This latest blog from Tania goes deeply into the literature and arguments that TSH is not a safe or accurate diagnostic tool. It isn't that it is sensitive, but a measurement can be accurate but uninformative.
Can a normal TSH rule out thyroid disease?
BY THYROIDPATIENTSCA on JULY 17, 2022 • ( 0 )
If you are well-informed by current thyroid science, you already know the answer to the question in the title. “No. A normal TSH cannot rule out thyroid disease.” Since the 1990s, physicians have been taught to use simplistic category-based interpretations of TSH (and Free T4) as “in or out of range” to classify people as “euthyroid” or with degrees of “subclinical” or “overt” hypo- or hyperthyroidism. However, a recent scientific article asked a similar question in its title: “Does TSH Reliably Detect Hypothyroid Patients?” the answer was also “no.”
Thank you for bringing this to our attention. Sadly it is not the people on this forum who need to read these documents, informative though they are.
It is the GPs and Endocrinologists who hold our health and well-being in their hands who require some educating, they seem to be largely behind in their knowledge of thyroid disease especially when the patient does not present with the standard symptoms or blood test results i.e. very high TSH.
I have contemplated producing physical copies of, say, both the paper and Tania's document. Binding them. And sending an individual copy to each GP at my surgery. With a hand-written individual covering letter. (Switch to reader view and print to PDF - and Tania's article comes in around 41 pages.)
Knowing me, this is an idea which I'll never carry out. But I think we have to look at something beyond emails and links. And I see one element as being something that is directly and personally targeted.
Yes - Don't make contact with organisations. Do so with specific real humans who have real names.
"Dear Dr Jane Doe,
You might remember when I had an appointment with you last month?
I think the document I've attached might make it clear why I look at my thyroid testing as I do. Hope you find it as interesting as I did.
Yours etc."
Re-word as you see fit. Avoid (hopefully) antagonising. Try to engender some interest. Make the doctor feel that you are contacting them as human beings.
(I'm more than happy if anyone else adds a few suggestions. There are so many possibilities.)
If you have, say, four GPs at your surgery, write four letters. Each tailored to the individual doctor.
I’ve sent letters to my GP with links to diogenes papers. I can bet he hasn’t bothered to look at them and it would be a waste of paper and ink printing them out, they would probably end up in the bin 😟
But if just one GP in ten practices picks it up and reads, that could make quite an impact. One voice might sometimes be raised in practice meetings, in CCG and future ICS meetings.
And I think having links ios half the problem. They might need links. They might want links. As well as ignoring them as something to look at later - the to do so never arriving. A physical copy, with a hand-written letter, just might see some scan reading the front page and getting drawn in.
If only. Everything I’ve said and every link I’ve sent has fallen on deaf ears (or should that be blind eyes) ☹️ I get the feeling that “he’s the doctor and I’m only the patient”
'My' GP seems to be a big fish in the local 'GP training' pond ....and i have often wondered similar to you about using personally targeted information to engender some interest /progress.
However then i think about it again, and find the idea of any contact at with him a bit dangerous, since i'm (thankfully) being left well alone at the moment .... and i decide not to do it today .. (since 2020 )
They are all real endocrinologist but don’t know if they are friend or foe, by the law of averages I’d say more likely to be the latter but I will remove any who don’t deserve to be under that wave should relevant information be forthcoming!
I was shocked to see the named one has a greyhound - I didn’t have the heart to add it in under the calamity about to hit after all it’s not it’s fault who it’s master is and I guess no person is completely bad - at least he’s a dog lover.
Thanks for posting. I think the article misses some of the more basic reasons TSH is a very poor marker of thyroid status (and very good at detecting primary hypothyroidism in many cases).
1. it's quite possible to have concurrent failure of pituitary TSH secretion and primary hypothyroidism such that TSH stays within the 95% reference interval, an interval that is extraordinarily wide. For argument's sake, assume TSH has an inverse log relationship with fT3 and fT4 (not strictly true). With a (0.5 - 5.0) reference interval we can see that ln(5.0) - ln(0.5) =2.302585 and ln(50) - ln(5.0) = 2.302585. In other words, a typical TSH reference interval is nearly as wide as all the 'high' values of TSH. Indeed if we use the TSH > 10.0 diagnostic limit the 'normal range' is as wide as a 10.0 - 100.0 'abnormal range'.
2. The TSH assay counts TSH molecules, 'dead or alive'. It does not measure TSH bioactivity.
3. The evidence suggests TSH stimulates deiodinase, including type-2 deiodinase which regulates local T3 levels in organs such as the brain. Subnormal secretion of TSH will result in lower fT3, fT4 and cruically lower local T3 levels which are not reflected in the blood test. Patients on this forum with low normal TSH, fT3 and fT4 invariably present with much more severe symptoms than might be expected by just looking at the serum hormone levels.
4. Testing of potential endocrine disrupting chemicals (EDCs) uses TSH to detect effects on the thyroid. This catches most EDCs. However, a small number of EDCs will disrupt peripheral thyroid hormone action without affecting the pituitary (which has different receptors). These EDCs slip through the net, their effects are not be detected by a TSH assay (and probably not by fT3, fT4 either).
5. The TSH assay is claimed to be (statistically) sensitive, meaning there are few false negatives. The experience of thousands of patients and great doctors like Dr Skinner and Dr Lowe show this is not true. It is important to continually remind doctors that the TSH assay is NOT sensitive. It is specific but not sensitive.
Yes. The first thing I was taught on my computer studies course was GIGO - Garbage In Garbage Out. I think blood test numbers are like electricity, a good slave but a poor master.
Halfway through- Coming back to this article tomorrow. The witching hour is upon me! Brilliantly written and relatively accessible for considering I’m still reading up to the subject. Thank you for sharing diogenes 😊👍
Guffaw!🤣 now that is a unique handle! Nah I just meant it was after midnight and I was off making effigies of Numpty GPs. Don’t worry, I’m selective, I don’t make effigies of the good ones! 😂🤣😂😂🤣👍
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Overactive again, but why? What to do?
Sorry another query on test results
What's the best way to get an accurate TSH reading? 
