Updated July 01, 2014.
One of the nation's top hormonal health care experts, Erika Schwartz, MD, has shared her approach to optimal treatment for hypothyroidism, as part of this series featuring practitioners with expertise in hormone balance and hypothyroidism diagnosis and treatment.
Dr. Erika Schwartz believes that the thyroid is a most important piece of the puzzle that is our entire health, and to illutraste that point, she tells the story of her patient.

LM was a 49 year old woman with a twenty year history of hypothyroidism. With access to the best endocrinologists in New York City, LM has been consistently and solely prescribed Synthroid (levothyroxine) over the past 20 years.
At times, when seeing an endocrinologist for the twice a year mandatory blood check and cursory visit, LM asked for help with stubborn weight gain, foggy thinking, memory loss, cold intolerance, progressive fatigue and lack of energy. The doctors predictably offered the same advice: "go on a stricter diet and make sure you exercise." Diligently, LM followed a slew of " medically proven" diets and worked out for hours at the gym.

The results were never noticeable or satisfactory to LM.

She decided to take matters into her own hands and find a doctor who looked at her thyroid problem with fresh eyes.

She found me.

Today, a short 8 months after starting to work together, LM is 20 pounds lighter, thinks clearly and is chock full of energy. In her own words, she jumps out of bed every morning raring to go. When I see her at her three visits each year, she tells me her improvement is nothing short of a miracle. I beg to disagree.

In the world of medicine where evidence based medicine is king LM is the evidence.

For Dr. Schwartz, the case of LM illustrates a critical issue that she finds to be the norm in her clinical experience: "Levothyroxine (Synthroid) alone may correct the blood picture (TSH goes back to normal range) but it does not provide long term consistent clinical improvement for the patient. Says Dr. Schwartz, "Using an arbitrarily determined, absurdly broad range blood test (TSH) as the primary and often sole marker and decision maker for the diagnosis and treatment of hypothyroidism doesn't work and is illogical if we are looking to help patients feel better and eliminate the long term effects of hypothyroidism Not treating the patient's symptoms because the blood tests are arbitrarily determined to be within normal range is a gross and inexcusable mistake in the general practice of medicine. I treat patients, not blood tests."
As a conventionally trained physician, Dr. Schwartz did send LM for a battery of blood tests and evaluations to eliminate obscure causes for her symptoms, which were caused primarily by her long-standing, partially-treated hypothyroidism. Once found to be normal on paper, Dr. Schwartz treated her clinically. Her clinical picture improved dramatically when she was placed on a compounded combination of T3 (liothyronine) and T4 (levothyroxine).

According to Dr. Schwartz, LM represents thousands of patients she treats on a regular basis with similar issues caused by under diagnosed and undertreated low functioning thyroid. Dr. Schwartz has shared a quote from a paper she cowrote with Dr. Kent Holtorf, titled "Hormones in Wellness and Disease Prevention: Common Practices, Current State of the Evidence, and Questions for the Future," which was published in the journal Primary Care Clinical Office Practice, in 2008:

Historically, an elevated thyrotropin with normal thyroxine and triiodothyronine levels has been considered compensated or subclinical hypothyroidism and diagnosed as euthyroid with no requirement for treatment. A plethora of studies have, however, demonstrated that in spite of the normal triiodothyronine and thyroxine values, subclinical and non-diagnosed hypothyroidism is often associated with significant symptoms and an increased risk of morbidity and mortality. In light if this, it has been proposed that the term subclinical hypothyroidism be replaced by the term mild thyroid failure (MTF). The diagnosis of MTF is particularly important in the aging population in the areas of prevention and wellness. MTF is a treatable condition associated with increased cardiovascular risk and numerous signs and symptoms that might otherwise be attributed to "usual" signs and symptoms of aging, including fatigue, depression, memory loss, cognitive dysfunction, dry skin, constipation, leg cramps, cold intolerance, weakness, water retention, diminished sweating, weight gain, and diminished exercise tolerance. Significant improvement may occur with treatment.

Erika Schwartz, MD is a holistic physician, founding director of the Bioidentical Hormone Initiative, and Chief Medical Officer for AgeMD: The Age Management Institute, a practice in New York City that focuses on hormone treatment, nutrition, fitness support, and biomarker evaluation.
Erika Schwartz's websites: www.DrErika.com and www.BioidenticalHormoneInitiative.org.

_{Source: Email interview with Erika Schwartz, MD - December 2010}