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Pseudo-Endocrine Disorders
Practical Management Strategies
2018
Michael T. McDermott MD
Director, Endocrinology and Diabetes Practice
University of Colorado Hospital
Michael.mcdermott@ucdenver.edu
Internet Information / Misinformation about
Endocrine Disorders is Abundant
Pseudo-Endocrine Disorders
Wilson’s Reverse T3 Adrenal
Syndrome Syndrome Fatigue
Cortisol-Related Mifepristone
Diabetes Treatment for
Type 2 Diabetes
Case History
38 y.o. woman self-referred for hormone evaluation because of
chronic progressive fatigue. She began feeling fatigue at age 28,
about 1 year after the birth of her second child. She also endorses
hair loss, inability to lose weight and persistent “brain fog”. She has
read the internet and is convinced this is a hormone disorder. She is
adamant that this is not due to depression. She has ordered some
tests on-line (cycle day 4) and they are abnormal.
PMH: Negative Meds: Vitamins
PE: BP 129/74 P 74 Ht 5’7” Wt 158 lb. BMI 24.8 kg/m2
General: normal Thyroid: normal Skin: normal
Case History 38 y.o. woman self-referred for hormone evaluation because of chronic fatigue, hair loss, inability to lose weight, “brain fog”. Test Results from On-line Orders (Cycle Day 4, 10:00 AM): TSH 2.1 mU/L (nl: 0.45-4.5) Free T4 1.0 ng/dl (nl: 0.78-1.81) Free T3 2.4 pg/ml (nl: 2.3-4.2) Reverse T3 23 ng/dl (nl: 10-24) TPO Antibodies: negative Tg Antibodies: negative Cortisol 12 ug/dl (nl: 10-20) ACTH 19 pg/ml (nl: 10-50) Testosterone 27 ng/ml (nl: 30-95) Estradiol 101 pg/ml (nl: 27-123) Progesterone < 1.5 ng/ml (nl < 1.5) DHEA 188 ug/dl (nl: 145-395) GH 0.04 ng/ml (nl: 0.05-3.0) IGF-1 57 ng/ml (nl: 60-220) She asks, “Do I have Wilson’s Syndrome or Reverse T3 Syndrome?
Wilson’s Syndrome
"Wilson’s syndrome" was coined in 1990 by E. Denis Wilson,
a physician practicing in Longwood, Florida.
http://www.wilsonssyndrome.com/meet-dr-wilson/
https://en.Wikipedia.org/wiki/Wilson%27s_temperature_syndrome
Wilson’s Syndrome
Pro-Survival Adaptation: lowering metabolism to deal with
famines / low food availability at the expense of enzymatic
efficiency. In normal circumstances, the body resumes normal
functioning when food supply is restored and/or stress removed.
This “conservation state” may persist for years and can lead to
chronic fatigue, allergy/immunological problems, and other
“poorly defined” health complaints may become common.
This state may be reset with proper therapy.
Wilson’s Syndrome Website
Wilson’s Syndrome
Susceptible People
Famine Survivors or Their Descendants
Scotch / Irish / Russian Ancestry
American Indian Ancestry
Holocaust Survivors
High Stress Survivors
Divorce
Death of Loved One
Family or Job Stress
Chronic Dieters
Wilson’s Syndrome Website
Wilson’s Syndrome
Susceptible People
To This May We Add:
Candida Albicans and Yeast Sufferers
Persons having Hypoglycemia
Persons with Eating Disorders
Persons with Sleep Disorders
Wilson’s Syndrome Website
Wilson’s Syndrome
Testing Protocol
Use an accurate mercury thermometer.
Take your temperature every 3 hours beginning
3 hours after you get up.
Average the readings over several normal days.
If average body temperature is > 1 degree below
normal, you may have Wilson’s Syndrome.
Wilson’s Syndrome WebsiteWilson’s Syndrome
Proposed Mechanism
Deiodinases (1 + 2)
T4 T3
Pro-Survival Adaptation
Chronic T4 to T3 Conversion Reduction
Specific Circumstances
Specific Individuals
MTM Adaptation from:
Wilson’s Syndrome WebsiteWilson’s Syndrome
Treatment Protocol
Cycling body temperature up to the normal range using the
proper thyroid (T3) supplements, then cycling down again.
Cycling is repeated several times until the body temperature
remains at normal level after stopping T3 supplements.
Typically this may take 3-4 cycles. In difficult cases, it has taken
as many as 11-12 cycles.
Using the wrong ratios can exacerbate the syndrome.
Wilson’s Syndrome WebsiteWilson’s Syndrome
ATA Public Statement
No scientific evidence supports the
existence of Wilson’s Syndrome.
Unsafe
ATA Website: www. Thyroid.OrgWilson’s Syndrome (1988) A 50-year-old woman died of an arrhythmia and heart attack while on excessive amounts of thyroid hormone prescribed by Wilson. (1992) the Florida Board of Medicine accused him of "fleecing" patients with a "phony diagnosis". The Board of Medicine and Wilson agreed to a 6-month suspension of Wilson's medical license, after which Wilson agreed to attend 100 hours of CME, submit to psychological testing, and pay a $10,000 fine before resuming practice. (1992) Wilson also agreed not to prescribe thyroid medication unless the Board of Medicine determined that the medical community had accepted "Wilson's Syndrome" and his treatment. Reference: State of Florida, Department of Health. February 12, 1992. Final Order Number: DPR9200039ME
Wilson’s Syndrome
(2012) Since I’ve published my book there has been growing interest
in and mention of Reverse T3, and the use of T3 in the treatment of
low thyroid symptoms. For example, many thyroid-related health
sites, books, fitness trainers, physicians, spokespeople, and
businesses, tout the importance of peripheral conversion of T4 to T3
and/or Reverse T3 (RT3) and the usefulness of T3 in the treatment of
low thyroid symptoms in patients with normal thyroid blood tests.
Over twenty years ago, I received a lot of opposition both from
mainstream and alternative medicine circles. Now, it’s great to see
that my ideas are being embraced and disseminated more and more.
Best regards,
Denis Wilson, MD (June 21, 2012)
http://www.wilsonssyndrome.com/meet-dr-wilson/Did I hear you right?
Wilson’s Syndrome
Check Your Order Your
Temperature Own Lab Tests
Find a Provider
Who Treats
Wilson’s Syndrome
Wilson’s Syndrome Website 2018Reverse T3 Syndrome
www.stopthethyroidmadness.comReverse T3 Syndrome
NDT: Natural Desiccated ThyroidReverse T3 Syndrome
Reverse T3 Dominance Syndrome (Alternative Name)
Theory
Reverse T3 (RT3) competes with T3 for thyroid receptor (TR).
High RT3 prevents T3 binding to TR: hypothyroid symptoms.
Fact
T3 has 100 x Higher Affinity for the
Thyroid Receptor Compared to RT3.
Schuster LD, Schwartz HL, Oppenheimer JH.
J Clin Endocrinol Metab 1979; 48:627-32If Only I Had a Little More T3!
Case History
A 47 year old woman has been experiencing fatigue for about 15
years but complains of “total exhaustion” progressively over the
past year. She does not sleep well but does not snore. Appetite is
poor. Mild weight gain (5 lb) in the past year. Cannot exercise
due to fatigue. She had a test for “adrenal fatigue”, says it is
positive and requests treatment for this condition.
PMH: Mononucleosis at age 18
Meds: Occasional prescription pain medication
PE: BP 128/70 P 80 Ht 5’8” Wt 157 lb.
(Orthostatic VS negative) Complete exam normal
Lab Report: Full Day Salivary Cortisol Profile –
Adrenal FatigueAdrenal Fatigue
Salivary Cortisol Profile
Normal
Adrenal FatigueAdrenal Fatigue Website
Adrenal Fatigue Website
Sometimes I Just Can’t Keep Up
Adrenal Support Products
“Adrenal support with real adrenal”Adrenal Support Products
“Made from raw, cold- “Raw Adrenal “Natural glandular”
processed bovine Glandular
glandular tissue” Concentrate”
“Blend of glandulars,
herbs, vitamins and
more”
?I Feel So Good on Adrenal Support!
Mayo Clinic Adrenal Fatigue Website
Hormone Foundation (Endocrine Society) Fatigue Website
Primary Adrenal Insufficiency
Diagnosis
Serum Cortisol and Plasma ACTH
▪ Cortisol < 5 ug/dl and ACTH > 2 x ULN - Supportive
ACTH Stimulation Test (250 mcg)
▪ Peak Cortisol (30 or 60 min.) < 18 ug/dl - Diagnostic
Salivary Cortisol Profiles Have Never Been Validated
Bornstein S, J Clin Endocrinol Metab 2016; 101:364-89Primary Adrenal Insufficiency
ACTH Stimulation Test
30
Normal
Serum
Cortisol 20
ug/dl Partial Adrenal Insufficiency
10
Complete Adrenal Insufficiency
0 30 60
Time (Minutes) After ACTHACTH Stimulation Test
Meta-Analysis: Primary Adrenal Insufficiency
Sensitivity: 92% (CI: 81-94%)
Good But Not Perfect
Specificity: Not Estimable
Bornstein S, J Clin Endocrinol Metab 2016; 101:364-89
Ospina NS, J Clin Endocrinol Metab 2016; 101:427-34Primary Adrenal Insufficiency
Stages of Development
Adrenal Functional Impairment Occurs in 4 Stages
Stage 1: h Plasma Renin Activity (PRA)
i / Normal Plasma Aldosterone (PA)
Stage 2: Stage 1 plus i Cortisol Response to ACTH
Stage 3: Stage 2 plus h Plasma ACTH
Stage 4: Clinically Overt Adrenal Insufficiency
Debellis A, J Clin Endocrinology Metab 1993; 76:1002-7Secondary Adrenal Insufficiency
Opioid Induced – Central ACTH Inhibition
On Fentanyl Off Fentanyl
Oltmanns K, J Intern Med 2005; 257:478-80Case History 48 year old man self-referred for treatment of Type 2 Diabetes Mellitus. His PCP told him that she was told Mifepristone (Korlym) is a new and very effective treatment for type 2 diabetes. He would like to be started on this new medication. You check with your local pharmacies. The cost for this medication is: $13,737.60 for 30 days $164,848 for one year You want to know what is the data for efficacy in type 2 diabetes. And where did this advice come from?
Diabetes in Cushing’s Syndrome
Treatment with Mifepristone
Mifepristone (Korlym) is approved for people with Cushing’s
syndrome who have type 2 diabetes or glucose intolerance.
Mifepristone blocks the glucocorticoid receptor and thereby
blocks cortisol action on tissues.
Fleseriu M. J Clin Endocrinol Metab. 2012;97(6):2039-2049Diabetes in Cushing’s Syndrome
Treatment with Mifepristone
Glucose AUC Oral Glucose Tolerance Test
Fleseriu M. J Clin Endocrinol Metab. 2012;97(6):2039-2049Diabetes in Cushing’s Syndrome
Treatment with Mifepristone
HbA1C
HOMA-IR
Fleseriu M. J Clin Endocrinol Metab. 2012;97(6):2039-2049Pseudo-Endocrine Disorders
Patients with Pseudo-Endocrine Disorders
Are Equally Important and Deserve Our
Full Attention and CompassionPseudo-Endocrine Disorders
What the Patient Says:
Fix My Thyroid, Adrenal, or Pituitary
Condition
What the Patient Means:
Please Help Me!Pseudo-Endocrine Disorders
The Patient’s Quality of Life is Poor
And He/She is Frustrated
It’s an Honor that She/He Entrusts You
With an Opportunity to Help Her/HimPseudo-Endocrine Disorders
Can you play a role in improving
this patient’s quality of life?
Can you help this patient even if
there is no apparent endocrine
disorder?Pseudo-Endocrine Disorders
Recommendations
Listen Attentively
Examine Your Patient
Offer Additional Testing, if Appropriate
Admit that Current Testing Options Have
Some Limitations
Always Provide Honesty, Encouragement,
and CompassionStand Out Above the Crowd
Pseudo-Endocrine Disorders
Recommendations
Good Sleep Regular Good
Habits Exercise Nutrition
Stress Depression Illness
Reduction Management Treatment
▪ Support Supplements – No Proven Benefit
▪ Hormone Replacement Therapy – Avoid Unless
Deficiency Documented.Comment I Found on Internet
“Many Endocrinologists are Trained
but not Educated.”
I Strongly Disagree.
But We Must All Be Lifelong Learners.
Never Stop Learning!Parting Thoughts
It’s An Exciting Time to be an
Endocrinologist!
There is So Much Still to Learn.
And So Many People We May Be Able to
Help!Thank You
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