Dear Dr. Repas, on Treating Hypothyroidism

Dear Tom

I read your article in magazine from January 10, 2009 and wish to reply. To restate your position, being that most people with hypothyroidism and normal thyroid function tests who continue to report complaints typical of thyroid hormone deficiency, are generally suffering from other conditions such as depression, polycystic ovarian syndrome or non-endocrine conditions.

I have heard similar analyses of resistent hypothyroid symtoms many times at endocrine conferences or hallway “round tables”. The speaker generally rolls their eyes and gives a sly smile to the audience while reporting their conclusion (meant to imply frustation at kooky patients and their persistent complaining).

I do not have the definitive study which confirms or refutes this type of conclusion. I do have a few questions for those who hold beliefs similar to yours, however.

First, why is there such a wide range of normal for thyroid hormones, and TSH? For TSH there is almost a 10 fold difference between high and low normal values. Second, why is there such a wide spectrum in the function and tissue location of 5′ deiodinase (to convert t4 to t3)? Additionally, why are t3 levels so exquisitly sensitive to minor metabolic challenges such as missing a meal or coming down with a virus ? Thirdly, do you think a single does of t4 daily can even remotely reproduce the daily variation and rhythm of thyroid hormone economy produced by a normal thyroid-pituitary axis? Given the extraordinary variability of thyroid hormone levels in the blood, I imagine there are at least a billion different combinations of set points for these levels available for each individual. Finally, in all the years that synthetic thyroid hormone has been available and promoted by pharmaceutical companies, where are the studies that show pure t4 preparations are clinically superior to biologic extracts such as Armour thyroid or careful t4 with t3 combination therapy?

I don’t have the answer to these questions either. What I do have is a healthy respect for persistent complaints by hypothyroid patients. Unlike the results you report with combination treatments my success has been much better. I will be happy to help out my fellow endocrinologist who wishes to dismiss these difficult patients, by accepting them into my practice.


Gary Pepper, M.D.

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  • gina

    Dear Dr. Pepper,

    I belong to an thyroid patient forum, which alerted us to several articles on thyroid topics by Dr. Repas. A number of us have commented on his blog, but, as expected, the good doctor gave us “kooky patients” the online equivalent of rolling his eyes .

    I just wanted to tell you how fantastic it was to read your response. Because it is so difficult to understand why endocrinologists, the ostensible experts on thyroid disorders, usually don’t “get it”, it is especially gratifying to hear from one who does.

    Thank you!

  • Dr. G. Pepper


    I appreciate your comment. Doctors who “buck the system” by speaking up about the benefits of using t3 and Armour are also subject to the “kooky” label. When I introduce the subject of combination therapy to a patient who expresses dissatisfaction with Synthroid or similar pure t4 therapy, I always let them know that other physicians may consider my approach “off beat”.

    In fact, just this week, one of my patients on Armour visited an internist in our town for the first time, and was told that my approach to treatment was completely unacceptable. I sent this doctor a copy of the same letter I sent to Dr. Repas.

    Perhaps to gain some exposure for this “off beat” treatment, you and the other members of your group could request that the editors of endocrinenews put my letter on the homepage of so other physicians could be esxposed to another point of view to this common situation.

    Gary Pepper, M.D.

  • blogcterv

    Thanks for the useful site.Keep up the good work.God bless you and keep you.

  • Renee

    Thank goodness there are Doctors like you out there! We need more like you, who are willing to take the “problem patients” off the hands of those endocrinologists. To some extent, we patients can still vote with our wallets when we know who to go to, and where you are. Thank you!