Can’t lose weight? High cholesterol? Tired all the time? Hair getting thinner? It could be your thyroid!
What is the Thyroid?
The thyroid is a butterfly-shaped gland that sits in the neck just above your collarbone that produces hormones.
Symptoms of Hypothyroid or Suboptimal Thyroid Function
- Weight gain
- Difficulty losing weight
- Dry skin
- Hair loss or thinning hair
- Swelling in face, hands, ankles, or feet
- Feeling cold – especially cold hands and feet
- Hertogue’s sign (lateral eyebrow thinning)
- Heavy periods or irregular bleeding
- Slower thinking
- Goiter (swelling of the thyroid gland that is visible in the neck)
- Feeling down or depressed
- Memory loss
- Arthralgias, muscle aches
- Too tired to exercise
- May have heat intolerance as well as cold intolerance
- Fluid retention
- Periorbital or ankle edema
- Hypertension (elevated blood pressure)
- Brain fog
What Does the Thyroid Do?
The thyroid is responsible in taking certain nutrients that are consumed from the food we eat and supplements we take and converting it into thyroid hormones. These hormones are important in how your body uses energy, body temperature regulation, maintaining optimal health with the brain, heart, muscles, and other organs. Every cell in the body depends on thyroid hormones for regulating their metabolism.
Why is it important to have my thyroid tested?
People with untreated hypothyroidism are at an increased risk for: heart disease, heart failure, high cholesterol, weight gain, metabolic syndrome, elevated blood pressure, and giving birth to a baby with birth defects.
What is the difference between our approach vs. “traditional approach?“
The conventional approach to diagnosing thyroid dysfunction primarily revolves around the measurement of TSH (thyroid stimulating hormone). If the TSH is elevated over 4.5 mIU/L, it is a sign that the pituitary gland is sensing low thyroid hormones, and the TSH rises in order to stimulate the thyroid gland to produce more thyroid hormone. If the TSH is normal, many physicians believe that this lab value automatically rules out a sluggish thyroid gland.
Our approach, a more holistic/integrative approach, involves more extensive testing rather than just measuring the TSH. Ideally, we want to get to the root of the problem rather just prescribing a thyroid hormone medication. Depending on the patient and clinical circumstances, our practitioners may recommend a comprehensive thyroid panel, nutritional testing, food allergy testing or an elimination diet, detoxification, stool testing to look for stealth infections or yeast, sex steroid (testosterone, estrogen, progesterone) testing, and adrenal (cortisol) testing. In addition, we also recommend a 2 hour glucose tolerance test to investigate if insulin resistance or sugar handling is contributing to poor thyroid function.
Essentially, having an optimally functioning thyroid requires a complex chain of events that reinforces itself through a feedback loop. The thyroid is effected by inflammation, cortisol levels, toxins and triggers, and blood sugar spikes. The thyroid requires many nutrients to make thyroid hormones and convert T4 into T3. Appropriate stomach acid and a healthy intestinal lining are needed for digestion, absorption, and assimilation of nutrients.
In addition, the diagnosis of a thyroid illness is a clinical one, supported by findings in the patient history and physical as well as integrative testing of blood, stool and saliva. Many times thyroid disorders can be corrected without the use of medication. Simply augmenting thyroid gland function with appropriate vitamins/minerals, lifestyle changes and detoxification will help many thyroid disorders. On occasion, medications may be necessary. When this situation arises, we believe in combination therapy with T3 and T4 rather than T4 only productions. Even when using T3/T4 medications, an individualized approach is given as some patients have sensitivities/allergies to fillers and components of the various medications.
What is a comprehensive thyroid panel?
The thyroid is best tested with a blood test. The labs that we look at are:
TSH – TSH stimulates the thyroid to make mostly T4 and a lesser amount of T3. TSH is not a metabolically active hormone! When the pituitary gland senses there are adequate amounts of thyroid hormone, TSH levels are lowered so that the thyroid gland can lower its production of hormones. However, it is important to note that the pituitary is the most sensitive organ to circulating thyroid hormones. In other words, although your pituitary may detect there are optimal thyroid hormones, the rest of your body may still sense inadequate levels. Our practice sees this with our patients on a daily basis. We see patients who have only had a TSH checked and were told that their thyroid is normal. In addition, the “normal” value for TSH is very controversial in the medical community- particularly in Cincinnati. Most laboratories have a reference range for TSH of 0.45- 4.5. In 2002, the American Association of Clinical Endocrinologists narrowed the reference range of TSH to 0.3 to 3.0. Other societies have also lowered the reference range for TSH including the National Academy of Clinical Biochemistry.
Most integrative or functional medicine physicians focus more on the metabolically active free t3 rather than on TSH. However, when TSH is elevated over 2.0, functional medicine/integrative physicians believe that this is not optimal.
Furthermore, there are many situations that render the TSH a poor marker for thyroid function. For example, TSH is not reliable in those with chronic illness such as diabetes, depression, inflammation, stress/cortisol abnormalities, obesity, PMS, autoimmune disease, insulin resistance and fibromyalgia. In fact, many times, TSH is actually suppressed and below the reference range when the active hormones are optimal. This is a lot of controversy over whether a suppressed TSH is associated with bone loss. There is medical literature on both sides of the fence as to whether bone loss occurs or not with suppressed levels of TSH. We monitor bone turnover (additional link) closely in our patients who have a suppressed TSH.
Free T4 – (thyroxine). 80% of the thyroid hormone produced in the body is T4. T4 is 300% less biologically active than T3 . Rather, T4 is considered a prohormone in that it must be converted to T3 for its true action to happen. We rely on our body to convert the secreted T4 into the metabolically active T3.
Free T3 – (triiodothyronine). 20% of the thyroid hormone produced in the body is T3. T3 is the active hormone that works at the cellular level to drive the metabolism of each and every cell. T3 is made from the prohormone, T4. Clinically, T3 is approximately 4 times more powerful than T4. A free T3 at the lower half of the reference range is the best laboratory test indicating suboptimal thyroid function. In addition, thyroid resistance, like insulin resistance, can occur even when T3 and TSH levels are normal.
Reverse T3 (RT3) – This is produced from the prohormone T4 also. It is normal to have some RT3, but not too much! Your body makes RT3 as a way of getting rid of any unneeded T4 in any situations where your body needs to conserve energy (and slow down the metabolism). High levels of reverse T3 slow your metabolism. Chronic stress and abnormal adrenal function (low cortisol, high cortisol) is one of the main reasons why the body wants to slow down the metabolism and make more RT3. Vitamin deficiencies (B12 and iron), inflammation, hormonal imbalances and many other situations that impair conversion of T4 to T3 can also lead the body down the pathway of making more RT3 rather than FT3.
Thyroid peroxidase (TPO) and Anti-thyroglobulin antibodies – These tests detect antibodies in your blood. When these levels are elevated, it means that there are antibodies in your blood that are attacking or killing off the thyroid gland. This also suggests that the cause of the hypothyroidism is an autoimmune disease, Hashimoto’s thyroiditis. When an autoimmune disease, such as Hashimoto’s thyroiditis, is detected it is very important to get to the root of the problem to decrease the chances of other autoimmune diseases (e.g., multiple sclerosis, rheumatoid arthritis, Crohn’s disease) developing.
What are the causes of Hypothyroidism or Low thyroid function?
There are many reasons for the development of hypothyroidism, a sluggish thyroid, or a lowered metabolism.
- Hashimoto’s thyroiditis is the most common cause of hypothyroidism.
- Adrenal/Cortisol imbalance – high cortisol interferes with the conversion of T4 to T3. High cortisol also suppresses TSH.
- Bromide toxicity – Bromide is a chemical compound found in commercially prepared baked goods, soft drinks, some vegetable oils, pesticides and plastics, carpets and mattresses. Bromide displaces iodine from the thyroid molecule so that thyroid hormones are not getting made.
- Selenium deficiency – Selenium is needed to convert T4 into the active hormone T3.
- Prescription medications – Birth control pills, Lithium, seizure medications, sulfonylureas, amiodorone interfere with how thyroid hormones are made.
- Age/Menopause – Thyroid hormones are not made as effectively as we age.
- Dysbiosis – Organisms in the gut such as yeast can unleash an immune attack on these invaders which then releases chemicals that affect thyroid hormones.
- Environmental toxins – Fluoride, mercury (usually from tooth fillings), bisphenol A, phthalates and tobacco can block thyroid hormone function.
- Any problems that interfere with the conversion of T4 to T3 (see below).
- Thyroid hormone resistance – A patient may have adequate levels of T3 but if the hormone can’t get into the cells to do its job, symptoms of low thyroid will remain. Normal levels of cortisol are needed for thyroid to get into the cells. Iron is also needed for this transfer to occur
What is Hashimoto’s?
Hashimoto’s Thyroiditis is an autoimmune disease that affects the thyroid and destroys the thyroid tissue. This is the most common cause of thyroid dysfunction. The immune system makes antibodies that damage the cells in the thyroid and affect their ability to make thyroid hormone. Over time, this can lead to hypothyroidism. This disease is the most common cause of an underactive thyroid that is rarely screened for. It is seven times more likely to occur in women than in men.
How does one get an autoimmune disorder such as Hashimoto’s?
In conventional medicine, there is no consensus as to why someone develops these types of diseases. However, functional medicine/integrative practitioners know that inflammation is not the cause of the autoimmune diseases, it is the consequence. In general, in order to develop an autoimmune disease such as Hashimoto’s thyroiditis, three situations must be present – genetic susceptibility, antigen trigger (usually food allergy or pathogenic bacteria/yeast/parasite) and increased intestinal permeability. Another contributing factor in the development of Hashimoto’s thyroiditis has been nutritional deficiencies. Nutritional deficiencies (e.g., zinc, selenium, iron, vitamin D, Tyrosine, B vitamins, Vitamin A) can cause oxidative damage to the thyroid and then the body defends itself by producing these antibodies against its own thyroid tissue. The treatment of this is to correct the deficiencies with supplementation. Studies have also shown an improvement in thyroid illness when a gluten free diet is followed.
What can be done to decrease antibody production?
Antibodies are produced in response to the immune system mounting an attack on the thyroid. Removing the triggers (food sensitivities) is the first key to stopping the attack on the thyroid. If a patient is unable to afford the food allergy test, then we recommend removing the most common food allergens – gluten, dairy, corn and soy for at least three months. Other supplements are used to modulate the immune system such as vitamin D and omega 3 (fish oil) fatty acids. Selenium doses up to 400 mcg has also been shown to lower antibodies. Low dose naltrexone can also be used to stop the progression of the autoimmune attack. Supplementing with vitamin D, C, magnesium and B vitamins will also help with the inflammation in the thyroid gland. Supplementing with high doses of iodine is controversial.
This approach is usually helpful for dampening the immune response and decreasing antibody production but getting to the underlying cause of Hashimoto’s is what prevents the damage from occurring again as well as preventing other autoimmune diseases from developing.
How do you treat the underlying cause of Hashimoto’s?
Essentially, the treatment is a 4-step process:
- Reducing triggers (food allergies/gluten/heavy metals/toxins)
- Treating “leaky gut” or intestinal permeability
- Nutritional support which allows the thyroid to regenerate and make hormones
- Rebalancing the immune system.
This process can take anywhere from six months to three years. Simply taking thyroid hormones is not going to make the majority of patients feel better.
Our body still needs to convert some T4 into the biologically active form of thyroid hormone, T3. Therefore, we need to optimize this conversion and decrease the situations that decrease this conversion. What are the factors that decrease Conversion of T4 to T3?
- Anti-TPO antibodies
- Birth control pills
- Chronic Illness
- Estrogens (oral)
- Growth hormone deficiency
- Heavy metal toxicity (mercury)
- Medications (beta-blockers (used for blood pressure), amiodarone, lithium, propylthiouracil, methimazole, dexamethasone, proton pump inhibitors (AKA stomach acid blockers)
- Progestins (Mirena IUD, synthetic hormones)
- Soy (genetically modified)
- Stress (abnormal cortisol)
- Vitamin deficiencies
- Elevated reverse T3
- Yo-Yo dieting
- Toxins (bisphenol A, pesticides, etc)
- Diabetes and Insulin resistance
- Low progesterone
The conversion of T4 into T3 occurs in the liver and gut. Therefore, it is important to have an optimally functioning liver and gut . We recommend a potent, high quality probiotic to all of our patients to prevent/treat dysbiosis.
What are the thyroid hormone replacement options?
T4 preparations are the most widely used thyroid hormone replacement medications. This is how the majority of traditional physicians are treating their patients and are most likely getting inferior results. T4 is not an active hormone. It is a prohormone and does not have any activity in the body. T4 must be converted to T3 to work on the cells of the body. Our practice primarily uses combination products that contain both T4 and T3. Many patients will ask, “If T3 is so important, then why do I even need T4?” This is a great question. The answer is that T3 has a short half-life, which means that it doesn’t stay in the body very long. Some T4 is needed so there is always a resource to make T3. However, when given a combination product of T4 and T3, our body needs to still convert some T4 into T3.
T4 Thyroid Hormone Preparations
Synthroid® (also contains cornstarch, dyes, lactose)
Unithroid® (also contains lactose)
T4 and T3 Combination Preparations
Armour® Thyroid is a porcine derived thyroid hormone that also contains calcitonin, selenium, and the thyroid hormones T2 and T1. This medication also contains dextrose made from cornstarch so those with an allergy to corn products may not do well with this medication.
Nature-Throid™ and Westhroid™ are identical agents and they have the same active ingredients as Armour® Thyroid. They are also derived from porcine thyroid. Nature-Throid™ is formulated using hypoallergenic inactive ingredients and does not contain any artificial colors or flavors, corn, peanut, rice, gluten, soy, yeast, egg or fish/shellfish. We have found that Nature-Throid™ and Westhroid™ may be more difficult to obtain from local commercial pharmacies.
Thyrolar® is a synthetic thyroid preparation that contains T4 and T3. For those opposed to a porcine product, this medication is a good option. This medication also contains cornstarch and lactose as fillers.
Compounding pharmacies can also make ANY dose of pure T4 and T3 without additives and fillers. This is the best option for patients with allergies. The benefit of using this route of hormone replacement is that each patient can receive a unique customized dose and the use of slow- release T3 hormone. The downside to using this formula over the other combination preparations is cost.
T3 Thyroid Hormone Preparations
Cytomel® is only available as two doses: 5 ug and 25 ug and many patients may need a different amount of T3. This medication also contains sucrose and talc as inactive ingredients. One major downside of using cytomel is that it is rapidly absorbed and this can cause a “roller-coaster” type effect leading to palpitations, insomnia and anxiety and then a crash – leaving the patient feeling fatigued. There is also a generic Liothyronine sodium that is similar to Cytomel®.
Why is treatment with T4 unsuccessful in many patients?
The thyroid gland secretes T4 in response to TSH and the body’s needs for thyroid hormones. However, many patients don’t adequately convert the prohormone, T4, into the more active hormone, T3. When this conversion is not happening adequately, symptoms of hypothyroidism will ensure – even with a “normal” TSH! Therefore, our approach to treating thyroid dysfunction with thyroid hormone is to use a combination of T3 and T4 hormones and optimize the T4 to T3 conversion. This approach has been shown in the literature to be more effective than using T4 alone and patients prefer combined therapy.
It makes sense to use a combined T4/T3 product when you understand thyroid physiology. Why are some doctors opposed to this method of treatment?
Traditionally – perhaps because of large pharmaceutical companies, doctors have been trained to test only the TSH and occasionally the T4 levels and thus, replace only the T4 hormones. There was a met analysis (review of 9 individual studies) performed by Joffe RT et. al. that was sponsored by a pharmaceutical company that revealed no significant difference in psychiatric symptoms when T4 alone or T4/T3 was used. Our criticism of this study is that many of the papers they examined were not using a high enough dose of T3(only 5 ug of T3) to even make of difference. So, of course, the conclusion of the paper was that there was no benefit to using a combined regimen.
What are symptoms of thyroid excess?
Inform provider if you have any symptoms of overactive thyroid activity after starting on medication, such as:
- Restlessness or shakiness
My doctor told me that my low TSH would put me at risk for osteoporosis and atrial fibrillation. Is this true?
In the traditional medical community, there is a lot of concern that suppressing the TSH will cause medical conditions such as osteoporosis and atrial fibrillation. It is true that endogenous hyperthyroidism (patients developing hyperthyroidism on their own – not treating hypothyroidism) is associated with osteoporosis. There is medical literature on both sides of the fence as to whether bone loss occurs or not with suppressed levels of TSH. We monitor bone turnover closely in our patients who have a suppressed TSH.
For more information:
What our Patients Say!
“At 29 years old I first came to Dr. Brenner’s in the fall of 2012. I was wanting to dig deeper into
a diagnosis of Hypothyroidism from my family Dr. I was around 210 pounds, exhausted, had
joint pain, brain fog, and plenty of other frustrating symptoms. I felt there was more to what was
going on with me than just under active thyroid. Being a stay at home mom of two small
children, I felt so defeated dealing with all my body was putting me through. I wanted to be
healthy for them, for my hubby, for me! I was so thankful even at my first appointment with Dr.
Brenner. We were on the same page with digging deeper into my thyroid diagnosis. She did a
full thyroid panel right away as well as vitamin D and B12. My family Dr. had only checked my
TSH, and then had the nurse called to tell me it was severely elevated, to pick up synthroid at
my pharmacy, take it for 6 weeks then come back for blood work. I then decided to schedule
with Dr. Brenner for a second opinion. When my results came back it showed that I had
Hashimoto’s, an autoimmune condition that attacks the thyroid. Right away this was fully
explained to me, I was shown all the levels of my thyroid and what they should be optimally. We
made a plan with Natural thyroid meds, diet changes, cutting out gluten, adding in therapeutic
doses of vitamin D because I was deficient, along with other supplements. I’m so thankful I came
to Dr. Brenner’s. In addition to my supplements and medication, I’ve worked with Lauren on
detoxing, nutrition and better health over all in my body. I have now lost 51 pounds since my 1st
visit, I have energy, I feel like myself again! There are still things I’m working on to better my
health, further diet changes and digging to find the root cause of my Hashimoto’s but I’m beyond
THANKFUL for the support from Dr. Brenner, Dr. Theiman and all the staff! I feel younger at 32
than I did at 29!”