Middle-aged lady, twenty pounds overweight.

Doing everything I can, doctor. Everything imaginable. Diet: I eat practically nothing. Exercise: all the time! Weight Watchers doesn’t work. Jenny Craig, South Beach, the Zone; I’ve tried it all. Nothing works. Have to lose weight. Have to lose weight.

Yada, yada, yada.

Oh look: A few years back I diagnosed you as hypothyroid and gave you some Synthroid. Are you taking it?

Nah; I stopped that. I just didn’t want to take it.

Hmm. Send some blood work. Low and behold: TSH is 7. That’s high, and it means her thyroid is underactive, which is probably a big part of why she’s having so much trouble with her weight.

She’s asked to be notified by email, so I sit myself down at my little keyboard and compose:

Labs are back; report attached. Cholesterol, sugar, blood count all fine. BUT: I don’t want to hear one more word from you complaining about not being able to lose weight IF YOU DON’T TAKE THE DAMN SYNTHROID. Your TSH is 7. That’s hypothyroidism. Until we get you titrated to a dose that gets your TSH below 2, nothing is going to change, including difficulty losing weight. So put your big-girl panties on and let me know where you want me to send a new prescription for Synthroid. Then get back here in 6-8 weeks for another TSH. Dig?

But my finger hesitated over the SEND button. Could I really send that?

I hit SAVE DRAFT and started over:

Labs are back; report attached. Cholesterol, sugar, blood count all fine, but the TSH is still a little high. I really think you should try the Synthroid again. It’s almost certainly the reason you’re having so much trouble with your weight. Why don’t you let me know what drugstore you use so I can send a new Synthroid prescription. Then we can check another TSH in about 6-8 weeks. OK?

I read both versions over again. Back and forth. Over and over.

Then I hit SEND.

Guess which one?

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

Image credit: Shutterstock.com