Rethinking Thyroid Imbalance

June, a 24-year old, came in with her mother to discuss chronic fatigue.  For seven years, she suffered from extreme fatigue every day.  She had an extensive work-up by mainstream and alternative providers and the only abnormality found by a naturopath was a low cortisol level in the morning.  This suggested adrenal gland insufficiency from some cause but treatment with an adrenal support supplement didn’t help her energy level much.

Her mother and sister had an autoimmune thyroid condition, so they wondered if an under active thyroid could be the cause.  Her thyroid panel showed numbers in the normal range, but I have come to find that this does not always tell the full story.

I agreed to a trial of armour thyroid and when I saw her a month later, she was remarkably different.  She seemed more alert and interactive.  She said the fatigue had mostly resolved.  I ordered repeat thyroid levels to make sure she wasn’t overmedicated and they had shifted from one end of the normal range to the other.

The thyroid gland is a butterfly-shaped gland at the base of the neck.  Through feedback mechanisms with the pituitary gland in the brain, it secretes a hormone that has a wide variety of effects on the body.  There are two main forms of the hormone: T4 and the more active T3.

A person with an under active thyroid can exhibit fatigue, unexplained weight gain, constipation, menstrual irregularities, hair loss and other signs.  A person with an overactive thyroid gland can have palpitations, tremor, diarrhea, weight loss and other signs.

Most physicians are trained to view thyroid testing as a black and white issue.  If the thyroid stimulating hormone (TSH) level is in the normal range, that’s it, the person does not have thyroid dysfunction.

One of the great lessons of clinical medicine is not to interpret blood results as simply normal or abnormal.  Many abnormal results, especially those just on the outside of the normal range are inconsequential.  Other results considered normal, however, can provide clues into an important health issue.

On the advice of a patient, I read David Brownstein, M.D.’s Overcoming Thyroid Disorders.  The reference took a much more sophisticated look at the thyroid gland.  One of the essential take home messages: to truly evaluate a complicated issue, you often need to assess a wide variety of factors, not just a single blood test.

When it comes to the thyroid, a clinician is better served by looking at symptoms, physical exam, family history, various thyroid levels (not simply the TSH) and even possibly a person’s basal body temperatures.  A 35-year-old female with fatigue, constipation, weight gain, missing the lateral half of both eyebrows with a morning temperature of 97.0 whose mother and sister have an autoimmune thyroid condition should not be sent home empty-handed if her TSH level is 3.8 [normal range varies, but usually 0.3 to 4.5 or so].

For the record, the TSH tends to be opposite of thyroid function, i.e. if low, the thyroid gland is overactive and if high, the thyroid gland is under active.

Brownstein contends that the majority of Americans with thyroid dysfunction are undiagnosed.  He says the people in this group include those with autoimmune causes, but others from thyroid problems from stress, poor eating habits and iodine deficiency.

There is also a potential link with genetic methylene tetrahydrofolate (MTHFR) anomalies because an under active MTHFR enzyme can lead to low levels of BH4.  BH4 is used in the production of thyroid hormone.

Brownstein believes that a high percentage of people diagnosed with fibromyalgia, chronic fatigue syndrome and other chronic conditions are caused completely or in part by thyroid dysfunction.

Another area where Brownstein diverges from the mainstream is in management.  Physicians tend to use synthetic levothyroxine almost exclusively, which is T4.  He advocates for more use of options like armour and nature-throid.  These more natural options have a ratio of 80% T4 and 20% T3 which more closely mimics the optimal balance of hormone.

Applying Brownstein’s principles has lead me to diagnose many more patients with a thyroid problem.  Managing the issue has improved the quality of life for many that would otherwise be in poor health.  If you are wondering about a thyroid condition, I would not be satisfied with a simple TSH level.  Pick up one of Brownstein’s books and try to find an open-minded provider.

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