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A Critique of Dr. Richard Guttler's Beliefs About Hypothyroidism |
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Richard Guttler and the "Real Thyroid Experts": Note to Readers: In this critique of Dr. Richard Guttler’s beliefs about hypothyroidism, I quote him extensively. The quotations, like his prose in general, are littered with errors in grammar, punctuation, spelling, and syntax. Customarily, when I quote another writer’s passage that contains an error, I include the error and follow it with [sic] within the quotation. In this critique, however, I don’t follow the custom. If I did, the clutter of [sic]s would surely distract readers. Simply put: If you see what looks to be an error or a typo, the mistake is Guttler’s. And even if you don’t see them, there is at least one error (and usually several) in most of the quotations from Guttler. In one of his newsletters, Dr. Guttler included what he implied were quotations from others. The people apparently wrote to him protesting his attacks on patient advocate Mary Shomon. These quoted statements are written in pure Guttler style: choppy, truncated, declarative, and laden with errors. The writing style suggests to me that Dr. Guttler didn’t just copy and paste the people’s statements from their emails; instead, he attempted to transcribe them. If so, I also presume that the errors in the "quotations" are his. I believe the plethora of errors in Guttler’s prose is important; carelessness in one area of conduct generally betokens carelessness in other areas. Guttler’s written errors are consistent with a pattern of carelessness that, as I show below, includes his false beliefs about hypothyroidism. This pattern has a distinct bearing on the credibility of his judgment as—to quote him—"the real thyroid expert."[5] Introduction Mary replied to Dr. Guttler each time with her characteristic aplomb.
Her replies were thoughtful, tempered, civil, and well-written. In stark
contrast, Dr. Guttler’s attacks on Mary were littered with the
grammatical and spelling errors and the poorly formulated sentences that
distinguish his writing. His statements about her were condescending,
insulting, and disparaging. His obvious intention was to mock, ridicule,
demean, and discredit Mary as a thyroid patient advocate. Indeed, in his
first salvo, he wrote, "She is a poor thyroid patient
advocate." Guttler made his reason clear for derogating Mary as a patient advocate: through her website and books, she promotes beliefs about the diagnosis and treatment of hypothyroidism that are contrary to his own. Her beliefs are contrary to his, he asserted, because she lacks the education and qualifications to responsibly advise thyroid patients. "How can someone like you," he asked, "with no background in thyroid disease put out such bad advice in the name of a thyroid advocate?" As evidence for her misguiding her readers, Guttler wrote of those who sent him emails protesting his attacks on her: "Your email fans were the most uneducated thyroid patients, I have ever run across in the 7 years on the web answering questions. The emails convinced me that you were filling them with half truths, and out right falsehoods." [3]Dr. Guttler wrote that Mary’s guidance of her readers might harm them: "There should be a big Pop Up prior to all your ads on your website that states, Thyroid Patients, This site may be hazardous to your thyroid health." [3]In my opinion, Dr. Guttler libeled Mary. He did so in two ways: by attacking her personally and by accusing her of incompetence. He attacked her personally by writing, "TOP TEN THINGS WRONG WITH MARY SHOMON." This statement addresses Mary’s person rather than her beliefs. In the U.S., one is free to mock, ridicule, or demean another’s ideas, opinions, or beliefs; but not another person’s character. Guttler accused Mary of incompetence when he wrote, "She is a poor thyroid patient advocate." In my opinion, this is libelous because Dr. Guttler didn’t cite credible evidence of Mary being incompetent as a patient advocate. But wait a minute! A defense attorney for Dr. Guttler might argue in a libel case: Guttler did show Mary to be a "poor thyroid patient advocate." He gave evidence in his newsletters and in replying to emails from her defenders. As Dr. Guttler says, he’s "a real thyroid expert," [5] and in that Mary publishes beliefs in the thyroid field that are contrary to his, she must be disseminating false information. So he’s correct when, as an expert, he writes, "Her statements are not fact but her misguided opinion."[5] So, the attorney might conclude, she’s incompetent and therefore a "poor thyroid patient advocate." Since truth is the ultimate defense against a libel charge, she might as well not sue him. To continue the hypothetical attorney’s line of reasoning, Mary could easily become a good patient advocate; all she’d have to do is revise her beliefs so they agree with those of Dr. Guttler.I would vigorously refute the attorney’s argument, however. I’d contend that it’s not Mary’s beliefs that are false but Dr. Guttler’s. I’d also argue that if he’s truly a "real thyroid expert," it’s because of something other than holding scientifically-grounded beliefs about hypothyroidism. And I’d present scientific evidence to prove my points. That’s exactly what I do below—present scientific evidence to prove that Dr. Guttler promotes false beliefs about the diagnosis and treatment of hypothyroidism. I also present evidence to show that some of these false beliefs potentially imperil the health, well-being, and even the lives of many hypothyroid patients. And finally, I explain the dilemma this evidence imposes upon Dr. Guttler. I’ve written this critique mainly because Dr. Guttler’s beliefs risk harming patients. I want to alert patients to studies—in the very field in which Dr. Guttler claims expertise—that point to ominous possibilities: that accepting his false beliefs as true, and permitting those beliefs to guide their treatment, may diminish the quality of their lives or even end their lives prematurely. Dr. Richard Guttler’s False and
Potentially Harmful Beliefs
To keep this critique as short as possible, I selected only one sign of hypothyroidism, weight gain, and one symptom, depression, to prove that Dr. Guttler’s belief is wrong. I selected weight gain and depression for two reasons: (1) many patients develop these only after becoming hypothyroid, and (2) many patients report that they continued to suffer from weight gain and depression while on "adequate" T4-replacement, but then recovered from them upon switching to TSH-suppressive doses of thyroid hormone (usually T4/T3 or T3). Many alternative thyroid doctors have anecdotally confirmed these patients’ reports. But we don’t have to depend on anecdotes to confirm them; we have studies that do. Weight Gain He expressed yet another belief about weight gain and thyroid hormone in replying to another protestor: He quoted the protestor as writing, "Hugh [Huge] weight gain on Synthroid [.]" And he retorted: "There is no reason that any thyroid medication would cause weight gain, unless the dose was inadequate [remember that Guttler defines "inadequate" as not enough to keep the TSH within the normal reference range]. Excessive Armour could be the reason you have lost the weight. [From Guttler’s words, we must assume that the protestor lost weight after switching from Synthroid to Armour.] You need a TSH. If it is low you have your reason for abnormal weight loss due to induced hyperthyroidism." [5] (Italics mine.)Dr. Guttler again expressed his belief about weight gain and T4-replacement when he tried to convince a female patient with a hot thyroid gland nodule to undergo radioiodine therapy. "She claimed fear of radiation," he wrote, "and even more important to weight gain without a thyroid gland. Even after reassurance about the safety of RAI [radioactive iodine] and the weight neutral aspects of post radiation therapy of thyroid hormone replacement, she refused." [9] (Italics mine.)These quotations from Dr. Guttler make clear that he believes: (1) if a hypothyroid patient’s thyroid "testing is stable and normal," [5] any weight gain can’t be caused by too little thyroid hormone regulation; and (2) a patient will not gain weight on thyroid hormone replacement after she undergoes radioactive iodine treatment of her thyroid gland.It’s noteworthy that Dr. Guttler expressed these beliefs about weight gain in 2004. He implies that his beliefs are based on 50 years of science. [3] Why then would he hold these two beliefs when a high-quality study by some of his own colleagues—published in 2000—shows exactly the opposite to be true.I’m referring to a study coauthored by Drs. Geoffrey Beckett and Anthony Toft—a biochemist and an endocrinologist who promote T4-replacement as tenaciously (albeit far more civilly) as Guttler does. Beckett and Toft commented on hyperthyroid patients made hypothyroid by treatment that destroys thyroid gland tissue. "Despite restoration of serum thyrotropin (TSH) concentrations to normal, many [hypothyroid] patients complain of weight gain." [11]Beckett and Toft compared the outcome of the treatment of thyroid cancer patients with that of Graves’ disease patients. Thyroid cancer patients used TSH-suppressive doses of T4 to suppress further thyroid tumor growth. On the TSH-suppressive doses of T4, the now hypothyroid cancer patients didn’t gain weight. Graves’ disease patients used T4-replacement doses—doses that kept the TSH within the current reference range. They were matched with the cancer patients for age, sex, and severity of hyperthyroidism before antithyroid therapy. The patients on T4-replacement after becoming hypothyroid gained a significantly greater amount of weight. [11]Beckett and Toft wrote that ". . . one of the most commonly expressed anxieties of patients with hyperthyroidism attending a thyroid clinic is that any treatment that causes the development of hypothyroidism is associated with excessive weight gain. This is particularly the case for those offered treatment with 131I [radioactive iodine], as thyroid failure is inevitable in the great majority of patients, usually within the first year." They continued, "Although the standard medical response is that any weight gain after stabilization of T4 replacement therapy is simply that which was lost during the period of hyperthyroidism, many patients remain unconvinced, and some may even choose not to be treated with 131I." [11,p.1110]This was the case with Dr. Guttler’s patient—the one with a hot thyroid gland nodule I mentioned above. She apparently rejected his assurance of "the weight neutral aspects of post radiation therapy of thyroid hormone replacement." [9] (Italics mine.) Beckett and Toft’s following comment suggests that Guttler’s patient knew more than he: "Our results have affirmed [patients’] fears, namely, that treatment of Graves’ disease by surgery or 131I, resulting in hypothyroidism, is associated with excessive weight gain if the thyroid failure is treated with T4 in a dose that restores the serum TSH concentration to the reference range."[11] (Italics mine.)Beckett and Toft also wrote, ". . . our findings are supportive of growing evidence that the current policy for treatment of hypothyroidism with T4 alone and in a dose that restores serum TSH concentrations to the reference range may be flawed, at least in some patients." [11]The Beckett/Toft study is sufficient evidence that Dr. Guttler’s belief is wrong: T4-replacement after antithyroid treatment is clearly not weight-neutral. For the record, though, other studies also show his belief to be wrong. In one study, women who had undergone radioactive iodine or surgical treatment for hyperthyroidism were questioned. Eighty percent of the women were taking T4-replacement. The weight of women who complained of weight gain had increased an average of 15.6%. (For example, a woman whose weight began at 110 lbs. now weighed approximately 127.2 lbs.) Even those who didn’t complain of weight gain had gained weight; the average increase was 6.7%. (In this group, if a woman began at 110 lbs., she now weighed approximately 117.4 lbs.) The prevalence of weight gain is highlighted by the title of the researchers’ report: "Overweight—a common problem among women treated for hyperthyroidism." [17]Another research team reported, "This data suggests that all patients treated for thyrotoxicosis will gain body weight irrespective of the treatment used . . . ." [20] (Italics mine.) And other researchers have confirmed weight gain after antithyroid therapy.[18][19]In the recent Walsh study, [26] (which Dr. Guttler implies he’s read[7]) patients were included in the study if they had persistent hypothyroid symptoms despite using T4-replacement. They had to have been on a steady dose of T4-replacement for at least two months, and they had to have "normal" TSH levels. Among the symptoms of these dissatisfied patients was weight gain.One must wonder why Dr. Guttler holds his false belief about weight gain. Most studies I cited above were published between 1990 and 2000. But as far back as 1984, thyroid researchers had concluded, "Effective treatment of hyperthyroidism is accompanied by weight gain." [19] That’s somewhat far back in time for Dr. Guttler—who claims to be "the real thyroid expert"[5]—to plead that he’s just a little behind on his reading of the modern thyroid research literature.Depression Guttler quoted someone who protested his attack on Mary Shomon: "Depression on Synthroid, relieved by Thyrolar. You are a kook[.]" Guttler replied, "Thyroid disease can cause worsening of depression, and the worsening will be corrected by normal amounts of any thyroid medication[.]" [5] (Italics mine.)It takes but little reading of the psychiatric research literature, however, to show that Guttler’s pronouncements about depression in the two paragraphs above are wrong. Studies show that not just "any thyroid medication" [5] relieves all hypothyroid patients’ depression. The studies also show that hypothyroidism can cause depression despite patients being on T4-replacement and having "normal" TSH levels.Consider a report by three psychiatric researchers from the Department of Psychiatry, University of Toronto. [33] They studied nine thyroid disease patients on T4-replacement who were depressed. The purpose of the study was to see whether adding T3 would improve the patients’ depression. The depression of seven of the nine patients (78%) decreased by at least 50% after they added T3 to their T4 dosage.[33,p.16]A stubborn defender of "adequate" T4-replacement such as Dr. Guttler might argue that the patients in this study (depressed on T4 alone) simply weren’t taking enough T4. But this wasn’t true. As the researchers noted, the TSH levels of all nine patients showed they were taking what Guttler would consider an "adequate" dose of T4: "All nine patients," the researchers wrote, "had [TSH] levels near or below the lower limit of normal for our laboratory prior to the addition of T3, indicating at least adequate T4 replacement therapy." [33,p.17] (Italics mine.)It’s noteworthy that eight of the nine patients in the study had thyroid disease before they got depressed. This suggests that thyroid disease caused their depression. It also suggests that "adequate" T4-replacement failed to prevent them from developing hypothyroid-induced depression. [33,p.16]The results the Toronto psychiatric researchers reported are far from solitary in the research literature. Other psychiatric researchers also report that T4-replacement often fails to completely relieve depression caused by hypothyroidism. [30][43] This contradicts Dr. Guttler’s claims that depression or its worsening "will be corrected by normal amounts of any thyroid medication."[5] (Italics mine.) Like the Toronto researchers, others also report that T4-replacement often fails to improve depression that clears up when the patient begins taking a small amount of T3.[33] And still others report that dosages of T3 higher than replacement dosages—that is, enough to suppress the TSH—augment the depression-relieving effects of antidepressants.[30][31][32][33][34][35]In a large, community-based study by general practitioners published in 2002, researchers compared matched control patients to hypothyroid patients. All the hypothyroid patients were using T4, and most had "normal" TSH levels. Despite their use of T4-replacement, the hypothyroid patients had a significantly higher incidence of depression than did the controls. The researchers concluded: "This community-based study is the first evidence to indicate that patients on thyroxine replacement even with a normal TSH display significant impairment in psychological well-being compared to controls of similar age and sex." [21] (Italics mine.)Researchers who are endocrinologists have also shown that Dr. Guttler’s belief about depression and "normal" thyroid function test results is false. To take part in the endocrinologists’ study, patients had to have a diagnosis of hypothyroidism. [27] They also had to have been on T4-replacement for at least six months, and had to have "normal" TSH levels. In addition, they had to have depression according to scores on the General Health Questionnaire on two separate occasions at least two weeks apart.Moreover—and this is important—patients could not take part in the study if they’d had a diagnosed mood disorder before becoming hypothyroid. This latter criterion for being included in the study reasonably points to hypothyroidism as the cause of the patients’ depression. In other words, to be included in the study, patients had to be living examples of exactly what Dr. Guttler denies can happen: patients who become depressed after becoming hypothyroid and who remain depressed despite being on "adequate" T4-replacement. The result of the study was that neither T4-replacement nor T4/T3-replacement relieved the patients’ depression. Hence, that patients qualified to be in the study is evidence against Dr. Guttler’s belief, and the outcome of the study verifies that his belief is false. Failsafe Thyroid Function Tests Implying that thyroid testing is unerring, Dr. Guttler criticized Drs. Richard and Karilee Shames. (Dr. Richard Shames is a physician, and Dr. Karilee Shames a holistic and psychiatric nurse. They are thyroid experts who often write articles for Mary Shomon’s website. They are also the authors of the popular book, Thyroid Power. [10]) Dr. Guttler wrote of them: "This doctor and wife have clearly stated on their website that people can be hypothyroid with normal tests! That is grounds for not paying any further attention to them as experts in thyroid disease."[7] He went on, "Why should patients pay any further attention to any doctor who is selling 10 step programs, books, and advocating that, obese, fatigued, cold, and muscle aching people with 100% normal T4, T3, and TSH tests, are hypothyroid! That is scientifically impossible!"[7] (Italics mine.)Dr. Guttler is fervidly dogmatic that thyroid testing is absolutely flawless—if the test results are "normal," then it’s categorically impossible that any symptom the patient has is a result of too little thyroid hormone regulation. However, so many studies show that thyroid testing is highly unreliable that only blind faith can account for Guttler’s ardent advocacy of the tests. A study by Fraser, [44] for example, showed that the TSH and free T4 tests—which Guttler uses—are in fact highly fallible. Fraser studied patients on T4-replacement. Of 108 patients who were free from hypothyroid symptoms—and any signs of overstimulation—53 (49%) had TSH levels below the lower end of the reference range. This was a TSH level that thyroid specialists such as Dr. Anthony Toft have falsely designated a "thyrotoxic" level.[47,p.91]The endocrinology specialty has intimidated most conventional doctors into accepting without question Toft’s false designation. As a result, most doctors would have had Fraser’s patients—who were free from hypothyroid symptoms but had low TSH levels—reduce their T4 dosages. Of course, this would have raised the patients’ TSH levels. And most likely, it would have caused them to begin suffering again from hypothyroid symptoms. Most conventional doctors also accept without question dogmatic pronouncements, such as Guttler’s, that patients cannot have hypothyroid symptoms when their TSH levels are "normal." Because of this, conventional doctors would blame the new hypothyroid symptoms of Fraser’s patients on mysterious new diseases, like "fibromyalgia" (see Addendum 1) and "chronic fatigue syndrome." [23][24][25]Fraser also found that some patients who had hypothyroid symptoms also had low TSH levels. Most conventional doctors would falsely believe these patients, too, were overtreated with T4. They would therefore lower the patients’ dosages, intensifying the hypothyroid symptoms they were already suffering from. The Fraser study also shows the fallibility of the free T4 test. Among 18 patients who were still suffering from hypothyroid symptoms, 4 (22%) had free T4 levels above the upper limit of the reference range. This gave a false signal that the patients were overtreated with T4, when it fact they were undertreated. Again, most doctors would make these patients lower their dosages. This would most likely worsen the patients’ symptoms. In the recent community-based study in the UK, 48.6% of patients had persisting hypothyroid symptoms despite being on T4-replacement and having "normal" TSH levels. [21] Moreover, each of four replacement studies published in 2003 showed that hypothyroid patients on T4-replacement still suffered from hypothyroid symptoms or abnormal scores on tests of health status.[26][27][28][29]In the UK community study, 35% of people considered not to have hypothyroidism had hypothyroid or hypothyroid-like symptoms. My Editor, Jackie Yellin, made a noteworthy conjecture about these people whom the researchers presumed not to have too little thyroid hormone regulation: Many hypothyroid patients on T4-replacement with "normal" TSH levels continue to suffer from hypothyroid symptoms; [21][26][27][28][29] similarly, it’s quite possible that the "hypothyroid-like" symptoms of this 35% were caused by too little thyroid hormone regulation, despite their "normal" TSH levels.In my forthcoming book, Tyranny of the TSH, I cite many other studies that show levels of the TSH, free T4, and free T3 to be highly variable. I’ve included some of the studies in Addendum 2 below. In summary, the studies show: (1) TSH levels don’t significantly correlate day-to-day [42] or week-to-week;[38] (2) every 30-minutes, "a significant regular variation" occurs in men’s levels of TSH, free T4, and free T3;[39] (3) sleep loss raises the TSH level the next day;[40] and (4) taking a dose of T4 raises the T4 level and lowers the TSH level for some 9 hours.[41]These studies and others prove a point that should horrify anyone with a humane concern for the welfare of patients: Many thyroid diagnoses and dosage decisions doctors make based on blood level testing are bound to vary, depending on timing. In other words, which thirty-minute period on which day and which week the patients’ blood is drawn for testing can cause variation in test results, and thus variation and inconsistency in decisions that are based on those results. As Dr. Guttler criticized, Drs. Richard and Karilee Shames believe that patients can be suffering from hypothyroid symptoms despite having "normal" thyroid test results. Mary Shomon has long held the same belief. This belief is entirely consistent with scientific studies such as those I’ve cited. Those studies prove patently wrong an authoritative declaration of Guttler’s: that the Shames’ belief is "scientifically impossible!" [7]Only "Real Thyroid Experts" In a posting to the newsgroup alt.support.thyroid on May 15, 2004, Dr. Guttler asked readers, "Why do you think there is no postings by experts" at the newsgroup? Considering himself one of the missing "experts," he wrote, "I stopped posting in 1998, when I felt the hostility from a small group of self proclaimed ‘experts’ without portfolio." [48]He advised readers of the newsgroup: "Any serious thyroid patient looking for advice, needs to look elswhere [elsewhere], until thyroidologist, providers of thyroid care, are wlecome [welcome] to post. Go to thyroid.org, and go to these excellent reviews of thyroid on the web. They will outline ‘good sites for obtaining patient information." [48]Of course, hypothyroid patients who visit www.thyroid.org—as when they visit Dr. Guttler’s website—always get the same canned, simplistic, "expert" advice: take T4 and let your doctor adjust your dose by your TSH level. Several recent studies, however, show that many patients who take this "expert" advice will regret doing so. [26][27][28] Patients who took part in the studies had hypothyroid symptoms despite using T4-replacement. By including these patients in the studies, the endocrinologists who conducted the studies acknowledged that T4-replacement was ineffective for the patients.The outcome of the studies was that both T4-replacement and T4/T3-replacement left the patients suffering from hypothyroid symptoms. Based on this negative outcome, each group of endocrinologists reached a curious conclusion: that T4-replacement should remain the thyroid hormone therapy of choice. Several other researchers who published editorials on the studies reached the same odd conclusion. [36][37]Since the studies proved that many hypothyroid patients have hypothyroid symptoms despite "adequate" replacement therapies, the advice to keep T4-replacement the treatment of choice suggests to me disregard for the suffering of these patients—disregard that is a flagrant violation of the Hippocratic oath. Some of the endocrinologists who conducted the studies [26][28] or wrote editorials about them[36][37] noted the recent large, community-based study completed in the UK.[21] That study suggested that many patients on T4-replacement have an increased incidence of hypothyroid-associated diseases that are potentially fatal. And, the patients regularly use more medications for these diseases. To note that study and then advise that T4-replacement remain the treatment of choice also suggests a lack of concern that many patients restricted to this treatment may suffer from and even die from hypothyroid-associated diseases.T4-Replacement clearly can sustain hypothyroid patients’ symptoms. It can increase the incidence of other diseases that may prove fatal, and it can increase the patients’ use of drugs to control the symptoms of hypothyroidism and the other diseases. [22] These findings are grounds for two requirements being imposed on doctors: (1) having patients read, understand, and sign an informed consent document before the doctors can prescribe T4-replacement for the patients, and (2) providing an alternate thyroid hormone therapy if the patients decline to use T4-replacement because of its potential for ineffectiveness and harm. Currently, of course, most conventional doctors simply coerce patients to use T4-replacement, and if asked, the doctors refuse to prescribe alternative thyroid hormone therapy. This is especially true of members of the endocrinology specialty. It’s probably true of Dr. Guttler, too, judging from his dogged advocacy of T4-replacement and his damning of T4/T3 and T3 therapies.Yet, these are the "thyroid experts" whom Dr. Guttler urges "any serious thyroid patient . . ." [48] to seek out for advice. Clearly, for many patients, T4-replacement is neither effective nor safe. That being the well-documented case, it seems to me that hypothyroid patients who value their health and longevity will pass on Dr. Guttler’s "thyroid experts." In lieu of them, the patients will seek out other doctors who’ll let them use alternate thyroid hormone therapies that are safe and effective for them.In referring to Dr. Guttler’s attack on her, Mary Shomon wrote, "It . . . makes me even more committed to being an advocate for the many thyroid patients who struggle every day to cope with thyroid disease, despite having doctors who are not knowledgeable, compassionate, or focused on helping us truly live and feel well." [1] I laud Mary for her commitment to helping thyroid patients forsaken by the false beliefs of doctors like Guttler. My Editor, Jackie Yellin, observed, "Doctors like Guttler are the raison d'être of patient advocates like Mary." Indeed, without the doctors’ false and potentially harmful beliefs, patients would have no need for advocates to rescue them. But as this critique of Dr. Guttler’s beliefs shows, thyroid patients do indeed need patient advocates. They need advocates to inform them of the risks inherent in the advice of Dr. Guttler’s "real thyroid experts." Because of this, it’s a boon to them that Guttler’s attacks on Mary have made her more committed than ever. And the controversial publicity Guttler has provided will fortunately bring more patients to her website.Only "Real Thyroid Experts" Are He then commented on her advising patients to take copies of published papers to their doctors: "She is also wrong about women with little papers brought to doctors during an office visit. If the papers come from sources that are medically sound, there is no problem. When they come from her [Mary’s] paper mill, the real thyroid expert has to groan, and spend time explaining why the information is usually wrong." [5] (Italics mine.) The two sections below, however, cast serious doubt, at least in my mind, on Dr. Guttler’s ability to accurately "review and summarize"[5] information from medical publications.False Summary of Replacement Seven months later, he commented on another study comparing T4-replacement with T4/T3-replacement: "More recent evidence against T4/T3 combination therapy [.] No matter what Mary and her army of combination T4 and T3 users say about how great they feel, there is more evidence that there is no scientific value to these therapies. Studies published in Journal of Clinical Endocrinology, by Walsh et. al. Vol.88 (10) 443-50 2003, confirm that no improvement in well being, cognitive function, or quality of life compared to T4 alone." [7]The exact nature of the studies appears to have escaped Dr. Guttler. The studies compared the effectiveness of T4-replacement to T4/T3-replacement—T4 or combined T4/T3 in doses that kept subjects’ TSH levels within the reference range. For an accurate and meaningful interpretation of the studies, it’s crucial to know that the researchers tested only replacement doses—not any and all approaches to combination thyroid hormone therapy. They tested neither Armour nor Thyrolar, nor preparations that contain the ratio of T4 to T3 in these two products. Nor did they test Cytomel/Cynomel. And because the researchers didn’t study these medications, the results of the studies are completely irrelevant to the question of how effective these T3-containing thyroid preparations are. In his comments on the studies, Dr. Guttler committed the same logical error that the endocrinologists who conducted the studies did: He twisted the valid conclusion of the studies—that neither T4-replacement nor T4/T3-replacement relieved patients’ symptoms—into the broader, invalid conclusion that no approach to T4/T3 therapy is more effective than T4 alone. The researchers’ and Dr. Guttler’s careless reformulating of the valid conclusion into the invalid one is a disservice to both doctors and patients; it will leave them with the false belief that no type of T4/T3 therapy is more effective than T4 alone. Dr. Guttler may have read only the invalid conclusion of the endocrinology researchers and accepted it without question as true. If he did, then he’s an example of what I’ve expressed concern about—doctors hearing only the invalid conclusion and incorporating it into their frames of reference as gospel. On the other hand, Dr. Guttler may have read the full published reports of the studies. If he did, he clearly committed the act he falsely accused Mary of—inaccurately summarizing the results of research reports. [5]False and Self-Contradictory Summary Consider his judgment of Armour in his May 15, 2004 newsletter: "Thyroid extract [desiccated thyroid] was the standard of therapy until it was noted to cause many symptoms secondary to excess thyroid hormones T4, and T3 in the animal extract." [53] This statement of Guttler’s implies that any use of desiccated thyroid results in overstimulation. This, of course, is patently false. When patients use desiccated thyroid properly, it’s no more overstimulating than any other thyroid hormone preparation, including synthetic T4. If desiccated thyroid were invariably overstimulating, its widespread use through most of the twentieth century would have been disastrous for patients. It wasn’t, as the historical record clearly shows.Dr. Guttler wrote that after it was learned that desiccated thyroid, or "extract," caused overstimulation (a false statement of fact), "There followed a rapid decline in it’s use, replaced by T4. Extract is now the darling of the alternative medicine set. It still has all the old problems, and none of the benefits [of T4]." [53] (Italics mine.)In his assertion that desiccated thyroid has "none of the benefits" [53] of T4, Dr. Guttler flagrantly contradicts himself. He made this assertion only a few paragraphs after he wrote, "Marnus-Levey [actually the researcher’s name was "Magnus-Levy"(46)(55)] . . . fed dried animal thyroid glands, the precursor of the alternative doctor’s beloved Armour, to normal men." He then wrote that in response to the dried thyroid substance, "there was marked rise in metabolism." Then, referring to "the powerful substance causing this increased metabolism," he stated that it "had beneficial effects on cretins," that "Murray cured myxedema" with it, and that it was "proven to treat thyroid gland failure." (Italics mine.) He then wrote, "Effective therapy for hypothyroidism was known by the end of the 19th century."[53] (Italics mine.)This "effective therapy for hypothyroidism" of course, was desiccated thyroid. It had to be, since, as I wrote in The Metabolic Treatment of Fibromyalgia, [25] researchers didn’t isolate T4 until 1915,[52] didn’t synthesize it until 1919,[51] and didn’t determine its chemical structure until 1927.[49][50] So, at the same time that Guttler cites the benefits of desiccated thyroid, he claims it provides "none of the benefits"of T4.[53]As well as Dr. Guttler contradicting himself, other thyroid specialists also contradict his statement that desiccated thyroid has "none of the benefits" of synthetic T4. [53] (Italics mine.) In a major textbook, The Pharmacological Basis of Therapeutics, thyroid specialist R.C. Haynes cited research that contradicts Guttler’s opinion. Haynes wrote that researchers have tested the effects of different thyroid hormone preparations after injecting them beneath patients’ skin. The tests showed that different preparations have different quantitative effects; for example, T3 is more potent and faster acting than T4. The tests also showed, however, that there’s no appreciable difference in the qualitative (perceptual) response of a hypothyroid patient to proportional amounts of T3, T4, or desiccated thyroid. Specifically, he wrote, "Equivalent clinical responses are obtained from the daily administration of approximately" 65 mg of desiccated thyroid, 65 mgs of thyroglobulin, 100 mcg of T4, or 25 mcg of T3.[45,p.1372] (Italics mine.)Any mindful reader of Dr. Guttler’s statements about desiccated thyroid can see that his judgment is flawed; through clear-cut self-contradiction, he proves this himself. And, of course, his summary of the T4- and T4/T3-replacement studies is grossly inaccurate. These two examples show that his ability to accurately "review and summarize" [5] medical reports is egregiously poor—at least as poor as his written use of the English language. Consequently, I’m not reassured by his comment, "the real thyroid expert has to groan, and spend time explaining why the information is usually wrong."[5] Instead, I breathe a sigh of relief that Mary Shomon will continue her reviews and summaries of research papers for patients who need scientifically accurate information.Dr. Guttler’s Dilemma
These two proven points impose a dilemma on Dr. Guttler: On the one hand, he can maintain his beliefs as they are, despite the scientific evidence refuting them. In that case, we must classify his beliefs as unscientific. On the other hand, he can reform his beliefs to correspond with the scientific evidence. If he does, however, his reformed beliefs will concur with those of Mary Shomon. Most likely, these two options will be equally objectionable to Dr. Guttler. After all, he’s dogmatically propounded his beliefs as irrevocable, scientifically-established facts. Recanting now in public may prove embarrassing. And he has venomously criticized Mary Shomon for holding beliefs contrary to his own, implying that her doing so proved her incompetent. Conceding publicly now that she was right and he was wrong may be distasteful to him, in that, according to his own line of thinking, it will show that it was not she who was incompetent. Dr. Guttler may find it unpalatable to reform his beliefs to concur—as Mary’s do—with the scientific evidence. But he surely stands to gain by doing so. By reforming, he’ll show that he’s committed to scientific truth. For that, I for one would admire him. But more importantly, by reforming, he’ll show that he’s committed to move in any direction that science tells us is favorable to the health and well-being of hypothyroid patients. For that, we could justly see him as an honorable man. References  2. Guttler, R.: Dr. Guttler’s Thyroid Newsletter. March 17, 2004, http://www.thyroid.com/thyroid-news03-172004.html. 3. Guttler, R.: Dr. Guttler’s Thyroid Newsletter. April 8, 2004, http://www.thyroid.com/thyroid-news04-082004.html. 4. Eisinger, J., Dupond, J.L., and Cozzone, P.J.: Anomalies de la glycolyse au cours des fibromyalgies: étude biologique et thérapeutique. Lyon Méd. Méd., 27:2180-2181, 1996. 5. Guttler, R.: Dr. Guttler’s Thyroid Newsletter. March 30, 2004, http://www.thyroid.com/thyroid-news03-302004.html. 6. Bennett, R.M., Clark, S.R., Campbell, S.M., et al.: Symptoms of Raynaud’s syndrome in patients with fibromyalgia: a study utilizing the Nielsen test, digital photoplethysmography and measurements of platelet alpha2-adrenergic receptors. Arthritis Rheum., 34:264-269, 1991. 7. Guttler, R.: Dr. Guttler’s Thyroid Newsletter. May 2, 2004, http://www.thyroid.com/thyroid-news05-022004.html. 8. Guttler, R.: Dr. Guttler’s Thyroid Newsletter. Oct. 2002, http://www.thyroid.com/thyroid-news1002.html. 9. Guttler, R.: Dr. Guttler’s Thyroid Newsletter. April 12, 2004, http://www.thyroid.com/thyroid-news04-122004.html. 10. Shames, R.L. and Shames, K.H.: Thyroid Power: Ten Steps to Total Health. New York, HarperCollins, 2001. 11. Tigas, S., Idiculla, J., Beckett, G., and Toft, A.: Is excessive weight gain after ablative treatment of hyperthyroidism due to inadequate thyroid hormone therapy? Thyroid, 10(12):1107-1111, 2000. 12. Warmingham, P.: Fibromyalgia has been solved. Fibro Focus Supporter, 3:1-3, 2002. 13. Teitelbaum, J., Bird, B., Greenfield, R.M., et al.: Effective treatment of CFS and FMS: a randomized, double-blind placebo controlled study. J. Chron. Fatigue Syndr., 8(2):3-28, 2001. 14. Starlanyl, D.J., Jeffrey, J.L., Roentsch, G., and Taylor-Olson, C.: The effect of transdermal T3 (triiodothyronine) on geloid masses found in patients with both fibromyalgia and myofascial pain: double-blinded, crossover N of 1 clinical study. Myalgies International, 2-2:8-18, 2001. 15. Lowe, J.C., Reichman, A., and Yellin, J.: A case-control study of metabolic therapy for fibromyalgia: long-term follow-up comparison of treated and untreated patients. Clin. Bull. Myofascial Ther., 3(1):23-24, 1998. 16. Lowe, J.C.: T3-induced recovery from fibromyalgia by a hypothyroid patient resistant to T4 and desiccated thyroid. J. Myofascial Ther., 1(4):21-30, 1995. 17. Jansson, S., Berg, G., Lindstedt, G., et al.: Overweight—a common problem among women treated for hyperthyroidism. Postgrad. Med., 69:107-111, 1993. 18. De La Rosa, R.E., Hennessey, J.V., and Tucci, J.R.: A longitudinal study of changes in body mass index and total body composition after radioiodine treatment for thyrotoxicosis. Thyroid, 7:401-405, 1997. 19. Hoogwerf, B.J. and Nuttall, F.Q.: Long-term weight regulation in
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Introduction
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