Hormone Imbalance IV: Adrenal and Thyroid
Of all of the topics I have researched over the past 10+ years during my reeducation, the thyroid is at or near the top of the list. There is no question for me that adrenal and thyroid issues are amongst the most important in health today.
When I was going through training in medical school in the 1990s, the thyroid was presented as a simple issue. I was told that thyroid problems were relatively uncommon and only one blood test, the thyroid stimulating hormone level or TSH, was necessary. If the TSH was normal, case closed, the person did not have a thyroid issue. If the TSH was low, they might have Graves’ disease so send to endocrinology. If the TSH was high, start Synthroid and recheck the TSH in two months to try to get the number into the normal range. Have a nice life.
It turns out the thyroid is one of the most common sources of chronic health issues and extremely complex in nature. Most are familiar with the more typical symptoms of an underactive thyroid including fatigue, weight, constipation, fluid retention, dry skin, hair loss and others.
The minimum starting place for my perspective for those with potential signs and symptoms of thyroid dysfunction would be TSH, free T3, free T4 and the Hashiomoto’s TPO antibody level. T3 is the most active form of thyroid hormone so free T3 is potentially the most important number, but any lab value should be evaluated relative to the other numbers.
The first key point—and this is a general principle of functional medicine—is that “normal is not necessarily optimal” when it comes to lab results. There are differing opinions, but for many the optimal thyroid numbers are:
Free T4 1.4-1.6
Free T3 3.5-4.0
TPO Ab low/undetectable
Anti-thyroglobulin Ab low/undetectable
Basal body temperature above 97.0
But it can be a mistake to micromanage the labs. The best approach is to evaluate the person in total including symptoms, physical exam, first morning basal body temperature, family history, gut status, diet/nutrition and other factors.
In terms of physical exam, people with an underactive thyroid often have puffiness from fluid retention, scalloping of the tongue, loss of the lateral third of the eyebrows and other potential signs. (Below are several resources that get into all of these issues in more detail.)
If the overall assessment is that the person likely has thyroid dysfunction, I then do my best to try and figure the Why of it all.
One of my standard lines for people I see in the office is that we often have two parallel goals: 1. Improving the daily quality of life by managing symptoms and 2. Trying to figure out the underlying causes.
In terms of improving symptoms, the most effective strategy is to give people thyroid medication. My preferred option has changed many times over the past 10 years or so. Those inclined to avoiding pharmaceuticals and synthetic options tend to prefer options like Armour Thyroid, Nature-throid, WP thyroid and Thyro-Gold. For years, those were my primary options.
The problem, however, is that these treatments all have a set ratio of T4 hormone to T3 hormone at 80%/20% respectively. For some, this is just right. For many though, we need to find the optimal T4/T3 ratio that is more often 90/10 or 95/5. There are only two ways to optimize the ratio: medications from a compounding pharmacy (although that can be expensive) or use a combination of prescription levothyroxine (T4) and liothyronine (T3). I almost always start these days at 50mcg and 5mcg and then adjust as needed.
The other path for us is sorting out underlying causes and the first question might be - are there positive Hashimoto’s antibodies relative to an autoimmune process?
For this we have three paradigms.
The first is the traditional one that says that autoimmunity is caused by the immune system being “confused” and attacking normal tissue that it interprets as being an infectious microbe. From the beginning of my medical career this never made sense to me. Too simplistic.
The second is the functional medicine paradigm that links autoimmunity to leaky gut syndrome, immune dysfunction and food sensitivities. This is a complex topic and beyond the scope of this blog. Basics of this approach would be to avoid gluten, homogenized cow milk dairy and soy and get a comprehensive stool analysis done with zonulin through a lab like Genova. Based on the stool analysis, a regimen is used to “fix the gut.” I have had a number of people with Hashimoto’s completely reversed with this type of protocol.
The third and most radical paradigm links Hashimoto’s to a chronic infection of a strain or strains of the Epstein-Barr Virus. This seems to be getting more traction. Visit Dr. Izabella Wentz, Pharm D’s website to read more.
If Hashimoto’s antibody levels are normal, there is still some chance for an inflammatory, immune-mediated process that sometimes is only picked up by a classic pattern on thyroid ultrasound.
Another common aspect of thyroid dysfunction is related to nutrient deficiencies. The body requires a number of minerals to make T4 hormone and also to convert T4 hormone to the more active T3 hormone. These include iodine, magnesium, selenium, zinc, tyrosine and others. There are many ways to assess for these deficiencies. If the person is deficient, we have another question of Why. This problem has become the norm in modern society relative to depleted soil, poor food supply, excessive stress, alcohol intake, vigorous exercise and other factors.
The next contributor is the toxic load we have and this is yet another complex topic that goes beyond the scope of this blog. The endocrine system is under duress from many sources.
Are we overwhelmed yet? Probably. Here’s the good news though. When it comes to mineral deficiencies and toxic load on the thyroid, iodine replacement often reverses the “double whammy” on the endocrine system. It gives the cells what they need and displaces some of the most important toxins like bromine. The 24-hour urine iodine-loading test is likely the best option for assessing the degree of iodine deficiency. I have had some with chronic thyroid problems completely reverse with long-term iodine therapy ultimately getting off their thyroid medication.
Next we have adrenal problems that might need to addressed. Many of the experts that follow a functional medicine approach (cited below) say that thyroid treatments are often ineffective if adrenal problems are not managed in advance. This is yet another complex topic and you may need to do your homework.
The final aspect of optimizing thyroid function is the concept of “thyroid hormone resistance.” I have seen people over the years where we worked to support the adrenals and get all of their thyroid numbers into an optimal range and they still had fatigue, constipation, difficulty with weight loss and other signs of thyroid hormone deficiency. If those people have low basal body temperature, I will consider trying to uncover some chronic infectious or inflammatory process that would lead to a resistance to the effect of thyroid hormone in the cells and tissues, aka “thyroid hormone resistance.”
Additional readings include:
In my practice:
Friday, last week, the day before I started this blog, I saw a woman in the office with long-term thyroid problems. She had an abnormal iodine-loading test suggestive of chronic iodine deficiency, so I had recommended iodine supplementation. Her thyroid issues have been managed over the years primarily by an endocrinologist. She saw him recently and he threw a fit about her being on a relatively high dose iodine supplement. She showed me a piece of paper where he had written in bold, underline to stop taking it immediately. He apparently looked me up on the Internet and chastised her for listening to a family doctor when he was a thyroid specialist. He told her that he had written books on the thyroid. I looked him up and from a traditional medical perspective, his background was impressive. He had gone to an Ivy League medical school and is now the director of a thyroid center at another Ivy League medical institution. During her visit with him as he harangued her about my advice, she tried to tell them, “But my thyroid numbers have never been better…and I feel good.” He dismissed those points as having nothing to do with the iodine supplement. Friday, she asked if I would take over her thyroid management.
Monday, I saw an 11-year female diagnosed last year with autoimmune Hashimoto’s thyroiditis. She had one of the highest TPO antibody levels and one of the highest TSH numbers I’ve seen. She is being managed by the Head of Pediatric Endocrinology Department at a top Boston hospital. She is doing well on thyroid medication, but there will be no attempt to figure out why she developed Hashimoto’s. The plan from her specialist’s is thyroid medication for the rest of her life. I will pursue a functional medicine approach to her condition and hopefully help them reverse and normalize the process.
Andrew Lenhardt MD