The Optimal Treatment for Hypothyroidism: Ken Woliner, MD

Dr. Ken Woliner Shares His Approach to Treating an Underactive Thyroid

Dr. Ken Woliner: "The absence of hypothyroidism symptoms or side effects from therapy is what I am looking for...".

One of the leading practitioners on hormonal health and thyroid care, Ken Woliner, MD, has shared his approach to optimal treatment for hypothyroidism, as part of this series featuring practitioners with expertise in hormone balance and hypothyroidism diagnosis and treatment.

According to Dr. Woliner: "Rather than focusing on a specific range of various lab tests, I think of "optimal treatment" based upon my patients' symptoms [1].

More than any one laboratory test, the absence of hypothyroidism symptoms or side effects from therapy is what I am looking for [2]."

Dr. Woliner asks: Is my patient at an ideal body weight (or dress size)? Or does she/he have trouble losing weight? Does my patient have a low body temperature (cold hands or feet) or frequently feel cold? Is she fatigued? Is her cholesterol (especially the LDL cholesterol) high? What about her skin, hair, and fingernails? Even if someone is over 60, they shouldn't have rough, dry, brittle hair or hair thinning. Persistent muscle pain or joint aches? Perhaps their thyroid isn't balanced properly! Puffy skin, face, or tongue (with ridges on the side of the tongue) scream hypothyroidism that is in desperate need of treatment.

Says Dr. Woliner: "Regardless of "normal labs," when there aren't other obvious causes of troublesome symptoms that are likely caused by hypothyroidism, I will empirically treat the patient with thyroid hormone to free her/him from their suffering [3,4]."

When treating a patient more based on symptoms than on lab tests, Dr. Woliner uses the analogy of "driving a car with a broken speedometer." Imagine the traffic light turning green and you are about to turn onto the on-ramp of the local interstate highway. You don't look at the dashboard constantly, do you?

No. Instead, you put your foot on the accelerator pedal slowly but surely. Every so often you gauge your speed compared to the traffic. Not fast enough yet? Press your foot heavier to get your car up to speed. If you "feel" like you're going the right speed, you keep your right foot at the same place on the gas pedal. Oh no! The taillights of the cars in front of you are getting too close! No problem. Just take your foot completely off the accelerator pedal for a few seconds and your car will slow down. When you're now at the right speed, you'll put your foot back on the gas, but not as strongly as before, and you'll be just fine. If you're an attentive driver, you will hardly ever need to brake when driving on the highway!

According to Dr. Woliner:

I start at a low dose, and gradually increase, steadily but surely, with a dose change occurring approximately every two to four weeks. For example, a patient new to thyroid hormone may start on desiccated thyroid (Nature-Throid, Armour Thyroid, etc.) 30 mg (1/2 grain), 1 tablet per morning (1/2 hour before iron, calcium, fiber, etc.). Every two weeks, she would reassess her symptoms. Still feeling fatigued, constipated, cold, and not losing weight despite a decent diet of protein and colorful vegetables and fruits? It's time to go up by an extra tablet per day. By giving "extra pills" enough for four dose changes (1 --> 2 --> 3 --> 4 pills per day), my patients can get the equivalent of four visits in the price of one.​

Yes, there are potential dangers of over-treatment of hypothyroidism [5]. When going up slowly, however, side effects, when they do occur, are mild and transient. I advise my patient that if they get the "Cuban coffee" feeling of palpitations, anxiety, insomnia or an "inner restlessness" (a fidgety feeling is how my patients describe it), they are to take zero thyroid tablets for a day or two, their symptoms subside, and then they can resume, but at a slightly lower dose. If side effects do not resolve, or are especially troublesome, they can call me day or night to get advice on what to do next. Fortunately, real problems are rare and I don't have to field too many after-hours calls!

Dr. Woliner believes that the therapies employed to treat hypothyroidism are extremely safe, but he also wants to point out the potential harms of what he calls the "broken speedometer" method of hypothyroidism treatment. Too much thyroid can lead to an abnormal heart rhythm called atrial fibrillation. In addition to ordering an EKG at least once a year, he teaches his patients how to measure their pulse, so they know that they have a regular rhythm. According to Dr. Woliner:

Left unchecked, atrial fibrillation could lead to a stroke, but not right away. Typically, the heart would have to be irregular for at least two weeks. Note too that under-medicated hypothyroidism can also lead to atrial fibrillation [6].

The other theoretical side effect is thinning of bone density, or osteoporosis. I say theoretical because daily doses of up to 191 micrograms (mcg) of levothyroxine (Synthroid, T4) have been proven in the journal Lancet to make bone density thicker [7]! The equivalent dose is approximately 2 grains of desiccated thyroid (Armour Thyroid) or 50 mcg of liothyronine (Cytomel, T3). I've seen patients on doses of up to 12 grains of thyroid do extremely well with improvement in bone density [8]. To be on the safe side, I do order axial bone density (DEXA) scans at least every two years for my thyroid patients.

In discussing "optimal treatment of hypothyroidism," Dr. Woliner also wants to warn patients about three unusual situations that he's seen recently.

To summarize, Dr. Woliner believes that there are many "ranges of lab tests" out there, and, he says, the lab will use a reference range that compares to you to 95% of the population, many of whom are fatigued, overweight, and sick enough to be treated with prescription antidepressants and cholesterol-lowering meds [12].

Says Dr. Woliner:

Doctors that are still able to, and are willing "to think," realize that "common-normal" isn't the same as "optimal-normal", and will adjust ranges of the TSH, free T4, free T3, Reverse T3/Total T3 ratio, and thyroid antibodies to those that are more appropriate [13]. But "secondary hypothyroidism" and various types of "thyroid hormone resistance" are still missed by these narrowed ranges, so I emphatically feel that listening to my patients' symptoms, performing periodic physical exams, and monitoring for adverse effects to be far more effective than any one lab test in achieving "optimal treatment of hypothyroidism."

Kenneth N. Woliner, M.D., A.B.F.M. is a board-certified holistic physician. His practice, Holistic Family Medicine, is located in Boca Raton, Florida.

Holistic Family Medicine website:
Source: Email interview with Ken Woliner, MD - December 2010


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Revised 21 September 2000.
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[8] Marconi Transatlantic Wireless Telegraph. "Medicine Aids Girl Who Never Grew Up; ; Short Treatment Causes Increase in Height and General Physical Improvement. NEW VOCABULARY ACQUIRED Although 23, She Formerly Used Only Three or Four Words -- Now She Is Loquacious." NY Times. 27 December 1908.
[9] Goday-Arnó A, García Rico A, Martínez-Riquelme A, Cano-Pérez JF. [Graves Basedow disease following treatment with magistral formulae for obesity. Jod-Basedow phenomenon?]. Rev Clin Esp. 1996 Aug;196(8):536-8. Spanish. PubMed PMID: 8984540.
[10] FDA Enforcement Story 2005. "Smuggling, Selling, and Distributing hGH" EnforcementStoryArchive/UCM091079.pdf March 2006.
[11] Miranda EJ, McIntyre IM, Parker DR, Gary RD, Logan BK. Two deaths attributed to the use of 2,4-dinitrophenol. J Anal Toxicol. 2006 Apr;30(3):219-22. PubMed PMID: 16803658.
[12] Elrick H. Normal vs. optimal. J Natl Med Assoc. 2001 Oct;93(10):410-1. PubMed PMID: 11688922; PubMed Central PMCID: PMC2594072.
[13] Dickey RA, Wartofsky L, Feld S. Optimal thyrotropin level: normal ranges and reference intervals are not equivalent. Thyroid. 2005 Sep;15(9):1035-9. Review. PubMed PMID: 16187911.

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