I have been experiencing extreme fatigue, irritability, weight gain, and
depression for many months now and finally decided to get a complete
physical. My sister is a nurse practitioner in California and told me that
these symptoms often indicate a low thyroid condition. My thyroid T4
reading was 7.2 which my doctor insists is well within the "normal range",
but according to my sister this reading should be closer to 10 and that
I am really "borderline normal" and might benefit from thyroxin treatment.
My doctor does not concur. I am looking for personal experiences, articles,
or physicians who have researched this area who can either support or
refute the need for thyroid medication with a 7.2 T4 score. My doctor is
suggesting anti-depressants which I am loath to try if a less drastic
medication could possibly help me.

All advice/information is appreciated.

Barbara Roy

What other conditions did your physician rule out as possible causes of your
symptoms?

Please forgive me, but...

.soapbox ON

A reading of 7.2 on a T4 test is *not*, by itself, sufficient information to
diagnose biochemical depression.  It has been noted already by a number of
researchers that physicians are *sometimes* (not always; no flames, please) too
quick to ascribe women's symptoms to mental or emotional causes, when a male
presenting with the same symptoms would be tested for other physical conditions
before concluding that the cause of the symptoms is psychiatric.  Also, studies
of (e.g., women & men with heart conditions; also men & women who are HIV+)
show that males are more often treated more aggressively with more advanced
techniques, even when they present with the same severity of disease as women.

Now, I'm sure that there's lots of relevant info here which you did not mention
here, for the sake of brevity in your post.  I.e., I'm sure that your physician
did more in the "complete physical" than merely run a T4.  However, if, after
thorough testing, your physician believes that your symptoms (which you say
you've had for "many months") are caused by depression, doesn't it seem
appropriate for you to consult with a psychiatrist to determine the best course
of treatment for this depression (of substantial duration) rather than just
riding off into the sunset with a prescription for an antidepressant?

.soapbox OFF

Sorry for the diatribe.  Somehow this post just got to me, probably for all the
wrong reasons.

------------------------

Philosophy Department;Wesleyan University;USA

My "complete physical" consisted of drawing a tube of {*filter*}, checking my
{*filter*} pressure, listening to my lungs & heart, a PAP smear, and checking my
ears. Took 15 minutes tops including the discussion of my symptoms. The lab
results came back with a T4 of 7.2 and a TSH of .82 - within the normal
range according to the doctor. She recommends anti-depressants. But I
really believe that there may be a physical cause for my lethargy, depression,
weight gain, and irritability. If depression were my ONLY symptom, I wouldn't
mind taking the {*filter*}, but it seems like a quick fix solution that may not
attack the true cause.

Barbara

Weeg Computing Center
University of Iowa
Iowa City, IA. 52242

There undoubtedly IS a physical cause for your constellation of symptoms;
you're not an incorporeal being after all.  A diagnosis of depression is
certainly not inconsistent with these symptoms; in fact, it could very
well explain _all_ of them.  If this is the case, it is likely that anti-
depressant therapy would help all or most of these symptoms.  I won't
offer any particular opinion in your particular case, but it's not as
if your symptoms are necessarily pointing to thyroid replacement therapy.

You could always look for a second opinion from an endocrinologist
or a psychopharmacologist, I suppose.

--
Steve Dyer

Interesting.  My "complete physicals" are about the same, except they usually
include a urinalysis as well.

So just for fun, I called the Yale University School of Medicine, Internal
Medicine Department and asked about the "Corporate Medical/Executive Physical"
which they offer through the Yale General Medicine Group at Yale-New Haven
Hospital.  I asked, "Suppose I wanted a complete 'Executive Physical'?  I am a
XX-y.o. <sorry, not going to announce my age on the Net> female with no known
health problems, and no indications of acute illness.  Just looking for the ol'
complete checkup..."   Well, the receptionist said that she wouldn't book it
for me unless I had a corporate purchase order, or written assurance that my
insurance plan would pick up the tab.  I told her that my insurance co. would
NOT pay (we just got switched to an HMO, as of Jan 1), but that I would
self-pay.  She refused to book the appointment, because (she said) "The bill
can easily run to a couple thousand dollars for the whole thing," and she's
seen unsuspecting people get "stuck" with a huge bill before, so she wouldn't
do that to me...

Now I got off the phone & contemplated that a bit.  It leads me to wonder who's
the fool?  Is it me (unimportant as I am), for getting totally inadequate
medical checkups because that is all I can afford, or that is all I've elected
to pay, or that is all my insurance co. would pay?  Or is it the 'Executive'
who's paying (or having paid on her or his behalf) thousands of $$ annually for
a physical, most of which is unnecessary?  SHOULD I be saving $2000/yr/person
for myself & my family to get REALLY complete physicals?  Why does someone with
more money than I get more health care (without even ASKING me if I want to OPT
for that level of health care -- I guess its only for C.E.O.'s & not for us
huddled masses yearning to breathe free...)?  Or are those C.E.O.'s getting
taken for a ride?  Bilked, for unnecessary services?  Which is it?

I dunno ... maybe I've been reading sci.med for too long.  Maybe I need to take
a break.  But day after day after day I keep firing up Usenet News and finding
story after story after story after story on sci.med of folks who are afraid
that their doctors are 'shooting from the hip', are making snap diagnoses
without ordering enough tests, without collecting enough information; are
prescribing treatments *without addressing what is actually bothering the
patient* -- in short, from folks who feel that they are not being taken
seriously by the very experts they are turning to regarding something as
important as their health.  Some of these stories have even come from folks
with substantial medical training, when they, themselves, have been patients.
(c.f. Steve's remark about being surprised that <folks with a certain health
problem> aren't more disposed to commit {*filter*} -- after he, himself, was
dismissed without being taken seriously by his own doctor.)

Patients recount here story after story illustrating how and why they can't
TRUST their doctors.  Doctors recount here a fair number of stories of their
own, illustrating how & why they can't TRUST their patients.  C.E.O's get $2000
physicals.  Peasants get $95 physicals.  Lots & lots of people get no
preventative care at all, going instead to emergency rooms for band-aid jobs
when they feel so lousy that the prospect of dealing with some billing clerk
about how to pay money that they don't have - sounds better than putting up
with the acute illness or injury from which they suffer at the moment.

CLEARLY something is wrong here.

I have a message sitting on my answering machine from someone compiling a
medical ethics text of some sort, who heard (through the grapevine) that I've
been working on some kind of project involving biomedical ethics and trust, and
do I have a manuscript or something for this anthology?  I don't, but I kind of
wish I did.  (Somehow the Grapevine screwed up ...)

Please pass the Xanax...no, nevermind, make that Proz.. uh, Warm Milk, anybody?

------------------------

Philosophy Department;Wesleyan University;USA

[Ruth called Yale U. School of Medicine and asked about executive physical.
Told it could run to a couple of thousand so receptionist wouldn't book
without insurance coverage]
It's my understanding that a routine complete physical is not terribly
useful.  Once in a while, somebody has a condition detected through routine
tests, but the probability is too low to make the cost worth it for
asymptomatic people.  

But this is a different matter.  If someone does have symptoms, or if there's
a reason they're at risk for a particular condition (e.g. family history),
then there is some value to tests.  Otherwise, it's a waste of resources -
and not just financial ones.  I consider it enough of a hassle to find
a couple of hours to go in for the annual routine gynecological exam (that's
round trip drive time and time in the waiting room; the exam itself is just
a few minutes) but I recognize that pap smears can actually detect
conditions that are curable only if caught early.  Why on earth would I
want to spend my time on a whole battery of tests that are unlikely to show
anything, unless I actually do feel awful?  

But most preventive care has little to do with doctors.  There are a handful
of routine exams that are useful.  But most of what I would consider
preventive care is a matter of education on things like nutrition and
what symptoms actually mean anything.  

As for acute illness or injury, people go to emergency rooms because they
don't know where else to go.  Yes, that means they haven't established a
relationship with a doctor, but surely it isn't worth draining a couple of
grand a year for tests that are rarely useful in the name of establishing
such a relationship.  

It isn't clear to me.  I do have criticisms of our medical system, some of
which fall along the lines Ruth discusses (e.g. well-baby checkups are
probably useful and conventional insurance doesn't cover them).  But
there's a big gap between saying our system of funding medical care fails
the poor and/or unemployed who do fall ill and advocating extensive tests
for everybody.

Miriam Nadel

There is very little evidence to support almost any routine physical
examination.  There is good reason to check {*filter*} pressure, and some
evidence to support {*filter*} exams, testicular exams, and thyroid exams
in some populations.

For laboratory tests, Pap smears are clearly beneficial, and mammograms
are beneficial for women over age 50.  Cholesterol screening is
recommended, but there is still no evidence that this reduces mortality,
and treating high cholesterols may actually be harmful.

I believe in performing an initial complete history and physical
(takes me about 35 minutes for a healthy young {*filter*}) to have
baseline documentation, but there is no good evidence to support
doing this.

Various corporations do seem to want to pay for high-priced executive
physicals as if there were some evidence that these actually are of
some benefit.  There is no such evidence.

--
David Rind

I don't know of the data comparing responses to women vs. men, but there
is certainly data that overall physicians are much too *slow* to
ascribe symptoms to depression.  Depression is perhaps 50% underdiagnosed
by primary care physicians and is a cause of many extensive and
expensive medical workups looking for explanations for vague
constitutional symptoms.
--
David Rind

Well, doesn't it make sense to look for potentially curable causes of
vaguely ill health before assuming it's a problem that can only be treated
symptomatically?

By the way, is there any interesting research on _causes_ of depression?
I sometimes wonder if (given the way influenza or bronchitis can sometimes
cause depression) some episodes of depression are going to turn out to be
an influenza-like virus with no other symptoms.

[Note: I'm throwing this out only as a remote possiblity.  I do *not* want
to start a following of people who believe in it... I only wonder if anyone
more knowledgeable than myself has given it any thought and, if so, what
their reaction is.]
--
+ Michael Covington - Artificial Intelligence Programs - U of Georgia - USA
+ Unless otherwise noted, these are private opinions, not official statements.

When you say "thyroid T4 reading", it's not clear whether you mean
"total T4" or "free T4 index."  The former measures total T4, the
latter measures amount of T4 that is available for use (loosely
speaking).  You could very well be normal in total T4, and depressed in
the more physiologically significant free T4 index.  

Let's assume that the value you gave was for total T4.  Get your free
T4 index checked, and if it is low, in light of your normal TSH level,
ask your doctor about the possibility of TSH or TRH deficiency.  This
is because, if your free T4 really is low, your TSH should be much
elevated.

FYI, the suggested approach to the patient with suspected
hypothyroidism includes the following:
1.  serum T4 level.
2.  free T4 index.
3.  TSH level.
The results of these three tests, along with the patient history of
course, are usually sufficient to get a good idea of the diagnosis.

It appears you may be missing one important piece of information.

Simon.