Something is not quite right, but it’s not necessarily dramatic. Some feature of your vitality is, well, just a little bit under the weather. It could be a sinking of mood or energy, a little extra hair loss, a change in the quality of your sleep. Your mind doesn’t seem quite so sharp, you’ve gained a little weight, your voice is hoarse; perhaps you’ve become constipated.
Or perhaps things are just a little too revved up: some heart palpitations, anxious energy, or more trouble sleeping.
Your complaints are too vague to imagine describing them to your doctor, so you procrastinate until they are truly aggravating. Your wise physician orders a complete thyroid panel and tells you that you have developed thyroid disease, Hashimoto’s Thyroiditis to be specific.
What is Known
Hashimoto's thyroiditis is progressive (usually) inflammation of the thyroid gland that can cause it to function at either less than (usually the case) or more than its optimal function. In severe cases, the thyroid can become enlarged and tender, though that is rare. Hashimoto's is the most common cause of underactive thyroid in the US, four times as common in women as men, and affecting 3-4 women per 1000 every year.
While there are some presumably viral and situational (post-partum) causes of thyroid inflammation, Hashimoto’s is by far the most common cause of elevated antibodies to the thyroid gland in association with abnormalities of thyroid function. Of all the cases of low thyroid function, about 90% of them are due to an autoimmune mechanism, primarily Hashimoto’s.
Graves’ Disease is the name given to auto-immune disease of the thyroid that results in excessive thyroid hormone production, which leads to eventual thyroid “burnout” and defective hormone production.
If we compare our body’s hormone systems to an orchestra, there is no single conductor, but rather a team of hormone glands that must work in harmony for our health to be optimal. Among the full orchestra that is our hormone system, there are three key glands that carry the main melody and help everyone else stay on task. The three key glands include our pituitary glands (key message center in our brains), our adrenal glands (sitting atop our kidneys, they regulate our nervous system and our production of cortisol, a rival for thyroid hormone for maintaining basic energy and balance) and our thyroid gland: a butterfly shaped gland sitting on the front of our necks just above the notch in the sternum and below our Adam’s apple.
The thyroid gland synthesizes thyroid hormone from tyrosine (an amino acid abundant in animal products, nuts and seeds, and more) and iodine (a chemical element found primarily in the ocean and thus in seafood, both plant and animal). Thyroid hormone is released in two forms: thyroxine (T4) and triiodothyronine (T3), in response to circulating levels of Thyroid Stimulating Hormone (TSH). Thyroid hormones are produced in proportions of 80-90% T4 and 10-20% T3. T4 and T3 regulate the growth and function of many other systems in the body. T4 regulates its own production: when T4 is high, TSH falls and production is turned off. T3 is the more physiologically active form of thyroid hormone, and comes minimally from thyroid gland production and significantly from what is called “peripheral conversion”, in which T4 is transformed into T3 (in the liver and other tissues), producing the active and most helpful form of thyroid hormone. T4 can circulate for a long time; T3 is usually promptly used by the body.
Physical examination of the thyroid is usually performed with the examiner standing behind the subject who is asked to swallow a mouthful of liquid. During the swallow, the examiner’s gentle fingers resting on the skin will feel a soft (think raw liver) shape passing up and then down. Any notable firmness or irregularity warrants further diagnostic evaluation, but an under- or over-functioning thyroid might feel completely normal. In Hashimoto’s it is usually normal, but occasionally slightly enlarged.
The most commonly ordered blood tests are:
- TSH: reflects your body’s perceived need to make more or less thyroid hormone. Normal ranges are usually 0.5-3.0 (or 5.5) mIU/L. Levels up to 5.5 were once considered normal, but too many cases of mildly underactive thyroid production were missed, so most practitioners consider 3.5 as a threshold for possibly low thyroid function
- Total T4: the total amount of thyroid hormone circulating in your bloodstream, whether produced by your thyroid gland or taken in a daily supplement.
- Free T4: the amount of the “available for work” form of thyroid hormone in circulation. When this number is too high, the TSH should fall; when this number is too low, the TSH should be high, calling for more T4 production. A well-recognized pattern is normal T4 with elevated TSH, reflecting that your thyroid gland is producing enough for now, but it’s fading, requiring a high level of TSH stimulation to keep up production. Most doctors will prescribe thyroid hormone in this case, allowing your body’s own over-achieving TSH and high-effort T4 production to return to normal.
Less commonly ordered, but important to get the full picture are:
- T3 and Reverse T3: A normal T3 level means your body is effectively converting T4 to T3. A low level can mean you’re not converting, or, if your Reverse T3 is too high, that your body is producing the inactive or reverse form of T3 instead of the active one. Reverse T3 is usually elevated in response to physiological stress.
- Thyroid Peroxidase Antibodies (TOPAb): Antibodies that interfere with the enzymes involved in thyroid production and T4 to T3 conversion are elevated in thyroiditis, which is usually Hashimoto’s, but can also occur after significant stresses (post-partum, post-major illness.
- Thyroglobulin Antibodies: Antibodies to hormone producing thyroglobulin, that are elevated in various auto-immune thyroid conditions.
- Iodine levels in the urine: a spot urine is fairly reliable if you are not taking iodine by mouth. Healthy levels of iodine are 150 mcg/L and above. If you’re taking iodine, you need to stop your daily dose and arrange for a 24 hour collection of urine, collected after loading yourself with 50 mg. of iodine. The extent to which your body holds on to that single dose reveals how “hungry” it is for iodine. If almost all the iodine is found in the urine collection, your body has a good amount of iodine.
Additional lab tests to consider would be those for food allergies, specifically gluten. Let’s take a step backwards to explain why that information is helpful even if the tests are not necessarily useful.
Auto-immune disease of any sort occurs when your own immune system thinks some part of your own body is “foreign” and creates antibodies that attack that part of the body, causing inflammation and impaired function. As part of that inappropriate reaction, special cells called T-helper cells get out of balance. Types 1 and 2, Th1 and Th2, normally in a comfortable balance with each other, slip out of balance and one type or the other becomes predominant, causing the body to turn against itself.
Current thinking on the causes of (presently epidemic degree of) auto-immunity include a genetic predisposition AND an environmental trigger with repeated exposure. The environmental trigger has to gain entry to our blood stream, so it is likely inhaled or ingested, ingested being more likely as we put more strange things in our mouths than our lungs on a repeated basis. Additionally, certain food triggers – especially gluten – can cause our intestines to become unusually permeable, known as “leaky gut”. Gluten causes an increase in intestinal “zonulin” that in turn causes the normally obstructing “tight junctions” between intestinal cells to become loose and spacious, allowing gluten itself and other foreign proteins direct access to the bloodstream. A leading research pioneer in this field is Dr. Allesio Fassano whose work can be found here.
Conventional food allergy tests screen for only a portion of the gluten associated proteins; comprehensive testing is available through a health care practitioner who has an account with Cyrex Lab.
Conventional treatment for Hashimoto’s involves avoiding any iodine supplementation, and replacing low levels of thyroid hormone with synthetic versions of T4 and, if necessary, T3. Hashimoto’s is expected to be a permanent condition requiring lifelong hormonal replacement. Some people are easily managed by this approach, and for others the instability of their thyroid function continues despite treatment, making dosing a challenge.
Healthy Steps: Hashimoto's Thyroiditis—First Steps
- Protect your thyroid. Radiation is well known to be hazardous to the thyroid, so request thyroid shields for dental x-rays and avoid any unnecessary x-rays that may include your thyroid.
- Take 6 weeks completely off gluten. If you feel a lot better, stay off of gluten! If you feel somewhat better, but not entirely, consider going off other foods temporarily to identify any other allergens. Check out my Allergy Elimination diet.
- If you are taking supplemental iodine, stop until your level can be tested.
Healthy Steps: Hashimoto's Thyroiditis—Full Program
The hormone discussion is an important one to have with your physician. When I counsel patients we focus on three areas:
- For patients who don’t want to start a lifetime of hormonal replacement, I recommend following all the advice listed in the full program and following both their symptoms and their lab tests. Some people have quieted down their symptoms and normalized their lab values and are willing to continue the dietary and supplement changes as needed, not always permanently.
- For patients who want to start a prescription replacement, we discuss the two options: synthetic vs. dessicated glandular. Either one can work for them, and for many people one is far superior and in that realm I let the patient be the judge. We decide on a dosing that optimizes the patient’s sense of well-being and hopefully falls within normal laboratory guidelines, although it is not uncommon in Hashimoto’s to have a discrepancy where the patient needs more thyroid hormone than their tests would indicate. In my experience, those patients who require higher doses than their tests would indicate, often “settle down” by following many of the guidelines below and at that point their lab values are as normal as they are feeling.
- One option with any auto-immune disease is low dose naltrexone or LDN. Naltrexone is a prescription medication historically used to treat heroin and other opiod addiction because it blocks the opiod/endorphin receptors: people suddenly wake up from a heroin-induced stupor in the ER. Compounded into very small doses, LDN appears to temporarily block our opiod/endorphin receptors (endorphins are our natural feel-good hormones produced within our own bodies) and while doing, it balances the immune system cells described above, the Th1 and Th2 cells. Taken at night, there can be some temporary sleep disruption, but within 1-3 months patients will be able to report whether it is helping. If they feel no improvement, the medication can be stopped – which often reveals the improvement they had been feeling but hadn’t realized!
Foods to Eat
- Include some sources of selenium in your diet. An adequate daily allowance is contained in half an ounce of brazil nuts, or 4-5 ounces of oysters. Other good sources include beef, lamb, shellfish, seafood, kidney, and eggs.
Foods to Avoid
- Steer past the raw cruciferous vegetables, including cauliflower, broccoli, kale (in salad or smoothies), cabbages and brussel sprouts. (Does anyone eat raw brussel sprouts? I think not.) Cruciferous vegetables offer many health benefits, so please enjoy them cooked, probably with plenty of butter.
- Avoid soy, a potent thyroid toxin with little food value and lots of other controversial features.
- Take 6 weeks completely off gluten. If you feel a lot better, stay off of gluten! If you feel somewhat better, but not entirely, consider going off other foods temporarily to identify any other allergens. check out my Allergy Elimination diet.
- If you feel somewhat better and want to proceed with other eliminations, start with grains, legumes and dairy. This will put you on the Paleo Diet which many people find easy to follow for a lifetime. If you feel better, but want to re-introduce some foods, do it one by one. I’d suggest you start with fermented dairy (yogurt, kefir, cheese) and white rice, but you can start anywhere so long as you re-introduce just one food at a time!
- Avoid excessive alcohol, caffeine, and sugar.
- Vitamin D3 taken to achieve a blood level of 40-70 ng/mL. I recommend taking it in a liquid form, with meals, and with a good source of vitamin A and K2 in your diet as well.
- Fermented Cod Liver Oil is a general healthy tonic as well as a good source of all the fat soluble vitamins and fish oils. Adults take 4 capsules or ½ teaspoon daily.
- Magnesium deficiency is widespread, particularly so in both auto-immune and thyroid conditions. I suggest taking Magnesium Taurate or Glycinate in doses slightly less than the dose that causes a loosening of the stools.
- Selenium, 200 daily from all sources is optimal. Selenium is a key nutrient that supports healthy thyroid hormone production.
- Tyrosine, 100 mg taken 1 to 3 times daily, provides a nutrient essential for thyroid production.
- Get your iodine levels tested. Excessive intake of iodine is the most common iodine-related problem in Hashimoto’s, but I have also seen people with quite low iodine who feel better with very gentle supplementation. Some experts believe that iodine is only a problem when selenium levels are too low, so get enough selenium in your diet and supplement if you take supplemental iodine.
- Take good care of yourself in every way: get enough sleep, think carefully about how you handle stress, spend some time playing and definitely some time outside. Get some form of regular exercise. All of these considerations will help heal your thyroid as much as possible and keep your adrenal glands healthy, which can try to pick up an extra load when your thyroid gland is stressed.
From Dr. Deborah's Desk
Hashimoto’s Thyroiditis presents a particular challenge for conventional physicians who are wedded to laboratory tests, because they are so often useless. I think it’s important to look at the tests, but also consider my patient’s overall energy as well as “nervous energy”. When someone is quite tired, but still feels frazzled, they might be low in T4 but adequately converting to T3. On the other hand, someone who is tired with a normal T4 and T3, often has borderline TSH OR an elevated Reverse T3. In all cases, stress management is important, but it cannot take the place of adequate thyroid replacement.
I have had occasional patients who required more thyroid hormone than their laboratory tests might indicate. I also prescribed so that they would feel better and also encouraged them to follow the guidelines listed above. Almost always, within 6-12 months, they were happy, had better energy, and their endocrinologist would finally have been happy because their lab tests made sense!