Updated June 09, 2015.

Patient-oriented Web sites and books point out a fact that Rosenthal skims right by: The problem is not only inadequate patient counseling, but it's a fundamental lack of agreement in the medical community over whether hypothyroidism is even the goal -- and not just a side effect -- of RAI.

In fact, hypothyroidism is not clearly the standard goal of RAI for a number of prominent medical authorities, including the American Thyroid Association itself, whose "Treatment Guidelines for Patients with Hyperthyroidism and Hypothyroidism" clearly state: "The treatment of Graves' hyperthyroidism is directed toward lowering the serum concentration of thyroid hormones to reestablish a eumetabolic state." (2) This indicates that the goal is euthyroidism -- a normal TSH level -- and not hypothyroidism.

The other leading professional organization for thyroid care, the American Association of Clinical Endocrinologists, reinforces this, saying in their "Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism" that "...some [clinical endocrinologists] prefer use of a small dose [of radioactive iodine] in an attempt to render the patient euthyroid ." (3)

It's not just the endocrinologists who aren't all on the same page. Family physicians, who treat the majority of people with thyroid disease, recently published in their journal American Family Physician, that "the goal of hyperthyroidism] therapy is to correct the hypermetabolic state with the fewest side effects and the lowest incidence of hypothyroidism ." (4)

And finally, there's the granddaddy of thyroid references.

Werner & Ignbar's The Thyroid: A Fundamental and Clinical Text, Ninth Edition as late as 2005 wrote: "Some have suggested that large doses should be given to most patients and that hypothyroidism should be accepted as a desired consequence, rather than as a side effect, of [RAI] therapy." The implication here is that hypothyroidism is viewed as a side effect, and not the goal.

(5)

The bottom line: Rosenthal has it wrong. It is not agreed-upon fact that hypothyroidism is the intended goal after RAI.

Do Conventional Thyroidologists Mismanage Hypothyroidism?

Rosenthal is clearly of the opinion that conventional thyroidologists do not mismanage hypothyroidism. But where is the research to support her opinion?
The Colorado Thyroid Prevalence Study found that the majority of people being treated for diagnosed thyroid disease were outside the normal TSH range, and were therefore not at optimal therapeutic range. That same study estimated that millions of Americans had thyroid disease, but were not diagnosed. Various studies, including ones conducted by the Thyroid Foundation of America, have shown that patients -- and some studies report a majority of patients -- do not feel well when they become hypothyroid after a period of hyperthyroidism.

Clearly, someone is mismanaging hypothyroidism...but none of these studies pinpointed the specialization of the practitioners involved.

But until such time as studies have been done to compare and contrast the diagnosis and treatment success rates -- including qualify of life and patient satisfaction surveys -- of patients being managed by a thyroidologist/endocrinologist, versus other types of practitioners, there is no objective way to know who is mismanaging hypothyroidism . Until such studies have been done by unbiased researchers, it's all anecdotal discussion.

Is RAI Use Less Outside the U.S Because of "Cultural and Attitudinal Barriers?"

Rosenthal herself summarizes the dramatic differences in RAI usage in the U.S., as compared to other countries:

• 69% of the members of the American Thyroid Association use RAI as the treatment of choice, 30.5% used antithyroid medications
• Only 22% of the members of both the European Thyroid Association and the Chinese Thyroid Association use RAI as the treatment of choice, 77% used antithyroid medications
• In Japan and Korea, only 11% of members of the corresponding associations reported that RAI was the treatment of choice, and 88% used antithyroid medications
• Among members of the Latin American Thyroid Society, 15.3% chose RAI as the treatment of choice, 83% chose antithyroid medications
• In Australia, 19% chose RAI, compared to 81% for antithyroid drugs(1)

Yet, Rosenthal dismisses these dramatic differences as a result of "cultural and attitudinal barriers," in particular, the Asian fears of "radiation" in general after the atomic bombs of the 1940s.
Claiming that only cultural and attitudinal barriers are at play overlooks the serious medical concerns some practitioners have -- including some in the U.S. -- regarding RAI. And in particular, they do not explain why, even when practitioners outside the U.S. do use RAI, they rarely use it on women under 40, and almost never on children, citing concerns about the risks of cancer and genetic mutations, as well as potential impact on fertility. (6)