A (small) Defense of the TSH Test

I can KIND OF understand why doctors prefer using the TSH test to diagnose and treat hypothyroidism, instead of the old-school method of ACTUALLY LISTENING to their patients.

No, really, I can.



Look at it this way, thyroid hormone is tricksty stuff. If you don’t have enough, it will fuck your shit up. The thing is, if you have too much, it can fuck your shit up even more, and much faster.

I really believe this is the reason that one of my doctors made a concerted effort to reach out to me that one time TSH came back WAY lower than normal, but ignored the shit out of me when it was climbing steadily into myxedemaville.

You see super low could mean your thyroid hormones are super high; and super-high thyroid hormones can fuck up your heart – big time. It can cause heart palpitations, arrhythmia, atrial fibrillation, congestive heart failure, and eventually a heart attack. 

Even if your blood thyroid levels are normal, a super low TSH will give most doctors a righteous sphincter clinch. 

Conversely, a high TSH could mean your thyroid hormones are super low, and super-low thyroid hormones can fuck up your life… but not as imminently as super-high thyroid. 

People can live for YEARS with the effects of low thyroid. I mean, unless your entire thyroid ups and dies all at once, you can limp along getting not-quite-enough hormone for quite a long time – a large number of “subclinical” hypothyroid patients do just that.

Sure, you’ll feel like shit, your hair will fall out, you’ll ache all over, your neck will swell, and a bunch of other shit will happen, but you won’t die. 

As long as you don’t give up, and keep getting those thyroid tests every year, eventually your TSH will rise to the range that they have decided is worth paying attention to. 

And even if the standards change, and the clinical reference range is narrowed, they'll keep using the old, broader range. They'll err on the side of caution and delay diagnosis to avoid over-medicating the patient, and potentially causing them to have a heart attack or develop osteoporosis or go blind or, you know, die. 

The same philosophy applies when treating patients: be cautious and keep the numbers within range. After all, they took an oath to "above all do no harm," and giving someone a heart attack is definitely doing harm.

So, I totally understand. 

Of course, you could also argue that under-treating someone, and forcing them to deal with painful, and sometimes debilitating, symptoms is also doing harm. But doctors seem to operate in levels of harm. 

For example, chemotherapy can also fuck your shit up, but it can also fuck up cancer. So it's a trade off. Do the patient one type of harm to mitigate another. 

A little confession:

I recently over-medicated myself. I had gone up by half a grain. Over the course of about three weeks I started having heart palpitations and shortness of breath. I was having more frequent bowel movements and feeling a little anxious. I finally realized what was up when I started getting chest pains.

That day I stopped taking my meds for about two days, then gradually reintroduced my meds at half the dosage I'd been taking. It wasn’t enough medicine, but it also wasn’t going to kill me. 

The heart palpitations, chest pain, and overactive bowels stopped. I am now gradually increasing my dosage to where it was before I made the 1/2 grain increase.

I'm lucky. Unfortunately, not all patients are. Not all patients are as vigilant because they may not KNOW to be as vigilant. And most doctors don’t have the time, or resources, to give their patients the care, attention, or information they need.

As a result, the old-school diagnose-by-symptoms-and-adjust-the-dosage-until-the-symotoms-reolve method no longer works. Patients get  over-medicated, and become ill, and die. 

And, if the patient dies while following doctor's orders, the doctor could be liable. 

So, instead, they use a bullshit test as both a diagnostic tool and a treatment protocol. 

Because it is easier, and because no one is going to die if they have to live the rest of their lives with not enough thyroid hormone. At least not right away.

And  under-treating the disease, and forcing patients to live with their symptoms, is considered the lesser harm.