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Hypothyroidism in Chronic Fatigue Syndrome

  [ 342 votes ]   [ Discuss This Article ]
www.ProHealth.com • September 22, 2004


By James Burton

Editor’s note: James Burton, the author of this article (which is an excerpt from his book about hormonal abnormalities in CFS and FM) is a CFS patient who has conducted extensive research on the possible causes and effective care of CFS, and has written the following in the hopes of sharing the important information he has discovered with other CFS patients around the world. The following information is not treatment advice, but rather information to be considered based on one patient’s significant experience.

Introduction Thyroid treatment is one of the most contested areas of modern Chronic Fatigue Syndrome (CFS) treatment. The arguments begin when a patient has a test that either shows they are within the reference range but at the bottom of it or when a patient has a normal test result yet demonstrates strong symptoms of thyroid deficiency. According to current medical practice, neither should be treated. According to some CFS and fringe private doctors, they should. In practice, the difference treatment can make to these patients is significant, giving strength to the argument of the doctors in favour of treatment. However, in practice there are also major side effects that may only be narrowly avoided by treating these patients and this certainly gives strength to the conservative doctor’s argument. As a complex and contested area of medicine, there is no obvious and simple answer as to who is right; what’s more, there is little common ground on which a compromise between the two may be found. For these reasons, this chapter will examine both sides of the argument and present the beneficial and detrimental outcomes that can result from following the different treatment paths.

How and Where Is Thyroid Produced The thyroid hormones, produced by the thyroid gland located in the neck, are the most potent of hormones. The body constantly depends on thyroid hormones but also as with cortisol, they are of great importance in responding to stress. In a demanding situation, the body has the ability to augment its production of thyroid hormones, thereby making the body able to achieve a level of capacity which would be impossible without this ability to ‘gear-up’ bodily resources. Of course this is only a short-term solution. It augments the strength of some parts of the body, such as energy and heat production, at the expense of other parts. In short, as with all the steroid hormones, including cortisol, estrogen and testosterone, an above-natural quantity of thyroid is harmful long-term.

Symptoms The thyroid could be characterised as the metabolic gas-pedal of the body. It controls the general rate at which nutrients are burned for energy and heat. The main symptom of hypothryoidism is lethargy and there will also be an inability to increase fitness. The lethargy is pervasive, not just making one physically sluggish but also slowing down mental performance and causing emotional problems, such as a tendency towards depression. A low body temperature, intolerance to cold, problems adjusting to temperature variations and weight gain are also among the most common symptoms of hypothyroidism. There are also a great many other symptoms that can be caused by low thyroid, from minor ailments such as brittle nails to infertility, poor immunity and FMS-like joint pains.

The Great Smokies Diagnostic laboratory has noted that a significant decrease in serum DHEA levels was recorded in patients with hypothyroidism. By exerting an affect on the metabolic rate and controlling body temperature, the thyroid has a profound influence on the performance of a huge amount of bodily systems. The human body relies on the work of enzymes to perform a constant and omnipresent series of tasks, including breaking down food, detoxifying metabolic waste and breaking down spent hormones. Enzymes are very temperature sensitive; a low body temperature will impair their performance. The result is that the body as a whole is impaired in its natural function; even at best, parts of the body will operate at a sub optimum level.

Understanding this key importance of thyroid to general health is necessary if one is to appreciate why treating patients with a slightly under active thyroid can be so beneficial, not just at suppressing thyroid related symptoms but in restoring overall health as part of a comprehensive treatment plan. Another piece of information that is essential to understanding the controversy of thyroid treatment is that symptoms attributable to low thyroid can be caused by other health problems. For example, low body temperature may result from the impaired autonomic nervous system that is very common in CFS. As another example, many CFS patients have impaired production of cellular energy, which may cause a similar pervasive lethargy as is felt in hypothyroidism. This means that many CFS patients will have symptoms that are indicative of hypothyroidism, yet the thyroid itself may be operating normally or only slightly sub-optimally. However, thyroid hormones are powerful to the extent where supplementing thyroid in these patients will improve these symptoms. Symptoms attributable to the thyroid are of such importance, especially to CFS patients, that although in some patients they may originate from disorders other than the thyroid, thyroid treatment can still be efficacious and systemically beneficial.

Diagnosis A blood test that measures the three hormones TSH, free T3 and free T4 is the most informative of laboratory tests and should be carried out routinely on all CFS patients. T3 is the most potent form of thyroid hormone. T4 has some clinical affect although to a much lesser extent than T4. Its main function is to serve as a reservoir from which T3 can be made from. Thyroid Stimulating Hormone (TSH) is made by the pituitary. It is the hormone that commands the thyroid gland to increase production of T4 and T3.

T3 is the most significant thyroid hormone when doctors assess the clinical impact of thyroid deficiency. Primary hypothyroidism is where the thyroid gland is defective and no longer able to produce enough quantity of either T3 or T4. A patient with primary hypothyroidism will have a low level of T3 and / or T4 and is likely to have a high level of TSH. The latter is evidence that the pituitary has sensed the low level of T3 and / or T4 and is intensifying its signal to the thyroid gland to increase production.

A review of published findings about TSH levels reveals that readings of more than 2.0 may be indicative of adverse health problems related to insufficient thyroid hormone output. One study showed that individuals with TSH values of more than 2.0 have an increased risk of developing overt hypothyroid disease over the next 20 years (Vanderpump et al. 1995). Other studies show that TSH values greater than 1.9 indicate abnormal pathologies of the thyroid, specifically autoimmune attacks on the thyroid gland itself that can result in significant impairment (Hak et al. 2000). More ominous was a study showing that TSH values of more than 4.0 increase the prevalence of heart disease, after correcting for other known risk factors (Hak et al. 2000). Another study showed that administration of thyroid hormone lowered cholesterol in patients with TSH ranges of 2.0-4.0, but had no effect in lowering cholesterol in patients whose TSH range was between 0.2-1.9 (Michalopoulou et al. 1998). This study indicates that in people with elevated cholesterol, TSH values of more than 1.9 could indicate that a thyroid deficiency is the culprit causing excess production of cholesterol, whereas TSH levels below 2.0 would indicate no deficiency in thyroid hormone status. (‘Thyroid Deficiency’, The Life Extension Foundation, 2003).

Secondary hypothyroidism is caused when the patient has an insufficient amount of thyroid hormones T4 and / or T3 despite their thyroid gland being physically able to produce enough. Their TSH level would likely be from low to normal. This may be caused by a lack of TSH as a result of pituitary disease or in CFS, possibly as a result of low stimulation of the pituitary from the hypothalamus. In this case, although the thyroid gland may be physically capable of producing hormones, it is not doing because the brain is not stimulating it enough.

The TSH, T3 and T4 test are the only tests usually regarded as necessary. However, some doctors have found other tests or diagnostic knowledge useful, particularly in relevance to patients who present with symptoms of hypothyroidism despite normal test results. The specialist CFS doctor Majid Ali, MD, shares the view with other doctors who have treated CFS patients for thyroid deficiency that many CFS patients have difficulty converting T4 into T3 due to enzyme damage. This is also why Majid Ali has found that using T3 instead of T4 in CFS patients is much more effective. If a patient has symptoms strongly indicative of hypothyroidism despite normal test results for TSH, free-T3 and free-T4, it might be worthwhile also doing a T3 test.

In “The Super Hormone Promise,” Dr. William Regelson, M.D., and Carol Colman write, ‘Thyroid hormone is carried through the blood stream on a protein called transthyretin. It is advisable to also check the level of this or thyroid antibodies, especially if the other tests are normal and the patient is showing classic signs of deficiency…Even if all the thyroid hormones are normal, a deficiency of transthyretrin could mean they are not being delivered to the cells. Therefore levels of transthyetrin must also be tested.’ In cases where this is a problem, he says to supplement thyroid hormones, even if their level is normal on the standard tests. Other doctors have reported that some patients seem to have a resistance to thyroid hormones and so may be deficient despite all the levels of the thyroid hormones being normal. A few doctors will treat these patients with a much higher dose of thyroid hormones to correct the signs of deficiency. This treatment sounds particularly likely to induce suppression and could be dangerous. Patients considering it should discuss the matter thoroughly with their doctor, seek a third party opinion and conduct their own research until they are satisfied they are aware of potential risks.

Measuring Body Temperature A common request of physicians particularly interested in treating hypothyroidism in CFS patients is to monitor their temperature with a thermometer, either taken from under the arm or under the tongue. The latter is regarded as more accurate. This is an unofficial method of diagnosis because it has not established itself in clinical trials as accurate. As thyroid hormones have such a profound effect on body temperature and this in turn affects the performance of bodily enzymatic systems, the measurement of temperature is useful for quantifying how much a patient could benefit from thyroid treatment, even if their laboratory test results do not indicate treatment is necessary. An ideal body temperature is thought to be 97.5 to 98 degrees F when measured from under the arm and 98.2 to 98.6 degrees F when measured under the tongue.

The Main Concern of Thyroid Treatment: Suppression The brain continuously regulates the amount of thyroid hormones in the body. The main reason why doctors traditionally have such a cautious attitude towards supplementing thyroid output is that doing so can precipitate a response from the pituitary that reduces TSH and therefore suppresses the production of natural thyroid hormones; this is referred to as suppression. In practice, suppression will manifest as the TSH falling to an unnatural level after initiation of thyroid supplementation. When the TSH falls and the natural output of thyroid hormone falls with it, the patient will become more dependent on the thyroid medication. It is often the case that patients improve for a while after starting thyroid medication but then they lose the improvement. This is most likely due to suppression: thyroid medication increases the level of thyroid hormones, which is then counteracted by a drop in natural thyroid hormone production. The patient’s total level of thyroid, from being increased after supplementation, has now resumed its former level. The more the thyroid medication needs to be raised due to a diminishing clinical response, the more suppression will occur and the more dependant on medication the patient will become.

Patients who have outright hypothyroidism (where their natural output of thyroid hormone tests as below the reference range), will not have to worry too much about the possibility of suppression occurring as a result of taking thyroid medication. As their natural output of thyroid hormones is very low, providing the thyroid medication given is at a dose that will restore thyroid hormones to a normal level, it is unlikely the brain will regard the body as having too much thyroid hormones and will not cause suppression in response. In any case, overt hypothyroidism is a serious condition and certainly requires treatment.

The odds of precipitating suppression by administering thyroid medication are far more of a concern when the patient’s level of thyroid hormones is still within the reference range. The administration of thyroid to these patients may well cause suppression and doctors who are aggressive in the treatment of low thyroid may respond by increasing the dosage of thyroid medication to again produce a higher level in the patient. This will be effective but it may well again precipitate a suppression response by the brain, by which the brain reduces the secretion of TSH and therefore natural T3 and T4 production. This fight between trying to get the body to accept a higher level of thyroid medication and the body counteracting with suppression may happen numerous times. The net result is that after some time on the thyroid treatment, some patients end up with a very low output of natural thyroid hormones and are almost totally reliant on medication. The worse case scenario is that they will have no natural production left and they may be in danger of their thyroid gland atrophying. It could be argued that suppression would be a worthwhile burden if it were only temporary. However, suppression and reliance on thyroid medication is not temporary. Weaning someone off thyroid medication is extremely difficult, even for the most informed and experienced of doctors. Many doctors regard a patient started on thyroid medication as on it for life.

There are physicians who may use a comprehensive nutritional approach to help some patients come off thyroid but these are few in number, the treatment likely to be costly and time consuming; also, I am not aware of any studies demonstrating that it works. Even if the patient were to cure their underlying illness and therefore theoretically no longer require thyroid medication, they would still be dependant on it because of the suppression it had caused. In some it may be impossible to stop the medication without major problems. Although it is obviously highly undesirable to be reliant on a medication for the rest of one’s life, some patients may not fully understand the complications that can arise because of this situation. Hormone levels are continuously monitored by the brain, which then sends messages to the glands to change the level if beneficial. It does this minute by minute and can vary levels to an amazingly subtle degree that can never be imitated with medication. The health of the patient reliant on supplemented hormones has to be compromised because of this fact. In addition, a patient could have serious difficulties if they developed an allergy or intolerance to the thyroid medication.

Treatment

Traditionally Regarded Hypothyroidism:Traditionally regarded hypothyroidism, were the level of a thyroid hormone is below the lower end of the reference range, is a serious condition in anyone. If someone has this condition, it is very likely they will suffer clinical fatigue, mental and emotional lethargy, problems with tolerating temperature and a marked tendency to gain excess weight. They may also have many other symptoms that can be meliorated with thyroid treatment. Anyone with this condition needs treatment and it needs to begin immediately. Although studies are lacking as to the rate of this disease in CFS patients, it seems it is only present in an extremely small group of patients and for now is not considered more common than in the general population. A few cases of CFS have actually turned out to be misdiagnosed hypothyroidism. However, both conditions can be present concurrently. If a CFS patient has hypothyroidism, treatment will likely produce a huge improvement in their condition. At the very least, it will be one of the most beneficial single treatments the patient will ever receive and will be instrumental in a comprehensive treatment aimed at recovery. It is thought very unlikely a CFS patient with hypothyroidism will recover without it first being treated. Everyone is agreed that a thyroid level below the reference range needs treatment and that the benefit of treatment clearly outweighs the risk.

Treatment if the level of thyroid hormones is within the reference range but at the lower end (typically in the lower 20% of the reference range): A level of thyroid hormones within the reference but at the lower end is thought by some doctors to be of high clinical importance. In CFS, the fact that the symptoms attributable to low thyroid, such as energy and temperature, are of such importance in the whole condition and the fact they can be successfully treated with thyroid hormones, causes some doctors to treat CFS patients in this scenario. It is thought many CFS patients will fit into this group and the majority of these are thought to realise significant improvement with thyroid treatment and some can make a remarkable improvement. The doctors who argue in favour of treatment do not just regard thyroid treatment as one of the most effective single treatments they can offer to their CFS patients; some actually say the efficacy of all other treatments will, at least to a significant degree, be augmented by thyroid treatment.

Mainstream medicine regards thyroid treatment in these patients as unnecessary and dangerous. They assert the benefit from administering thyroid medication cannot be sustained due to the likely suppression that will result from treatment. They also believe that the benefit patients receive from treatment is simply because thyroid hormones are steroids and therefore likely to make any invalid feel better. As the patient’s level of thyroid hormone is only on the low end of normal, suppression of natural thyroid output is a realistic possibility. This will manifest in their TSH level falling after administration of thyroid hormone. The more this happens, the more the patient’s natural production of thyroid hormones will continue to fall and the more they will rely on supplemented thyroid. Suppression is indicated by a follow-up test revealing a drop in TSH to an abnormally low level. An obvious sign of suppression is where the patient feels benefit from thyroid medication and then finds this benefit diminishes, begetting the need for a rise in the dose of thyroid medication. Note that a drop in TSH is desirable if the TSH was too high to start with. If it wasn’t and it falls to an unhealthy level, the patient has the choice of whether to continue the thyroid medication and risk causing further suppression or to be weaned off the medication, which may precipitate a worsening in their condition but may stave off dependence on thyroid medication.

It is very difficult to assess the clinical significance of low-normal thyroid hormones in CFS patients. As already discussed above, benefits from treating the thyroid may compensate for problems that in part originate from other bodily systems, such as the autonomic nervous system and possibly mitochondria damage at the cellular level. This explains why treating these patients with thyroid hormones is prone to causing suppression of TSH despite the genuine improvement many will feel from treatment. The mechanisms in the body for controlling the level of thyroid hormones does not take into the account the fact that because of other problems elsewhere in the body, extra thyroid is beneficial. It simply measures and regulates the amount of thyroid hormones in isolation and will suppress them if levels get too high. On balance it is doubtful that treating these CFS patients with thyroid hormone is essential to recovery, although it is a potent treatment for many. Hopefully, if the thyroid medication is only administered in a dose sufficient to bring their level of T4 and T3 into the middle or slightly higher part of the reference range, suppression will be avoided but this is not guaranteed.

Treatment if the level of thyroid hormones is within the middle of the reference range: It has already been discussed how symptoms attributable to low thyroid are of such importance in the condition of CFS. It is for these reasons that a few doctors will administer thyroid hormones with disregard for test results; they simply use symptoms of low thyroid as a reason to administer treatment and will increase the dosage until it satisfactorily treats the symptoms. Whereas suppression of natural thyroid hormones is a concerning possibility of the above scenario, it is a likely possibility in this scenario. These patients are also the most likely to suffer from severe suppression as the body may be treated with a large excess of thyroid hormones. The body temperature test is often used in these patients to assess to what degree the patient may benefit from thyroid hormones. Dr. Jacob Teitelbaum for example, recommends patients be put on a trial of low-dose thyroid hormone if their temperature is routinely below 97.4 degrees F, regardless of test results. If the dose remains low and treatment discontinued if signs of suppression occur, suppression may well be averted. Very close monitoring is warranted in this treatment to detect signs of suppression, providing that the patient and doctor are actually trying to avoid suppression; not all consider it important.

Side Effects and Contraindications The likelihood of side effects will differ depending on the type and dosage of treatment and what the level of thyroid hormones was in the patient before treatment (baseline level). Therefore, some side effects have been discussed concurrently with the discussion of the different treatment perspectives above. Next will be described side effects that can result from any form of thyroid hormone treatment. When taking any thyroid medication, it is important to be watchful for signs of overdose. These include rapid heartbeat, anxiety and agitation, feeling too hot and sweating. If you feel you are having an adverse reaction to thyroid medication, you must contact a doctor immediately. For an unknown reason, a few patients may develop these symptoms of too much thyroid hormone despite taking their usual and appropriate dosage. The only thing these patients can do is to try the medication at a much lower dose and see if building it up slowly gives them better tolerance.

It is generally considered important that thyroid medication is taken at the same time every day. Providing the same routine is adhered to, the tablets may be taken with or without food. Thyroid medication can be stimulating, so it is best to take it early on in the day. Taking testosterone can raise thyroid levels if you are already taking thyroid medication. Some patients may experience a drop in cortisol after beginning thyroid medication. If their level of cortisol was already slightly low then this could cause concerning symptoms. If their level of cortisol was at the low end of the reference range or out of the reference range, administering thyroid medication could cause an Addison’s crash (a very serious deficiency of cortisol). If not already done, a patient should have their cortisol tested before starting thyroid medication. If they are in need of cortisol supplementation, starting it before starting the thyroid medication will avert the potentially dangerous drop in cortisol.

Iron and calcium inhibit the absorption of thyroid medication. Iron should be taken at least 6 hours away and calcium at least two hours away from taking thyroid medication. ‘…the Food and Drug Administration (FDA) is seriously considering a withdrawal of the thyroid drug [Synthroid (US) / Eltroxin (UK)] because “it has a history of problems” and cannot be recognised as “safe and effective”. The drug is also the subject of a raft of class-action suits in the US…The FDA noted that “Synthroid has not been reliably potent and stable”. As a result “patients receive tablets that are filled with a product of unpredictable potency”…Most side-effects of Synthroid and Eltroxin are related to overdose, which causes symptoms of hyperthyroidism’. (What Doctors Don’t Tell You, August 2001, Vol 12 No.5, Page 9.)

Forms of Treatment Usually a drug containing T4 is administered to hypothyroid patients. For a smaller group of patients, a T3 drug will be necessary either instead of or in addition to T4. T4 is the standard drug because it delivers a more even and predictable amount of thyroid hormone. If T3 needs supplementing with a drug, it will usually be given twice a day, as it is shorter acting than T4. It is thought a CFS patient will be more likely than traditional hypothyroid patients to require a T3 drug.

Animal Thyroid This is different from the usual animal glandular available in that it contains a potent quantity of the actual hormones. It has the advantage of containing T3 in addition to T4 in one product. The problem it has is that it may not contain the ratio of T4 to T3 that is right for the patient. Often, it contains too much T3. Therefore some doctors often prescribe it at a lower low dose together with a bit of synthetic T4.

Thyroid Glandular Some physicians have found a satisfying degree of success from using thyroid glandular. Despite the usual problems associated with glandular products, such as the lack of standardisation, the fact that they contain very little of the actual hormones and that they are extracted from animals, they do at least circumvent the main problem with thyroid treatment, which is suppression of TSH output. Patients whose thyroid test shows them to be at the low end of the reference range may find improvement taking a glandular without risking suppression. However, the efficacy of thyroid glandular is debatable. Many physicians still prefer to solely use drugs, as they are a more reliable and measurable form of treatment. If a patient particularly wants to try a glandular and their doctor is sure it is safe, the patient could try it for a predetermined period and if it fails to achieve the desired result, they could resort to drugs. A nutritionist is likely to be the most informed professional on the administration of glandular and nutritional support for hypothyroidism. This approach to thyroid treatment is not normally a part of any medical professional’s training so it is important to first ask questions of the nutritionist or other professional you contact, to gauge whether they have the knowledge to effectively prescribe this treatment and that they are familiar with thyroid treatment in CFS patients. For more information on glandulars and other thyroid treatments, consult http://www.thyroiduk.org/

Background Treatment Just as it is for all of the hormonal system from the hypothalamus down to the actual hormonal glands, general good health is important. In fact, the hormonal system is particularly sensitive to factors such as sleep and nutrition. It is incongruous for a CFS patient to pursue treatment for hormones without addressing such basics as nutrition and sleep. It is even possible that a few patients with slightly deficient thyroid hormones can find the problem rectified directly and quickly just through improving nutrition. A variety of nutrients are essential for the conversion of T4 to T3; a deficiency of any one may impact the level of T3. A good multivitamin and mineral on top of a healthy diet is specifically recommended.

Follow-up Testing Follow-up testing is particularly important when on thyroid treatment. The first should be done at three months after starting treatment. It is thought the blood taken for the test should be done within 1-4 hours of taking any T3 medication. The follow-up test is important in assessing whether treatment has raised the various thyroid hormones up to a desirable level and no more. It also gives an indication of whether suppression is occurring. Readers may want to consult this chapter again when they get their results back to decide whether the results have implications for changing their treatment. Patients should continue to receive follow-up testing every three to six months until their thyroid hormone levels are stabilised. Once stabilised, patients should be retested once a year.

Causes of Hypothyroidism Particularly Relevant to CFS The thyroid is particularly vulnerable to environmental pollution. Quite simply, it mistakes some pollutants as nutrients. Two pollutants known to induce thyroid damage are mercury and fluoride. Thyroid problems have been associated with pernicious anaemia. This is caused by a low amount of vitamin B12 in the blood. Although about two-thirds CFS patients are known to be deficient of B12 in the brain, a deficiency in the blood is probably rare.

Conclusion Hypothyroidism is a cause of CFS in only a very small number of cases. It seems that in most CFS patients, thyroid abnormalities, if any exist, are a result of the illness and not a cause. Some doctors believe that a more subtle form of thyroid disease is rife among CFS patients. This form of sub-clinical hypothyroidism is yet to be recognised by the mainstream medical profession. It can be treated with thyroid hormones and many patients improve on it; however, the safety and long-term efficacy of this treatment is in question. There is little common ground to this debate in which the medical community can meet. Unfortunately for the patient, this can mean the treatment they receive is not just based on medical diagnosis but also in what political camp their current doctor resides.

For the patient seeking treatment, hopefully this chapter will help them make an informed decision as to the type of doctor they consult (by asking specific questions beforehand) and enable them to fully comprehend any proposed treatment. If treatment is being considered, it is wise to first have a clear understanding and agreement with the doctor as to the intended benefit, likelihood of benefit, potential and likely risks, what monitoring of the condition should take place, the form and cost of treatment and the proposed duration of treatment. If there are any remaining doubts, the patient may either do more independent research or seek the opinion of a third party medical professional. Anyone with a chronic illness is liable to suffer more with the ‘fear of missing out on a good treatment’ than the ‘fear of potential dangers of treatment’. Never be afraid to turn away from a proposed treatment if you feel unsure, at least if only to consider it for a bit longer. This is a chapter, extracted from the book ‘Hormonal Dysfunction In CFS, FMS, CFIDS and M.E.’. More details on the book and how to purchase it at www.CFS-FMS-HormoneTreatment.co.uk

Bibliography for Thyroid Chapter Extract Books: Ali, M. M.D. (1995) The Canary and Chronic Fatigue, New Jersey, Life Span Press. Regelson, W. M.D., Colman, C. (1997) The Super Hormone Promise, New York, Pocket Books. Teitelbaum, J. M.D. (2001) From Fatigued to Fantastic, NY, Avery. Wilson, J. L. N.D. D.C. Ph.D. (2003) Adrenal Fatigue The 21st Century Stress Syndrome, CA, Smart Publications. Articles: Cannon, JG. Angel, JB. Abad, LW. O'Grady, JL. (1999) Hormonal responses to stress in CFS, www.immunesupport.com Dr. Charles, S. (2003) Chronic Fatigue Syndrome & Thyroid Function, www.immunesupport.com Dr. Friedman, T.C., Kimball, C., Endocrine Causes of Chronic Fatigue Syndrome (CFS)/Chronic Fatigue Immune Deficiency Syndrome (CFIDS): A Brief Guide for Patients and Primary Care Physicians, www.goodhormonehealth.com Jones, D. (August 2001) The Scandal of Thyroid Care, What Doctors Don’t Tell You, Vol 12 No 5. Jones, D. (December 2001) Thyroid Problems, What Doctors Don’t Tell You, Vol 12 No 9. Some CFS Patients Benefit From Low-Dose Steroid But Side Effects Too Risky (1998) Journal of the American Medical Association, www.immunesupport.com Dr. Myhill, S., Hypothyroidism - how to treat it, www.drmyhill.co.uk Dr. Myhill, S., Hypothyroidism - diagnosis of, www.drmyhill.co.uk Pinching, T. (November 2003) Thyroid Thoughts, InterAction No 46 (Quarterly newsletter for the UK charity Action for M.E.). Thyroid Deficiency (2003) The Life Extension Foundation, www.lef.org © James Burton. All rights reserved. Reprinted with permission of the author.



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