Thyroid Conditions Series - Part 2: Hypothyroidism & Hashimoto's Disease
In this series, I'm discussing my approach to diagnosis, treatment, and management of thyroid conditions. In Part 2, let's take a closer look at hypothyroidism and Hashimoto's.
Welcome back to my 3-part series on thyroid conditions. I frequently treat hypothyroidism, hyperthyroidism, and autoimmune thyroiditis in my practice. When I first meet patients who suspect they might have poor thyroid function, or if they already have an existing diagnosis of hypothyroidism, I often hear the same thing, "My labs are normal, but I still don't feel right." I love helping these patients find the right treatment so they can finally feel like themselves again. This is my approach to diagnosing and managing hypothyroidism and Hashimoto's. To learn more about hyperthyroidism, see Part 3.
Hypothyroidism & Subclinical Hypothyroidism
In case you missed Part 1 of this series (which can be found here), let's review some common symptoms associated with low thyroid status, or hypothyroidism:
Symptoms of hypothyroidism:
fatigue
difficulty losing weight / unexplained weight gain
hair loss
dry skin
weak or brittle nails
heavier and longer menstrual cycles
constipation
depressed mood
brain fog
cold intolerance
muscle aches
joint pain and stiffness
swelling or puffiness of the body, face, or tongue
Symptoms of Hashimoto's thyroiditis:
painless enlargement of the thyroid, aka: goiter (this is not seen in all cases of Hashimoto's, however)
hypothyroid symptoms listed above
In rare cases of Hashimoto's, patient's may first experience an overactive thyroid as the antibodies begin attacking the thyroid gland. This is called Hashitoxicosis and may cause symptoms such as heat intolerance, unintentional weight loss, increased sweating, rapid heart rate, tremors, and anxiety or irritability.
Hypothyroidism occurs when the thyroid gland isn't producing enough thyroid hormone. The two main thyroid hormones produced are thyroxine (T4) and triiodothyronine (T3).
An underactive thyroid can occur for a variety of a reasons. The most common cause of hypothyroidism in the US is due to an autoimmune condition called Hashimoto's thyroiditis. Hashimoto's, aka chronic autoimmune thyroiditis, causes chronic inflammation of the thyroid gland. Overtime, the autoimmune process causes damage to the thyroid gland and this results in decreased production of T4 and T3 thyroid hormones. We don't fully understand what causes autoimmune conditions yet, but it's likely multifactorial. Viral infections, stress (both emotional and physiologic), genetics, and exposure to toxins likely contribute to the immune system disruption seen in autoimmune diseases like Hashimoto's.
Other causes of hypothyroidism include: post-procedural (either removal of the thyroid gland or destruction of the thyroid following radiation or surgery in the surrounding area), over-response to treatment of hyperthyroidism, drug induced, too much or too little iodine, selenium deficiency, postpartum, inflammation of the thyroid secondary to another autoimmune disease or a viral infection, or problems with the pituitary or hypothalamus in the brain. Stress, nutrition, and a sedentary lifestyle also seem to have a role in the development of hypothyroidism. [1, 2, 3]
When researchers have looked at thyroid labs in individuals not previously diagnosed with a thyroid condition and with no known family history of thyroid disease, hypothyroidism was found in nearly 5% of study participants. [4] The majority of these individuals had what's called subclinical hypothyroidism (typically a more mild presentation in which T4 levels are not low yet).
This suggests that a significant amount of the US population has undiagnosed hypothyroidism. If you're experiencing any of the symptoms listed above, I'd love to work with you to see if an underactive thyroid gland is the cause.
Diagnosis
Diagnosis starts with a thorough medical intake to fully understand the patient's symptoms. I always perform a physical examination as there are further clues to the underlying cause of a patient's symptoms that may be observable. The next step in diagnosis is ordering comprehensive labs and/or imaging.
Hypothyroidism is diagnosed when the thyroid stimulating hormone (TSH), made by the pituitary gland in the brain, is high and T4 and/or T3 are too low.
Subclinical hypothyroidism is an earlier presentation. It is diagnosed when T4 and T3 are still within range, but the TSH is starting to become elevated. (TSH naturally increases as we age, and I take this into account when interpreting lab results for patients.)
In rare instances, some patients have hypothyroidism due to a problem stemming from their hypothalamus or pituitary. This is called secondary hypothyroidism. In these cases, both the TSH and the thyroid hormones (T4 and T3) will be low.
Diagnosis of Hashimoto's thyroiditis is made when specific antibodies are elevated. I routinely check TPO (thyroid peroxidase) and thyroglobulin antibodies for patients with known or suspected hypothyroidism to see if their underactive thyroid is due to destruction from an autoimmune disease.
If physical examination reveals an enlarged or nodular thyroid gland, or if the patient reports symptoms such as difficulty swallowing, a lump in the throat sensation, or hoarse voice, I will often recommend a thyroid ultrasound. If labs reveal Hashimoto's thyroiditis, I also recommend that patients get a baseline ultrasound so we can better assess how damaged the thyroid gland is. Hashimoto's can cause either enlargement or atrophy (shrinkage) of the thyroid gland and ultrasound is useful in this evaluation. Thyroid nodules can also occur in Hashimoto's and it's important to monitor these through ultrasound.
Labs - Looking Beyond TSH & T4
Remember when I mentioned in Part 1 of this series that when ordering labs, looking only at TSH and T4 is often insufficient for accurate diagnosis and management of hypothyroidism? This is because the body has to be functioning properly for good communication to occur between these two hormones. The amount of T4 your body makes is only part of the picture.
T4 is the inactive thyroid hormone. Your body converts T4 to the usable and active form called T3 as needed. Unfortunately, there are a number of causes that interfere with this conversion. [5] For many patients, especially those in earlier stages of subclinical hypothyroidism, TSH and T4 remain within or very close to the standard reference ranges. Yet their body is in a hypothyroid state and they experience symptoms reflective of this.
Causes of poor conversion of T4 to T3:
stress
pain
depression
acute and chronic dieting
obesity
iron deficiency
diabetes
autoimmune disease
menopause
heart disease
chronic infection
environmental toxins (including plastics, pesticides, mercury, etc.)
low testosterone
etc.
Another issue with only looking at TSH and T4 levels to diagnose hypothyroidism, is due to reverse T3 (RT3). Reverse T3 is an inactive byproduct of T4 metabolism. It's normal to have a certain amount. However, during times of significant physiologic stress, thyroid activity is further decreased. The body converts T4 to RT3 instead of T3. [5] If a patient has a normal amount of T4 and within normal limits of TSH, but their RT3 is elevated and FT3 is low, they will often feel hypothyroid (see list of symptoms above).
While every case is unique, in general, the labs I look at to assess for hypothyroidism and/or Hashimoto's are: TSH, free and total T4, free and total T3, reverse T3, TPO antibodies, and thyroglobulin antibodies. I typically evaluate adrenal status via AM cortisol and DHEA-S for these patients too because of the close relationship between thyroid hormones and adrenal function. I also check serum iron levels, ferritin, iodine, and Vitamin D status for most of my patients with thyroid conditions. Since patients with hypothyroidism are at an increased risk of developing high cholesterol, a lipid panel along with other cardiovascular disease risk markers are recommended as well. If a patient is diagnosed with Hashimoto's I generally recommend screening for Celiac disease and running an ANA, as they're at increased risk of developing other autoimmune diseases.
I often meet patients with concerns of fatigue, brain fog, and difficulty losing weight who were previously told their thyroid is "fine" and not the problem. But when we repeat labs and look at additional markers beyond TSH and T4, the full picture is finally revealed.
Treatment
One of the most rewarding parts of being a naturopathic physician is the wider variety of treatment options I can provide my patients with. Since I have training in conventional medications, diet and nutrition, botanical medicine, and other natural treatments, I can work with patients to find the best treatment approach for them.
For many patients with subclinical hypothyroidism, a drug-free and natural approach to improving thyroid function is possible. For other patients, especially those who come to me already taking thyroid medication, an adjustment to the strength, dose, or form of medication is needed to help them feel their best.
It's also possible that once we address the underlying cause of their hypothyroidism, including Hashimoto's, patients may eventually be able to get off their thyroid medications altogether.
Naturopathic Support: Diet, Lifestyle, Supportive Supplementation
Tolle causum and tolle totem - two principles of Naturopathic Medicine that make all the difference when treating patients suffering from hypothyroidism and Hashimoto's. When translated from Latin, they mean identify and treat the cause and treat the whole person. Medications are often indicated and necessary when treating hypothyroidism, but reducing inflammation, improving gut health, supporting immune function, and helping patients manage stress are equally important for successful management.
There are a few key nutrients that are particularly important for patients with hypothyroidism and Hashimoto's: iodine, selenium, and iron. [2] Magnesium, zinc, and Vitamins A, D, E, and several Bs are also crucial for optimal thyroid function. Ensuring patients are getting adequate amounts of these nutrients through their diet is part of my intake process. If any deficiencies exist, supplementation may be utilized.
Identifying individual food sensitives is also important for these patients, as food allergies and intolerances can lead to inflammation, gut dysbiosis, and worsen autoimmune prognosis. Gluten sensitivity and Celiac disease occur at higher rates in patients with Hashimoto's compared to the general population. One study found that patients with Hashimoto's required a lower dose of thyroid replacement hormone when gluten was removed from their diet. [6]
Exercise is one of the most important things patients with hypothyroidism can do for themselves. Studies have shown that hypothyroid patients have improved levels of TSH, T3, and T4 after implementing a regular exercise practice. [7] When patients first come to me feeling exhausted and achy due to untreated hypothyroidism, I work with them so they can regain the energy, stamina, and motivation required to exercise regularly.
Stress management and improved sleep are also important areas to address with most hypothyroid patients. Herbal medicine and homeopathy are particularly beneficial here. By reducing stress, patients can decrease inflammation in the body, improve gut health, and support healthy immune function. It's important that patients work with a knowledgeable practitioner trained in these alternative therapies as some herbs can further stimulate or suppress immune function, which would be harmful to the autoimmune process in Hashimoto's. There are certain herbs that are particularly beneficial for supporting the body's conversion of T4 to T3 thyroid hormone, while other herbs can actually suppress thyroid function.
One of the main differences in treatment approaches between conventional providers and naturopathic doctors, like myself, is the focus on reducing inflammation in the body and modulating the immune system to quell the autoimmune process.
Conventionally, treatment of Hashimoto's usually begins and ends with thyroid hormone replacement, which totally neglects the underlying autoimmune disease.
I use homeopathy and immune modulating therapies, such as herbs or low-dose naltrexone, to help patients with Hashimoto's achieve remission. This holistic approach improves patient outcomes and helps prevent future complications from hypothyroidism.
MEDICATION: SYNTHETIC, DESICCATED, COMPOUNDED
Hypothyroidism generally requires thyroid hormone replacement. There are three main types of medications to choose from: synthetic, desiccated, and compounded. Everyone is unique, and I am of the opinion that when possible, treatments should be individualized to the patient. When it comes to management of hypothyroidism, there's no one-size-fits all approach. Some of my patients report sensitivity to conventional synthetic forms of thyroid medicine. These instances are rare, but I like to offer my patients alternative and safe options when indicated. Other patients report sensitivity to and side effects from desiccated thyroid, and they do better on synthetic medications. As with any treatment, there are potential risks and benefits to each option and I always make this decision jointly with patients. Sometimes a bit of trial and error is required, especially for sensitive patients. It's also important to avoid over-medication to reduce risk of osteoporosis and cardiovascular problems.
Whichever medication is chosen for the patient, the goal of treatment is finding the lowest dose necessary to reduce their hypothyroid symptoms without causing side effects from over-medication.
Synthetic Thyroid
Conventionally, synthetic T4, which is biologically equivalent to the T4 your own thyroid gland makes, is the most commonly prescribed form of the thyroid hormone replacement. The generic form is called levothyroxine and the most common brand name is Synthroid. There are a variety of strengths available commercially. T4 medication is most commonly prescribed in tablet form, but there are now gel capsules and liquid forms available too.
If inflammation, stress, etc. are left untreated or unaddressed, patients taking synthetic T4 may struggle to convert enough hormone to active T3 and continue to suffer from hypothyroid symptoms. [5, 7] This can be particularly frustrating for patients when their provider monitors TSH (and occasionally T4) on repeat labs. TSH may have normalized and fallen back into a "normal" range, but often their FT3 level remains deficient or suboptimal. For these patients, the addition of synthetic T3, aka liothyronine, can be beneficial. Cytomel is the most common brand name of synthetic T3 and is available in tablet form.
Some advantages to synthetic hormones are they are covered by most insurance plans and are available at commercial pharmacies. Additionally, the dose is precise. However, sensitive patients may experience side effects or complications from the fillers. (The fillers used in these medications are standard for medications and FDA-approved. Fillers are the binders; they are what keep the tablet intact and stable when taking it orally.) One issue with commercial liothyronine is it's only available in three strengths. If a patient is prescribed liothyronine, they may need to cut the tablets in half or take several tablets daily to achieve the appropriate dose. Another important consideration when choosing the best medication for a patient is half-life. The half-life of T4 is much longer than T3, making a once-a-day dose of T4 more stable and continuous than T3. Because the half-life of T3 is so short, some patients require multiple doses a day.
Desiccated Thyroid
The oldest form of thyroid medication is actually desiccated thyroid. Desiccated thyroid, aka thyroid extract, is thyroid gland that has been dried and powdered for medicinal use. It was originally made from cow thyroid gland, but in the US today, all commercially available desiccated thyroid is derived from pig thyroid. Desiccated thyroid was the sole form of thyroid hormone replacement until the advent of levothyroxine in the 1970s.
Desiccated thyroid is considered a combination therapy as it contains both T4 and T3. This is beneficial for many patients, though it remains a controversial option, especially amongst conventional providers. The main criticism of desiccated thyroid is the ratio of T4 to T3 is higher than what our bodies naturally produce. There is concern that this will cause patients to become overmedicated (essentially hyperthyroid). While uncommon and usually clinically insignificant, there is also risk of variability in potency between batches compared to synthetic medication.
Currently, there are a couple commercially available brands of desiccated thyroid: Armour and NP Thyroid. Due to a manufacturer recall in 2021, a popular brand (Nature-Throid) remains unavailable. Desiccated thyroid tablets are available in various strengths and their dose is referred to in grains rather than micrograms. Since they are derived from pork, they are not always an appropriate option for some patients based on dietary restrictions, food allergies, or cultural and religious practices. Generally, though there are exceptions, desiccated forms tend to have fewer fillers than their synthetic counterparts. They also tend to be more expensive than most synthetic options and are not always covered by insurance.
Compounded Thyroid
Compounded T4 and T3 medications, available from compounding pharmacies, allow a provider to customize the dosage based on the patient's specific needs. This is a great option for patients who require a dose that's not commercially available or if they have sensitivities to common fillers. Another benefit is many compounding pharmacies offer immediate and slow-release forms, which can reduce side effects for some patients. Compounded medications are typically not covered by insurance, though in my experience, the price of compounded T4 and T3 is affordable especially compared to desiccated options. Whenever using compounded medications, it's important to ensure you're using a reputable pharmacy to ensure product potency and purity. Some of the compounding pharmacies I use offer both synthetic and desiccated compound T4 and T3 products, making them truly customizable based on patients' needs.
Management
When working with patients suffering from hypothyroidism, I always rely on their reported symptoms along with lab results to guide management. Both are equally important. If a patient still has fatigue or is unable to lose weight despite normalization of thyroid markers on labs, we'll work together to find other potential causes of their persistent symptoms. We will modify their treatment plan until they feel like themselves again.
Once my hypothyroid patients are stable on a steady dose of thyroid medicine and are feeling good, I recommend monitoring thyroid labs at least annually. I will continue to track Vitamin D, cholesterol, cardiovascular risk markers, and ANA periodically based on individual risk. Sex hormones may also be checked as needed based on their medical history and risk factors.
Sometimes discontinuation of medications is possible depending on the underlying cause and the patient's success with implementing significant dietary and lifestyle changes. While getting off thyroid hormone replacement may not always be possible, especially for patients with Hashimoto's (depending on how damaged their thyroid gland is due to the autoimmune disease process), it's always a goal of mine for most patients.
Achieving remission along with resolution of all hypothyroid related symptoms is always my goal for patients with Hashimoto's.
Know that it is possible to feel like yourself again.
With the proper dosage and forms of medication, when indicated, along with diet and lifestyle changes, patients suffering from hypothyroidism can find relief. Natural medicine can further support the healing process, often helping patients require less thyroid hormone replacement over time.
Does this approach sound like what you've been looking for? If so, I'd love to work with you and help you reclaim your health.
Know that you deserve to be heard, be healthy, and be well.
[1] Helmreich DL, Tylee D. Thyroid hormone regulation by stress and behavioral differences in adult male rats. Horm Behav. 2011 Aug; 60(3):284-91. doi: 10.1016/j.yhbeh.2011.06.003. Epub 2011 Jun 12. PMID: 21689656; PMCID: PMC3148770. https://pubmed.ncbi.nlm.nih.gov/21689656/
[4] Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III).J Clin Endocrinol Metab. 2002;87(2):489‐499. doi:10.1210/jcem.87.2.8182 https://pubmed.ncbi.nlm.nih.gov/11836274/
[5] Holtorf K. Peripheral Thyroid Hormone Conversion and Its Impact on TSH and Metabolic Activity. Journal of Restorative Medicine. 2014;3(1):30-52. doi:10.14200/jrm.2014.3.0103
Available from: https://journal.restorativemedicine.org/index.php/journal/article/view/41/69
[7] Bansal A, Kaushik A, Singh C M, Sharma V, Singh H. The effect of regular physical exercise on the thyroid function of treated hypothyroid patients: An interventional study at a tertiary care center in Bastar region of India. Arch Med Health Sci [serial online] 2015 [cited 2020 May 27];3:244-6. http://www.amhsjournal.org/text.asp?2015/3/2/244/171913
[8] Wekking EM, Appelhof BC, Fliers E, Schene AH, Huyser J, Tijssen JG, Wiersinga WM. Cognitive functioning and well-being in euthyroid patients on thyroxine replacement therapy for primary hypothyroidism. Eur J Endocrinol. 2005 Dec; 153(6):747-53. doi: 10.1530/eje.1.02025. PMID: 16322379. https://pubmed.ncbi.nlm.nih.gov/16322379/
