On April 11, 2016 an article, Doctors Hear Patients’ Calls for New Approaches to Hypothyroidism, appeared in the Wall Street Journal regarding the growing influence of patient preference on treatment selection for hypothyroidism (sluggish thyroid). The article was written by the WSJ health columnist Melinda Beck. I might have missed it but thanks to a motivated patient I received a copy within a week after its publication. With a glance I knew this report could be a highly significant addition in the on-going debate between specialists treating hypothyroidism (endocrinologists) and advocates of alternative approaches. (more…)
Our member, Ella, has analyzed her own T4 plus T3 thyroid replacement needs and offers a terrific explanation of how she arrived at her conclusions. Follow her thinking in her message to metabolism.com
John has recently been diagnosed with low testosterone levels and sends metabolism.com this inquiry:
Iâ€™m so glad I found this site! About a month ago I was diagnosed with low T â€“ mine is 140. Very, very low. Symptoms were NO libido, fatigue, massive weight gain (from 195 to 275 in 9 months), swelling below the knees. Not sure if the T is responsible for all of this, but would love your opinion (at the same time â€“ the same day, actually â€“ i was also told I had type 2 diabetes (blood sugar of 203). Is there a link here?
My endocrinologist put me on Enenthate shots, 1ml every 2 weeks (done 2 shots so far). Do you think this is a good dosage? Are the shots better than the cream? Iâ€™m concerned about see-sawing T levels â€“ will they go up after the shot but creep back down again before the next treatment?
Iâ€™d really appreciate any insight, my doc did not spend a lot of time going into these kinds of details with me, it was a bit disappointing. Iâ€™m a white male, a little over 6â€² and 42 years old. Naturally I understand you are only giving an opinion, not actual medical advice. Thanks so much.
Reply by Dr. Pepper:
Thanks for your inquiry John. My first thought about the situation you describe is why would a 42 year old man develop low testosterone? Personally, I never take it for granted that the cause of newly diagnosed low testosterone is “aging”. There are many significant medical conditions that need to be ruled out primarily disorders of the testicle, and pituitary gland. Additional blood tests such as LH, FSH and prolactin and possibly radiological tests are often needed to make that determination. I don’t want to go on a wild goose chase here but swelling of the legs, rapid weight gain, low testosterone and type 2 diabetes may all be caused by an excess of cortisol in the body, known as Cushing’s Syndrome. That could be one way to unify all the events you describe.
Testosterone is generally administered as an injection or rubbed on as a gel. In nature, testosterone levels are more or less constant from day to day, so applying testosterone gel every day mimics this environment pretty well. The injections given every two or three weeks cause a rapid increase of testosterone to unnaturally high levels followed by steady decline often to low levels again before the next shot. My opinion is that shots are much less desirable although they tend to be a lot cheaper and simpler than the daily gels.
You may want to seek a second opinion to find out if other problems exist to explain how you developed low testosterone in the first place.
Keep us posted and good luck.
These comments are for educational purposes only and are not intended to provide medical care or advise.
Gary Pepper, M.D., Editor in Chief, Metabolism.com
When I became an endocrinologist in 1981 I was truly excited about the field. At that time it seemed that the science of endocrinology was expanding rapidly and new discoveries were on the horizon particularly in regards to the way hormones effect the brain, mood and the immune system. Was I ever wrong! Itâ€™s thirty years later and none of those expectations were realized. In fact, I find that the field of endocrinology has barely budged since then and in some areas has actually lost ground.
Bringing on this round of pessimism on my part, is a recent â€œdevelopmentâ€ in the area of treatment for hyperthyroidism (over active thyroid). Ever since I was in training there have been two medicines, propylthiouracil (PTU) and methimazole (Tapazole), which are the mainstays of medical treatment for hyperthyroidism. Both medicines have been available since the 1940â€™s and show excellent efficacy and tolerability (and they are cheap!). Almost all endocrinologists I have met use these two drugs interchangeably although in pregnancy propylthyiouracil is favored due to rare birth defects in fetuses exposed to methimazole.
The â€œdevelopmentâ€ which I find so discouraging is the recent action by the FDA to place a very strict (black box) warning on the use of PTU due to the possible occurrence of a rare form of liver injury attributed to the drug. After almost 70 years of exemplary use, this has given rise to extensive debate in the endocrinology literature about how to restrict PTU use.
While it is true that methimazole is equally as effective as PTU to treat hyperthyroidism, I have personally seen numerous cases of fairly severe allergic reactions to methimazole. Fortunately it has been easy to continue medical treatment by simply switching to PTU. If we canâ€™t use PTU freely then the only other options are surgical removal of the thyroid or eradication of the thyroid using radioactive iodine, neither of which is free of potentially adverse outcomes.
I have never encountered severe liver injury with PTU nor has any of the colleagues I have polled. It has to be very, very rare. This is obvious because it has taken 70 years to get around to recognizing it formally. Can we really call it progress that we now have one less simple option for treating hyperthyroidism, a common and relatively benign disease? Let me take my cynicism to the next level. I wonâ€™t be surprised if a major pharmaceutical company soon announces the development of a new drug for treating hyperthyroidism. If Iâ€™m right the new drug will add nothing of real value that wasnâ€™t previously available but is many times more expensive then the drug it replaces.
So goes endocrinology into the new century, the stogy old lady of medicine.
In this video, Eric Cohen, endocrinologist, explains what he considers the principles that will result in the best outcomes for his patients. He also shares his life experiences that influenced him in his decision to specialize in diabetes care.
The mission of the The Thyroid Project is to encourage sharing of information and experience between the public and the medical community about the treatment of hypothyroidism (low thyroid function). For at least the past few decades there is a growing awareness of â€œsomething missingâ€ in the way suffers of hypothyroidism are treated for their disease.
Too many patients, as documented in an on-line study of 12,000 individuals conducted by the American Thyroid Association published in June 2018, (https://doi.org/10.1089/thy.2017.0681) , complain of persistent symptoms of hypothyroidism despite what their doctors believe is successful treatment with levothyroxine (brands include Synthroid, Unithroid, Tirosent, Levoxl). We believe something needs to be done to resolve this conflict between patients and their doctors.
Without effective intervention the early stage of type 2 diabetes known as prediabetes carries a high risk of progressing to outright diabetes. Metabolism.com provides an up-to-date summary of recommendations from national authorities, for preventing and possibly reversing this life long affliction
Diabetes can be defined simply as elevated blood sugar levels. What exactly is high blood sugar and when should someone be concerned about their level? Does having prediabetes mean diabetes is around the corner? Metabolism.com tackles this tricky but important topic in this comprehensive review.
By Gary M. Pepper, M.D. Ozempic, Rybelsus, Trulicity, Wegovy, Saxenda are the central players in the weight loss craze sweeping across the globe. Metabolisim.com has been monitoring this phenomenon from its beginnings in 2008 with its report “Lizard Spit Reduces Blood Sugar and Appetite”, regarding the first drug in this class, Byetta (exenatide). Caught In the middle of the current chaos are the medical experts who treat diabetes and have been prescribing these medications for more than a decade. Here is a brief commentary from one such board certified endocrinologist; “I started treating Type 2 diabetics with GLP-1 agonists more than 10 years ago. In some respects, these medications have revolutionized the treatment of diabetes by lowering blood sugar effectively and promoting weight loss at the same time, a unique combination of benefits. Not everyone benefits from these drugs to the same degree unfortunately, and I have seen lots of patients experience unacceptable side effects from them. Nothing though, has prepared me for what is happening now. Too often, I find myself confronting someone who expects me to prescribe one of these drugs just so they can lose weight. Sadly, one extreme example was someone who, despite battling a life threatening medical condition, was insistent on getting a prescription. At the same time my diabetic patients are scrambling to find a place to buy their medications if they can even afford it. It is disheartening, to say the least, and I dread the negative interactions with some of my patients I now face almost daily.”
Off- Label Use
The FDA is the U.S. government’s department tasked with evaluating and approving drugs for specific medical conditions. When a new medication is approved for treating a medical condition by the FDA the agency will, at the same time, set strict guidelines for exactly which patients may use the newly approved drug. When a medication is used “off-label” it means that these limitations are being overridden by the provider for a potential benefit which outweighs the drugs risks. It is a general misconception that off-label means illegal; it does not. This practice has been going on for ages and more than 20% of prescriptions in the United States are prescribed off-label. A common example is the use of beta-blockers (approved for heart problems) for the treatment of performance anxiety.
GLP-1 agonist drugs, as discussed recently by metabolism.com. were originally approved for the treatment of Type 2 diabetes in adults. In the past few years most of these same medications have gained unprecedented popularity for their “off-label” weight loss benefit. Of the 5 GLP-1 agents presently in U.S. pharmacies only Wegovy (semaglutide) and Saxenda (liraglutide) are FDA approved for treating obesity. Of these two, Wegovy is the newer and had been much more popular that its sister drug Saxenda, probably due to being dosed only once weekly compared to daily for Saxenda and less likely to cause side effects. Due to Wegovy’s soaring popularity, its manufacturer, Novo Nordisk, increased the price of Wegovy two times since its initial release.