Thyroid Conditions Series - Part 3: Hyperthyroidism & Graves' Disease
In this series, I'm discussing my approach to diagnosis, treatment, and management of thyroid conditions. In the final part of this series, we'll focus on hyperthyroidism and Graves' disease.
Welcome back to my series on thyroid conditions. I frequently treat hypothyroidism, hyperthyroidism, and autoimmune thyroiditis in my practice. While hyperthyroidism is less common than hypothyroidism, patients suffering from overactive thyroid often are left feeling poorly despite conventional treatment. This is my approach to diagnosing and managing hyperthyroidism and Graves'. To learn more about hypothyroidism, see Part 2.
Hypothyroidism & Graves’
In case you missed Part 1 of this series (which can be found here), let's review some common symptoms associated with overactive thyroid status, or hyperthyroidism:
Symptoms of hyperthyroidism:
insomnia
rapid or irregular heartbeat (tachycardia, palpitations)
unexplained weight loss
anxiety or irritability
heat intolerance
increased perspiration
diarrhea, loose stool, or more frequent bowel movements
trembling of the hands
shorter, lighter menstrual periods
fatigue
muscle weakness
hair loss
increased appetite
Symptoms of Graves':
protrusion of eyes or puffy eyes (exophthalmos) - only seen in about 30% of Graves' patients
gritty feeling or irritated eyes
light sensitivity (photophobia)
enlargement of the thyroid, aka: goiter (typically painless)
hyperthyroid symptoms listed above
Hyperthyroidism occurs when the thyroid gland produces too much thyroid hormone. The two main thyroid hormones produced are thyroxine (T4) and triiodothyronine (T3).
An overactive thyroid can occur for variety of a reasons. The most common cause of hyperthyroidism in the US is due to an autoimmune condition called Graves'. Other causes of hyperthyroidism include: multinodular goiter, inflammation of the thyroid gland due to infection, postpartum, certain medications, or radiation, issues with the pituitary gland, excess iodine ingestion, or overmedication from thyroid hormone replacement. Graves disease occurs when the body inappropriately produces autoantibodies against the thyroid receptor for TSH (thyroid stimulating hormone). These autoantibodies are referred to as TRAb. TRAb is a stimulatory autoantibody and results in continuous secretion of excess T4 and T3.
If you're experiencing the symptoms listed above, talk to your health care provider.
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 of the underlying cause of patient's symptoms that may be observable. The next step in diagnosis is ordering comprehensive labs and/or imaging.
Hyperthyroidism is diagnosed when the thyroid stimulating hormone (TSH), made by the pituitary gland in the brain, is suppressed (too low) and T4 and/or T3 are too high.
Subclinical hyperthyroidism is an earlier presentation. It is diagnosed when T4 and T3 are still within range, but the TSH is starting to become suppressed. Typically these patients are either asymptomatic or mildly symptomatic. It is much more rare than subclinical hypothyroidism.
In rare cases, a patient may have normal or high TSH with high T4 and T3 resulting in hyperthyroidism. This is typically caused by an issue with the pituitary gland.
Biotin supplementation can interfere with laboratory assays and cause results that (falsely) look like hyperthyroidism. Biotin is a common ingredient in many multivitamins, B complex products, and hair, skin, and nail supplements. I always instruct patients to discontinue biotin supplementation for 72-hours before having labs drawn.
Diagnosis of Graves' disease is characterized by hyperthyroidism due to autoantibodies. Thyroid-stimulating immunoglobulins (TSI) and occasionally thyroid peroxidase (TPO) or thyroglobulin antibodies will be elevated in Graves'. I routinely check for these antibodies when I suspect hyperthyroidism is the cause of a patient's symptoms.
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 Graves' disease, I also recommend that patients get a baseline ultrasound so we can better assess how damaged the thyroid gland is. Graves' can cause enlargement of the thyroid gland and ultrasound is useful in this evaluation. Thyroid nodules can also occur in Graves' and it's important to monitor these through ultrasound, especially because there is an increased risk of thyroid cancer in these patients.
Occasionally a special test called a radioactive iodine uptake is necessary to confirm the diagnosis. If further evaluation and workup is needed, I will refer patients to an endocrinologist.
Labs - Looking Beyond TSH & T4
While every case is unique, in general, the labs I look at to assess for hyperthyroidism are: TSH, free and total T4, free and total T3, TSI, TPO, 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, a complete blood count (CBC), and comprehensive metabolic panel (CMP) for most of my hyperthyroid patients. Since patients with hyperthyroidism are at an increased risk of developing osteoporosis and heart arrhythmia, Vitamin D status and comprehensive cardiovascular risk markers can also be helpful.
Comprehensive labs are helpful for making an accurate diagnosis, along with identifying additional problems that hyperthyroidism and Graves' are associated with.
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. Natural therapies can help improve quality of life and support healthier immune function.
For many patients with hyperthyroidism, the use of conventional medications is necessary and life-saving, but naturopathic medicine can still be helpful in supporting the body, mind, and spirit.
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.
Naturopathic Support: Diet, Lifestyle, Supportive Supplementation
An anti-inflammatory diet rich in antioxidants and omega 3 fatty acids, but low in iodine-rich foods is particularly beneficial for patients with Graves'. Avoiding excessive iodine consumption is important for hyperthyroid patients as iodine can worsen the disease process. [1] Similar to Hashimoto's, Graves' patients are also at increased risk of Celiac disease or gluten sensitivity. [2] I generally recommend patients with hyperthyroidism eliminate gluten from their diet for at least 4-8 weeks to see if they notice any symptom improvement, even if screening for Celiac was negative.
Since hyperthyroid patients are often struggling with excessive perspiration, heat intolerance, and tachycardia (increased heart rate), gentle and low-intensity exercise is often recommended, at least until thyroid hormone levels are controlled.
For patients with Graves', addressing gut health is especially important since the majority of our immune system resides there. Sometimes additional workup is needed, such as comprehensive stool analysis (through functional laboratories) or SIBO breath testing. Stress management, reducing inflammation, and helping to modulate the immune system are also key parts of the treatment plan for Graves' patients. Herbs, homeopathy, low-dose naltrexone (LDN), and lifestyle counseling are particularly beneficial in these cases.
For patients with mild elevation of T4 and T3 hormones, thyroid-suppressive herbs are sometimes a safe and appropriate alternative to conventional medications. These treatments should always be prescribed and managed by a well-trained and licensed professional, however.
Conventional Treatment Options: Thyroid Suppressive Medications, Radioiodine Ablation & Surgery
Hyperthyroidism can be a serious and life-threatening condition if left untreated. In most cases, collaboration with an endocrinologist is useful, especially in the early stages of disease management. For moderate to severe cases of hyperthyroidism, I will generally refer patients to an endocrinologist for further evaluation and guidance in choosing the best treatment approach for the patient.
Conventionally, there are three treatment options for Graves' patients: anti-thyroid drugs (medications that block the synthesis of thyroid hormones - methimazole and propylthiouracil), radioiodine ablation (a procedure that destroys the thyroid gland through the administration of radioactive iodine), or surgery. All three options are effective, but each therapy carries its own risks. The patient should be counseled on the potential risks, benefits, and expected outcomes of each option and should fully understand their options. Additionally, these three options are not mutually exclusive; sometimes thyroid suppressive medications are used for several months to years before a patient opts for radioiodine ablation or surgery.
For many patients with hyperthyroidism, beta blockers (a class of medications that manage abnormal heart rhythm) are also recommended.
For patients who require thyroid ablation or surgery, permanent hypothyroidism is usually the desired outcome. This requires that the patient take thyroid hormone replacement for the rest of their life since their thyroid gland has either been completely destroyed or removed.
Management
When working with hyperthyroid patients, I always rely on their reported symptoms and labs to monitor and guide management. If they report persistent symptoms despite normalization of TSH, FT4, and FT3, additional workup is done to figure out the underlying cause. I also focus on prevention of development of hyperthyroid-related complications such as osteoporosis and arrhythmias and will refer to a cardiologist when indicated. If the cause of their hyperthyroidism is Graves', regular examination of their eyes is also important. If they're taking thyroid-suppressive drugs, routine monitoring of liver enzymes and screening for anemia is recommended due to side effects and complications associated with these medications.
Addressing inflammation and gut health are also important to help prevent the onset of additional autoimmune diseases. I also work with hyperthyroid patients to help preserve their thyroid whenever possible.
Achieving remission along with resolution of all hyperthyroid related symptoms is always my goal for patients with Graves'.
Know that it is possible to feel like yourself again.
With the proper treatment to suppress thyroid function, along with diet and lifestyle changes, patients suffering from hyperthyroidism can find relief.
Are you ready to feel like yourself again and treat your hyperthyroidism holistically?
Great - let's work together!
You deserve to be heard, be healthy, and be well.
[2] Ch'ng CL, Jones MK, Kingham JG. Celiac disease and autoimmune thyroid disease. Clin Med Res. 2007 Oct; 5(3):184-92. doi: 10.3121/cmr.2007.738. PMID: 18056028; PMCID: PMC2111403. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2111403/
