressants are far in excess of those associated with taking thyroid hormones.
8) Many doctors appear to be unaware that low levels of thyroid hormones have a major impact on the body's ability to extract nutrients from food. As a result many people who come to this forum are often low in one or more of the following : vitamin B12, folate, vitamin D, ferritin, iron, zinc, selenium, and each of these low nutrients have their own dangers associated with them in terms of impact on health.
9) As is the case with many diseases that afflict women exclusively or more than men, it is considered to be a minor disease that really doesn't need that much fuss made over it. I have many health problems, almost all of which, with hindsight, I now blame on my pituitary and low thyroid hormone levels. I stopped working at a young age and have been supported by my husband ever since. I'm sure there are many women this has happened to.
Germany and France have their own T3 products which are much cheaper than the ones produced for the UK market, and as far as I know they prescribe them too.
I don't know about Germany, but although France has its own brand of T3, the majority of French doctors are reluctant to prescribe it - or even test FT3 - because they don't know what it is or what it does. And that is straight from the horse's mouth because they are not ashamed to admit it! Sometimes, that has worked in my favour because they prescribed it because they didn't know what it was! One top endo told me 'you can have it if you like, but it won't do you any good'.
I don't know if any of that is relevant to the subject in hand, but it does go to show that thyroid-related ignorance is a universal problem, not just a UK phenomena.
Well greygoose, there won't be many of us reading that who will be surprised will there?
So most of Europe have gone down the same route.
America are also going, or have gone down that road more, lately haven't they? They are seeing shortages of NDT aren't they??
Is it for the same reason, synthetic T4 cheap, as chips, sterile, is a much better med for low thyroid patients??
I am surprised that French and German hypo patients haven't been screaming about it by now, but then, it is understandable, those with a problem with Levo won't have the strength to fight for better treatment will they??
The surprise is that they so readily admit they know nothing about it. Doctors in the UK pretend they know everything about everything, in my experience.
My Tiromel is manufactured in Turkey, I bought 7 boxes of Tiromel 25mcg and the shipping a few weeks ago. I paid just over £85, including shipping by air, it got here in 5 days from HongKong and I paid for it through my current account via a phone call. No tax to get it into the country either and Royal Mail delivered it and even sent me an email telling me that it had arrived in the country. I have been buying it that way for a year. It will last me for months. But the Government was paying, was it £300 for a box??? I never could understand that.
Not sure if this will be any help, but as an example of the consequences of what they DON'T do:~They didn't test my TSH when i had crippling fatigue in pregnancy.
~They didn't test it when went a bit nuts a few months after.
~They finally tested it 4 years later by which time i'd had to alter my life/work prospects significantly.
Two years later when levo hadn't fully restored health and post exertional malaise joined in the party;
~They didn't inform me of the (then available) option to try combination T3 treatment .. they said it must be 'some thing else' cos my thyroid was 'treated'.
17 yrs later i learned there was an untried option that might just have allowed me to continue along my previous rosy looking path. Which would have been a self supporting and 'carbon neutral' lifestyle .... Instead, i took up a much needed council house and chucked shit loads of CO'2 into the atmosphere out of my gas boiler, and barely earned enough money to pay tax most years.
None of us have a 'right' achieve what we wanted to ... shit happens .... but i did surely have a right to be tested for a common disease at the point in time it's most likely to happen, and i surely had a right to be informed of the NHS options if treatment 'A' didn't work very well.
I’d love to know what my TSH was during pregnancy. I too had crippling fatigue, and post-birth felt absolutely dreadful for months (I’m not sure I ever really got back to “normal” actually). Alas, my notes from that time were lost in transit (we moved across the country when my son was 4 and they never made it to my new surgery). So I’ll never know.
As a self medicator, I sometimes wonder whether I could get away with saying I *was* diagnosed with sub-clinical hypothyroidism 22 years ago but was refused medication. That diagnosis has been denied to me subsequently because my TSH wouldn’t go above 4 and I don’t have antibodies.
So while I think it’s a great topic for “human rights”, this is more than whether or not liothyronine is prescribed appropriately. Quite often, many of us can’t even get levothyroxine prescribed. Doctors were bizarrely happy to prescribe antidepressants or to tell me I needed to exercise more and eat less (believe me, I’d have loved to exercise more but just getting through a working day left me exhausted. As for eating less, that just leaves me even more tired. I can do it for a fortnight or so and then crash ).
Zazbag - I’m virtually positive that if I’d presented the same symptoms to my doctor and I’d been male, I’d have been listened to.
It is unbelievable that they don’t test - do a thyroid panel in pregnancy -could have saved me like you having to go through major life changing health crisis afterwards.Why do they not test this in pregnancy when it is totally known and accepted that the pregnancy can alter thyroid function.
they said it must be 'some thing else' cos my thyroid was 'treated'.
This has been said to me throughout life in many contexts.
"It can't be X because X is or has been treated. It must be something else."
In my case the "something else" has never been looked for, and after hearing it a few times I realise it is just a sentence they use when they want you to leave their office and, preferably, never return. Because the one thing they ain't going to do is find the "something else". If they do anything it will be to prescribe anti-depressants, or tell you to lose weight and do some exercise.
Surprised Big Pharma haven't marketed a pill specifically for 'something else'.. they'd make a fortune.Come to think of it ... shouldn't there be some NICE guidelines for 'something else', since its so commonly 'diagnosed ' by GP's
And isn't that a human rights issue??? I was lucky, mine came along well after I had my children. But I started the first part of my Midwifery training in 1972 I think it was. My second child came along and prevented me from doing the second part anyway and she was born in December 1973 and I was 21 then.
But we never had any mention of patients having thyroid problems at all, whether hypo or hyper.
The only time I heard it discussed was on a postnatal ward and we had a new mum in who had a goitre and staring eyes and the sister talked a little about that patient with us, while making beds and teaching mum's to bath their baby when they got home etc (do they do that these days) but if I am correct, she would have even hyperthyroid, not low??
If it wasn't about pregnancy, delivery or postnatal, we weren't told of it. I suppose endos would have cared for mum's and babies.
Very pleased to hear of your proposed article. 👍 Which publication do you have in mind?
I concur with all of Humanbean's points. I don't have time to add my own perspective just now, unfortunately. However, there are valuable references at the rear of Doing Harm by Maya Dusenbery, an American medical journalist. In her chapter on the disadvantages faced by women with autoimmune conditions, she has a short section on the diagnosis and treatment of hypothyroidism. Her perspective is mainly US, though from memory she covers a few topics relating to the UK.
Anything you can do to highlight this disgusting situation that multitudes of women particularly find themselves in, is very much appreciated. My personal diagnosis was easy - I had a goitre on my neck 6 months after my baby was born. TSH of 75. However, my GP told me to take levothyroxine (T4) and get on with my life. I never felt better, I had deep depression, high anxiety, horrendous sinus problems, pains all over my body, migraines and many more terrible symptoms.
Over a 15 year period I was told by many GP's in a variety of towns, that I was adequately medicated for my hypothyroidism, and should be on anti depressants. I just took them, but all my symptoms were still there. I had a stint in a psychiatric unit as I felt I was going crazy. No psychiatrist ever questioned my thyroid medication or dosage. Then I managed to find an amazing private doctor who told me I had adrenal insufficiency and I should be taking T3 hormone tablets only. He prescribed 25mcg of T3 a day and left me on that dose. He disappeared thanks to the GMC, GP's had no idea what T3 tablets were or the reason they are vital for people like myself who have a mutated thyroid gene. (discovered about 4 years ago by doing a genetic test).
Having got my medical records about 5 years ago, going right back to when I was first diagnosed hypothyroid, I see that my TSH level all through a 30 + year period was anywhere between 8 and 10. I doubt the GP's ever tested my T3 levels. During the decades I was under medicated, I came across many endocrinologists who had absolutely no idea what was wrong with me, had no clue about the use of T3, and some of those classed themselves as lecturers on the subject !!
Due to being so under medicated for decades, I was unable to work, lost my marriage, lost my house, my poor son had a traumatic childhood due to a bad tempered, constantly ill mother, and I became a hermit.
Only after finding Thyroid UK and this forum did I find the knowledge, increased my T3 medication to 45mcg a day, and am more normal now than I was as a child and teenager.
I made enquiries with law firms and pro bono lawyers, intent on suing for loss of earnings, loss of my home, my son's disheveled childhood, but they all told me I was "out of time". I was in such a disastrous state, I have no idea how they can consider that the clock started ticking from the date I was told I needed T3. I quit as I didn't have the strength or emotional ability to fight.
The lesson from my story is that every doctor, from GP up to professor of endocrinology, also psychiatrists, need to be trained to fully comprehend every aspect of hypothyroidism.
So sorry to hear this. So angry really that so many women and men suffer such appalling treatment in what is a common problem. Shocking. These stories -yours, mine - our stories need to be heard.
I don't know whether this will be helpful to your background research, but here is an article in the BMJ which helps to explain common misunderstandings by doctors of routine lab blood tests.
One other thing it might be interesting for you to touch on is the availability of NHS endo appointments, both in "normal" times and the pandemic, given that lio is endo-only - if you can find enough data to be more than just anecdotal [not whether the endos were competent or had any interest in thyroid, but just how long the process actually took]
FWIW in my case, I had "abnormal" blood results in tests done one year in April (low TSH? over-range FT4? one or both); reductions in levo didn't work in changing the blood results but testing of FT3 that summer showed poor conversion, so I had a dexa scan in the autumn and a first referral to an endo initiated - so about 6 months after the "wrong" blood results. I then saw a locum endo 10 weeks later, in December, and we had a nice chat - but absolutely nothing happened after that appointment for almost a whole year: no change in prescription, no other blood tests, nothing. I then saw a non-locum endo about 50 weeks later, the following December and got the lio prescription I needed .... so from first "wrong" blood results to getting to see an endo who actually did anything took 20 months
A really good point to. Such a long wait like your asking to see Oz- the Wizard of…
Don't forget that it's not only women who suffer from disgusting treatment from the nhsPlease emphasise that patients MUST be told about the existence of T3, either as Liothyronine or a part of NDT, if doctors believe it could do them some good even if it is banned, recommended to not be prescribed.
This is set out in the following document from the GMC:
"Consent - patients and doctors making decisions together";
part 2 "making decisions about investigations and treatment, Sharing information and discussing treatment options" states:
"(9) You MUST give patients the information they want or need about:
(l) any treatments that you believe have greater potential benefit for the patient than those you or your organisation can offer."
In my area the CCG refuses point blank to prescribe NDT on a NHS prescription but also refers a few patients, if they complain enough, to a endocrine SURGEON in an NHS hospital who does prescribe NDT on a private prescription.
BUT no GP or endocrinologist is prepared to tell you about it voluntarily.
Pure and simple HYPOCRISY that condemns thousands of patients to a lifetime of HELL, like I suffered for 8 years!
In response to the “you must give the patient information of other remedies” - when I told my GP that I was going to try NDT, he asked me what it was !!!
I have Graves so opposite of hypothyroidism. I am being asked to have a permanent fix to my over the limit T4 and T3. I live in New Zealand and we do not prescribe T3 or NDT. So if u have your thyroid removed and require T3 too bad.. Work that out? Insanity
The options here are RAI or surgery for a permanent solution. AT drugs are carbimazole or PTU and u can do block only or block and replace with levothyroxine. No T3 prescriptions or NDT either. It’s T4 only. I was told this by my GP with whom I discussed my options. I’m only block only but my blood is weird. TSH 0.01T4 7.0 range 10-22
T3 6.4 range 2.0-6.0
I am being asked to do block and replace. I would not consider RAI or surgery due to the poor after care of drugs. What happens if u r the minority that need T3 or NDT. I presume and I would love to be proved wrong that the Endo brushes his or her hands and says we have done our job it’s a “YOU PROBLEM”. Goodbye
That sounds likely, doesn't it? Are you tempted to go it alone and buy in your own meds? Your problem is so much more complicated than mine though. I wouldn't know where to start if I had your problems.
I have decided for now to stay on AT drugs until such time as I have to make a definite decision. By that I mean if my liver was in trouble because of AT drugs then I would go for surgery. Right now I have to decide if I want to stay on block only. That comes with two choices. 1. Get T4 under range so T3 goes into range or 2. Get T4 into range and have T3 over range. 3. Take an appt at the hospital to talk about block and replace and what that means. I was told that the Endo wants to totally suppress my T3 and T4 with PTU before adding in levothyroxine. What I don’t know is at what levels my T3 and T4 will be before the levothyroxine is added in. More importantly is how will I function emotionally and physically in this transition phase as I hold down a job. I can’t afford to not work as like most people have a mortgage.
Yes, what a horrendous decision that you have to make. I hope you can get well very soon and good luck to you NIKEGIRL. I hope you get there very soon.
I have PTSD and am currently working through this with a psychologist. The PTSD is from doctors so I have lost all faith and trust in doctors. This is the biggest barrier to my own recovery. I accept that I need professional help but so far my GP and Endo have not done a referral for a psychologist so I pay privately every week £95. It takes all my savings but I need to work through the grieving I have. I don’t know that I will trust a dr at the end of the process. I accept that my non ability to trust will affect my ability to make a good decision. But I also feel I am in a health system that does not care about me. On my good days I get on with it. On my bad days I feel without hope. It’s tough. I don’t think it is any easier on the hypo end of the spectrum. Each of us are struggling and there seems little compassion and understanding. I struggle with that. I understand that drs are extremely stressed but that does not give drs the right to be aggressive in how they talk to us. Nor pressurise people into permanent solutions to get patient wait lists down nor discuss alternative drug options open to the patient so that they can make an informed choice. I find my process retraumatising. I go to an endo appt and I have a literal emotional and physical breakdown. I get told it’s all part of Graves when In actual facts it’s the PTSD and the re exposure to hospitals and drs causing the physical and emotional symptoms. And still no referral for a psychologist. So I am labelled difficult adding to the trauma. My regular GP has left our surgery for 6 months and I am finding his absence hard. He was a nice guy. We had debates over treatment but he was kind enough to listen and understand. Now I feel alone again. A new dr for 6 months and now the hospital want to discuss block and replace. I always say I cannot promise anyone anything. That way I don’t let people down. I’m not a liar but I am struggling. Drs just don’t get it and because of that I am non complaint and am difficult.
NIKEGIRL , I have speedily read through your profile. So sorry you have had so much sh*t over the last few years. Been there. You mentioned that your TSH was 4. Was that definitely before you started on carbimazole? When I presented to GP with a neck goitre, (1981) the GP immediately said I was hyperthyroid. In fact I was extremely hypo with a TSH of 75, so his knowledge was zilch. Is the doctor who diagnosed you definitely correct? Regarding PTSD, I too had that for decades. I found that the correct dose of T3 plus being extremely vigilant about vitamins & minerals (particularly folate, ferratin, Vit D & Vit B12 & all the other B vitamins, & zinc) slowly got me out of the PTSD state. I personally didn't find psychologists or psychiatrists any help at all.
I don’t think my hyperthyroidism is any more difficult to deal with than your situation, just different ends of the same disease. Same drs or diabetes specialists.
Hi. R u asking me that if a person in New Zealand has thyroid cancer and has their thyroid removed would they receive no T3 treatment? I can’t answer that sorry. All I was told when talking with my GP about thyroid drugs was that New Zealand so not prescribe T3 or NDT if I chose to have a thyroidectomy
I want to sue my Health Board - or should it be the NHS or the Government - as I believe I am right in saying that my GP gets paid for treating me and he thinks T3 is an illegal drug. He has told me that he will never again speak to me about it.
I think it is a downright disgraceful that GP's know little about the thyroid generally, don't seem to understand Hashimoto's, or how Levo turns into T4. And hypothyroid patients can't get diagnosed because the NHS is pushing up the levels of hormones all the time, just to stop us being diagnosed!
I truly believe that they think it is a piffle game little illness. They are treating our symptoms and not our illness itself.
My current GP told me last year, when I told him I wanted to trial T3 that he never wanted me to say the words 'T Three' to him again, because it was an illegal drug!
I still wonder if he realises that every healthy individual in the world makes T 3 themselves, including GP's.
Med School isn't teaching them to look after the few - in the scheme of things - who can't get well with Levo alone, the one's who can convert T4 to T3, or who need NDT (and I blame the Pharmacy companies for that, much wants more my Nana told me and they definately do make a mint and are trying to out every other possible way of treating low thyroid EXCEPT levo.
I am appalled that I have been in trouble with my hypothyroid since diagnosis in 1997 and it has gradually got worse over time.
I am now 69 and my life has been totally wasted over those years because no GP could apparently help me here in Wales. In total I have had seen 5 different GP's here. None of them had a clue or would refer me to an Endo.
I would have been out of jail by now if I had shot the first one wouldn't I?? LoL
They had me on anti depressants for over 4 years, I was self harming, took overdoses and my marriage split up because of it - though I am not sorry now about that!
My weight gain got me to well over 15stones, I was looking at a size 22 clothing. When I woke up in the morning, I never knew from one day to another which size clothes I might need that day.
And that for a woman who had been 10 stone 3 pounds for most of my adult life, excepting when pregnant. No wonder I was suicidal!!
And yet my GP could look me in the eye and tell me that calories in have to be less than calories out. And if I didn't stop sitting on my backside watching soaps and eating cream cakes and finally accept that I was obese because it was my own fault I couldn't possibly hope to lose weight!
Even my family think I am quite crackers because if it was something diagnosed in 1997, the NHS would not have let me get so ill as I have been would they?? They just think I am around the bend!
Is this right, or just? Where are my human rights and every other person who has gone through the same thing?
And why can GP's all over the country who have no idea about treating anyone' s hypothyroid who can't get well with Levo - treat us?
Prescribe God knows what drugs and potions to eat like sweets, but not either T3 or NDT which most of us realise is what we actually need?
Why are we sent to Endo's who are Diabetes specialists and would know a thyroid if it hit him in the face?
This is totally wrong, there doesn't seem to be any new drugs coming along in the pipeline that might give us some hope, there seems to be nothing, no future for hypo patients.
Diabetes - Type 1 and 2 - and Cardiac diseases among many others, seem to be a lot better off than hypothyroid patients, are in that respect - though I might have to be corrected - why are we stuck with one synthetic thyroid hormone - Levo - and an awful lot of us could have done better with aspirin for all we know?
I am also Epileptic, the difference I have seen in treatment for Epilepsy has been vast since diagnosis in the 80's.
They have left us to die be degrees, because most GP's leave us to that fate.
I hope you can sock it to them Zazbag, because Hypothyroid seems to be the odd one out to me.
I want to sue my Health Board - or should it be the NHS or the Government - as I believe I am right in saying that my GP gets paid for treating me and he thinks T3 is an illegal drug. He has told me that he will never again speak to me about it.
All he has to do to find out the status of T3 is to look up the British National Formulary to find out it is licensed in the UK :
Yes I did tell him that but he isn't really 8nterested in learning about anything, all he wants to do is the everyday routine work.
He has bought up at least 3 near surgeries nearby as the GP's retired.
He is great at organising everyone, he would never forget to let me know when my blood tests were due and vaccinations etc, beyond that he is a complete waste of time and effort. Hi has the same sized surgery, there is only him, 2 nurse practice's and a part time GP as well as him. But the part time GP only works on Thursdays when the main GP is off, so that is at least 4 surgeries worth of patients in a very small building. He is in it for the money and that's all. Trouble is we don't have any choice now, there is only one other surgery now.
Anything unusual turns up and you are told to go to A&E, before you get near the surgery. It is disgraceful, but the Health Board let him do it, though they are now reaping the benefits, the complaints are pouring in.
How about the few doctors who did take lowthyroid seriously and yet were practically forced out of their jobs, Dr Lowe wasn't, although am I right in thinking that he went to the US because of it? Dr Durrant Peatfield, I saw him shortly after I was diagnosed, he used to arrange to see privately around the UK and he used thyroid patients homes to consult with the patients who were desperately in need of seeing a doctor who knew what was wrong with us. He was the only doctor who I have seen since 1997 who did the sit/stand blood pressure test on me, looking for adrenal problems wasn't it? (I can't remember much but I do remember standing up and he said yes! You have it!
Low Cortisol wasn't it? Or have I got that wrong?????
I went to see my GP who told me there was no such thing wrong with me and he didn't test for it either.
That was around the time when I gave up and just decided to keep taking the tablets and just shut up and try to forget about it, because I was driving myself and my family crackers with my search to try to get better.
There must be more doctors who have gone the same way and been pilloried for their efforts to treat hypothyroid patients.
It is absolutely disgraceful that Doctors who are trying to bring to the attention of the government or the NHS and the world generally what was wrong and yet they were ignored.
I would say that that sounds like the Pharmo companies to me.
I remember Dr Robert Atkins in his first book, which I read in the 70's, said that he was not believed in the main in the US about his high protein, high fat diet, because the sugar, cereal, flour and I suspect the arable farmers in the States etc were up in arms as they knew if Atkins Diet Revolution took off they would lose money.
Fair enough the diet has had to be tweaked a bit, but this is exactly what we as patients, have holding us back I think.
It is the big money generated by the Pharmaceutical companies, they have the money to buy their way into stifling doctors who tried to make a difference and quite a few politician's pockets would have been filled with quite a lot of money too and I think it is still going on.
Thyroid charities are rarely seen in charity things such as marathon or other sponsorship etc either are they? We seem to be the poor relation.
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