You can’t teach an old dogma new tricks.
—Dorothy Parker
Diagnosis of any thyroid problem can include self-checks, but a reliable diagnosis requires a thorough clinical examination by a medical practitioner and a detailed review of the patient’s medical history and symptoms, as well as appropriate blood and imaging tests.
Self-Checks
Evaluating your thyroid can start with some self-checks. As with breast self-exams, although self-checks may help you identify a problem, they are not conclusive, and you always need a doctor’s evaluation to rule out any sort of thyroid condition.
THE THYROID NECK CHECK
You can perform a simple, at-home self-test to potentially detect some thyroid abnormalities. To do this “thyroid neck check,” hold a mirror so that you can see the thyroid area in the neck, just below the Adam’s apple and above the collarbone. Tip your head back while keeping this view of your neck and thyroid area visible in the mirror. Take a drink of water and swallow. As you swallow, look at your neck. Watch carefully for any bulges, enlargement, protrusions, or unusual appearances in this area. Repeat this process several times. If you see anything that appears unusual, consult your doctor right away. You may have a goiter (an enlarged thyroid) or a thyroid nodule, and your thyroid should be evaluated. (Be sure you don’t get your Adam’s apple confused with your thyroid gland. The Adam’s apple is at the front of your neck; the thyroid is farther down and closer to your collarbone.)
BASAL BODY TEMPERATURE TEST
It’s known that thyroid hormones have a direct effect on the basal, or resting, metabolic rate. And while hypothermia, or lowered body temperature, is a medically accepted symptom of hypothyroidism, the use of basal body temperature (BBT) as a diagnostic tool is quite controversial. The late Broda Barnes, MD, made the public more widely aware of the use of axillary (underarm) BBT as a diagnostic tool for hypothyroidism. It is a monitoring method still used by some complementary and alternative practitioners, but most practitioners suggest that, although regularly low body temperature may suggest a thyroid problem, it is not evidence of it.
To measure your own BBT, use an oral glass/mercury thermometer or a special BBT thermometer available at some pharmacies. For a glass thermometer, shake it down before going to bed, and leave it close by and within reach. As soon as you awake, with minimal movement, put the thermometer in your armpit, next to the skin, and leave it there for ten minutes. Record the readings for three to five consecutive days. Women who still have their menstrual period should not test on the first four days of their period but can begin on day 5. If the temperature regularly falls below the range of 97.8 to 98.2 degrees Fahrenheit, this may point to a possible hypothyroidism condition.
IODINE PATCH TEST
Some practitioners and alternative health resources recommend testing for a potential thyroid problem by putting a patch of iodine on the skin of the arm and seeing if it disappears, and if so, how quickly. (The idea is that if it disappears quickly, the body must be deficient in iodine and suffering from hypothyroidism.) Most holistic practitioners I’ve surveyed, though, say that they do not use the iodine skin test, since the only thing this test is measuring is how rapidly iodine evaporates. It appears to have nothing to do with thyroid function.
The Clinical Thyroid Examination
Diagnosis of thyroid problems should always include a thorough clinical examination by a physician. The following is a summary of the components of a clinical thyroid exam.
Hands-on examination of the thyroid
The doctor should feel your neck (or palpate) for thyroid enlargement, nodules, and masses. Your doctor will look and feel for goiter, which is an enlargement of the thyroid, as well as nodules or lumps in your thyroid. He or she will also be looking for “thrill on palpation; this is when the practitioner can “feel” increased blood flow in the thyroid.
Stethoscope examination of the thyroid
The doctor should listen to your thyroid using a stethoscope. He or she should listen for what is known as bruit, the sound of increased blood flow in the thyroid.
Reflex check
The doctor should check your reflexes. Hyperresponsive reflexes can be a sign of hyperthyroidism, and slow reflexes may point to hypothyroidism.
Heart and blood pressure check
Your blood pressure should be checked. Very high or very low blood pressure can be a sign of thyroid problems. Other heart-related issues the doctor should look for are:
Skin and hair examination
Your skin and hair should be examined for visible signs of a thyroid condition, looking specifically for:
Eye examination
Your eyes should be evaluated, and your doctor should be looking for the following possible signs of a thyroid problem:
Other clinical signs your practitioner will look for are
Thyroid Blood Tests
There are several different blood tests that are typically used to diagnose a thyroid condition.
An important note: In some cases, I’ve included normal ranges and values associated with different tests, but keep in mind that normal ranges can vary from lab to lab and may be expressed quite differently in various countries. Be sure to get a printout of your lab test results, along with information from the lab and your practitioner on what the reference range is for each test (most lab reports will provide this along with the results), so that you can review where your tests fall according to your particular lab.
THYROID-STIMULATING HORMONE
Most doctors rely on the thyroid-stimulating hormone (TSH) test to diagnose an overactive or underactive thyroid. The TSH test measures the amount of TSH in your bloodstream. (The test is sometimes called the thyrotropin–stimulating hormone test.)
When the pituitary detects that there isn’t enough circulating thyroid hormone, TSH is released. TSH is considered a messenger that says to the thyroid, “Produce more hormone.” So the TSH level goes up when you don’t have enough thyroid hormone. A higher TSH level indicates low thyroid hormone production, or hypothyroidism. Conversely, in hyperthyroidism, too much thyroid hormone is circulating, and the TSH level drops.
The TSH level typically remains in what is called the normal reference range when the thyroid gland is healthy and functioning normally.
You’ll need to know what the normal values are for the lab where your doctor sends your blood tests because “normal” varies from lab to lab. What is considered a normal thyroid range is in tremendous flux right now. Since the 1980s in North America, the “normal” TSH range has been from about 0.3 to 0.5 at the bottom end, to a high end of from 5.0 to 6.0. At the lab where they sent my blood tests, for example, a TSH level of over 5.5 is considered hypothyroid, and under 0.5 was hyperthyroid. Anywhere in between is considered “normal,” or euthyroid.
Values below the low end of the normal TSH range usually indicate hyperthyroidism. In more severe hyperthyroidism, this level may even be undetectable, or 0. Nonexistent or nearly undetectable TSH levels are also referred to as “suppressed” levels. The lower the TSH, the more suppressed the thyroid is considered to be, and the more hyperthyroid you may be.
Values above the top of the normal range can indicate hypothyroidism, an underactive thyroid. The higher the number, the more hypothyroid/underactive your thyroid is considered to be.
In November 2002, the National Academy of Clinical Biochemistry (NACB), part of the American Association for Clinical Chemistry (AACC), issued revised laboratory medicine practice guidelines for the diagnosis and monitoring of thyroid disease. Of particular interest was the following statement in the guidelines:
More than 95% of rigorously screened normal euthyroid volunteers have serum TSH values between 0.4 and 2.5 mIU/L…. A serum TSH result between 0.5 and 2.0 mIU/L is generally considered the therapeutic target for a standard L-T4 replacement dose for primary hypothyroidism.
Based on these findings, in January 2003, the American Association of Clinical Endocrinologists (AACE) made an important announcement:
Until November 2002, doctors had relied on a normal TSH level ranging from 0.5 to 5.0 to diagnose and treat patients with a thyroid disorder who tested outside the boundaries of that range. Now AACE encourages doctors to consider treatment for patients who test outside the boundaries of a narrower margin based on a target TSH level of 0.3 to 3.0. AACE believes the new range will result in proper diagnosis for millions of Americans who suffer from a mild thyroid disorder, but have gone untreated until now.
In the years since the original NACB guidelines were released, most laboratories have not yet adopted these new guidelines, and the medical world is still not in complete agreement about changing the guidelines. For example, Labcorp, a lab that is used around the country by many doctors, has a reference range for TSH of 0.45 to 4.50.
This debate continues between practitioners who are using the new range and the labs and doctors using the older, wider range. This means that for patients who test below 0.5 or above 3.0, getting diagnosed for a thyroid condition depends on how up-to-date both the laboratories and the patients’ physicians are, and whether they are using the new, narrower standards. The following table summarizes the situation.
TSH Levels
|
|
HYPERTHYROIDISM |
“TSH NORMAL” |
HYPOTHYROID |
|
|
Numbers below range are considered hyperthyroid/overactive |
Reference range (euthyroid)/thyroid is neither hyperthyroid nor hypothyroid |
Numbers above range are considered hypothyroid/underactive |
|
Former guidelines* |
Below 0.5 |
0.5 to 5.0–6.0 |
Above 5.0–6.0 |
|
New guidelines (per NACB & AACE, as of 2003) |
Below 0.3 |
0.3 to 3.0 |
Above 3.0 |
TOTAL THYROXINE (TOTAL T4)
Total T4 measures the total amount of circulating thyroxine (T4) in your blood. Total refers to both the T4 “bound” to protein and the T4 that is free and “unbound.” A high value can indicate hyperthyroidism, a low value hypothyroidism. Total T4 levels can be artificially high, however, because pregnancy and estrogen (including the estrogen in hormone therapy and birth control pills) both raise thyroxine-binding globulin (TBG), and TBG elevates total T4 even when the actual levels of T4 circulating in your bloodstream are normal. When bound, thyroid hormone is not available to the cells, so most practitioners prefer to use the free (unbound) T4 test.
FREE THYROXINE (FREE T4)
Free T4 measures the free, unbound thyroxine (T4) levels circulating in your bloodstream. Free T4 is typically lower than normal in hypothyroidism and higher than normal in hyperthyroidism. It is considered a more accurate and reliable test than total T4.
TOTAL TRIIODOTHYRONINE (TOTAL T3)
Total T3 is a measure of the triiodothyronine (T3) bound to protein as well as the T3 that is free and unbound. The total T3 level will typically be lower than normal in hypothyroidism and higher than normal in hyperthyroidism.
FREE TRIIODOTHYRONINE (FREE T3)
Free T3 measures free unbound triiodothyronine in your bloodstream. Again, the free T3 levels are considered more accurate than the total in the case of T3.
THYROGLOBULIN/THYROXINE-BINDING GLOBULIN
Thyroglobulin, also known as thyroxine-binding globulin, or TBG, is a protein produced by the thyroid primarily when it is injured or inflamed due to thyroiditis or cancer. The normal thyroid produces low or no thyroglobulin, so undetectable thyroglobulin levels usually mean normal thyroid function. But when TBG is leaking into the bloodstream and becomes detectable, it indicates some sort of thyroid abnormality. Thyroglobulin is typically elevated in Graves’ disease, thyroiditis, and thyroid cancer.
THYROTROPIN-RELEASING HORMONE
The thyrotropin-releasing hormone (TRH) test is a “stimulation” or “challenge” test, rather than a measure of circulating hormones. It’s much like a three-hour glucose tolerance test used to diagnose diabetes rather than a fasting glucose level test. The TRH test is considered particularly good for detecting subtle underactive thyroid problems. The time and cost involved in the test, as well as the difficulty getting the drugs needed to perform the test, however, have made it all but impossible to get from most physicians. It is therefore rarely used.
REVERSE T3
When the body is under stress, instead of converting T4 into T3 (the active form of thyroid hormone that works at the cellular level), it conserves energy by making an inactive form of T3 known as reverse T3 (RT3). Some practitioners believe that even when stress is relieved, people continue to manufacture RT3 instead of active T3. This in turn creates a thyroid problem at the cellular level, even though TSH lab values may well be normal. The values of RT3 tests are controversial, but this test has become somewhat more popular with open-minded doctors who are looking to assess a person’s full range of thyroid function.
THYROID PEROXIDASE ANTIBODIES/ANTITHYROID PEROXIDASE ANTIBODIES
One of the most common thyroid antibody blood tests is thyroid peroxidase (TPO) antibodies, also known as antithyroid peroxidase, or anti-TPO, antibodies. This test is often done as a first step in diagnosing autoimmune thyroid disease. TPO antibodies attack thyroid peroxidase, an enzyme that plays a part in the conversion of T4 to T3. They can indicate that the thyroid tissue is being destroyed, such as in Hashimoto’s disease and in some other types of thyroiditis, such as postpartum thyroiditis. TPO antibodies are detectable in approximately 95 percent of patients with Hashimoto’s thyroiditis. It’s thought that among patients with Graves’ disease, 50 to 85 percent will test positive for these antibodies.
ANTITHYROID MICROSOMAL ANTIBODIES
In some cases, antithyroid microsomal antibodies are measured, but the TPO antibody test is now considered more state of the art and has replaced this test in part. The level of antithyroid microsomal antibodies is typically elevated in Hashimoto’s thyroiditis. It’s thought that as much as 80 percent of Hashimoto’s patients have elevated levels of these antibodies.
THYROGLOBULIN ANTIBODIES/ANTITHYROGLOBULIN ANTIBODIES
Testing for thyroglobulin antibodies (also called antithyroglobulin antibodies) is common. Thyroglobulin antibodies are positive in about 60 percent of Hashimoto’s patients and 30 percent of Graves’ patients.
THYROID STIMULATING HORMONE RECEPTOR ANTIBODIES
TSH receptor antibodies are seen in most patients with a history of or who currently have Graves’ disease. They may be:
Patients with Graves’ disease tend to test positive for stimulatory TSH receptor antibodies, and patients with Hashimoto’s disease tend to test positive for blocking TSH receptor antibodies.
THYROID-STIMULATING IMMUNOGLOBULINS
Thyroid-stimulating immunoglobulins (TSIs) can be detected in the majority of patients with Graves’ disease. Their presence is considered diagnostic. The higher the levels, the more active the Graves’ disease is thought to be. The absence of these antibodies does not, however, mean that you don’t have Graves’ disease. Some people with autoimmune hypothyroidism also have TSIs, and this can cause periodic transient hyperthyroid episodes.
THYROID IMAGING TESTS
Several types of imaging and evaluation tests are used to make a conclusive diagnosis of thyroid disease.
Nuclear Scan/Radioactive Iodine Uptake
Radioactive iodine uptake (RAI-U) is used to help differentiate Graves’ disease, toxic multinodular goiter, and thyroiditis. In this test, a small dose of radioactive iodine 123 is administered as a pill. Several hours later, the amount of iodine in your system is measured, accompanied by an x-ray that views how iodine is concentrated in your thyroid.
An overactive thyroid usually takes up higher amounts of iodine than normal, and that uptake is visible on the x-ray. A thyroid that takes up iodine is considered “hot,” or overactive; an underactive thyroid is “cold.”
In Graves’ disease, RAI-U is elevated, and you can see that the entire gland becomes hot. (In contrast, in Hashimoto’s thyroiditis, the uptake is usually low, with patchy hot spots in the gland.) If you have thyroid nodules, RAI-U can show them and whether they are hot. Hot nodules may overproduce thyroid hormone, but they are rarely cancerous. Cold nodules (nodules that do not take up iodine) can be cancerous and require further follow-up. An estimated 10 to 20 percent of cold nodules are cancerous.
Computed Tomography Scan
A computed tomography (CT) scan—or “cat” scan—is a specialized imaging technique that can be used to evaluate the thyroid. The scan cannot detect smaller nodules, but it can diagnose a goiter or larger nodules.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is done when the size and shape of the thyroid need to be evaluated. MRI can’t tell anything about how your thyroid is functioning—that is, whether it is hyperthyroid or hypothyroid—but it can detect enlargement and may be done along with blood tests. It is sometimes preferable to x-rays or CT scans because it doesn’t require any injection of contrast dye and doesn’t require to radiation.
Thyroid Ultrasound
Ultrasound of the thyroid is done to evaluate nodules, lumps, and enlargement of the gland. It also can determine whether a nodule is a fluid-filled cyst or a mass of solid tissue. Ultrasound cannot tell whether a nodule or lump is benign or malignant, however.
Needle Biopsy/Fine Needle Aspiration
Needle biopsy or fine needle aspiration (FNA) helps to evaluate suspicious lumps or cold nodules. In a needle biopsy, a thin needle is inserted directly into the lump, and some cells are withdrawn and evaluated. In some cases, ultrasound is used to help guide the needle into the correct position. Pathology assessment of the cells can often reveal Hashimoto’s thyroiditis, as well as cancerous cells. Definitive information is available in approximately 75 percent of nodules biopsied.
Diagnosing a Thyroid Problem
Based on the results of the patient history, review of symptoms, clinical examination, and blood and imaging tests, doctors should be able to make an accurate diagnosis.
DIAGNOSING HYPOTHYROIDISM
To diagnose hypothyroidism, in addition to the history, symptoms, and clinical examination, conventional doctors consider the TSH test results. A TSH level above the reference range is considered hypothyroid and will be flagged as high on test results. Remember, however, that there is controversy over the reference range, with some groups recommending the new range of 0.3 to 3.0, and many labs and doctors still using the old range of 0.5 to around 5.5.
Other blood tests that are typically done to help diagnose hypothyroidism are
DIAGNOSING HASHIMOTO’S THYROIDITIS
Hashimoto’s thyroiditis is the most common cause of hypothyroidism. The characteristic Hashimoto’s thyroiditis patient would have high or high-normal TSH values and low or low-normal free T3 and free T4 levels. The greatest distinguishing feature for Hashimoto’s is a high concentration of thyroid autoantibodies, particularly anti-TPO antibodies. (Some patients have elevated antibody levels for months or even years before the TSH level changes. But elevated antibodies can cause symptoms, and there is some evidence that treating elevated antibodies with a low dose of thyroid hormone medication may help reduce antibodies and prevent progression to overt hypothyroidism.)
Occasionally, FNA of thyroid nodules/lumps will reveal evidence of Hashimoto’s disease, but FNA typically is not done just to diagnose Hashimoto’s disease.
DIAGNOSING HYPERTHYROIDISM
A diagnosis of hyperthyroidism is usually made by means of a TSH test. Levels below 0.3 to 0.5 may be considered hyperthyroid.
Other blood tests that may be done to help diagnose hyperthyroidism are
DIAGNOSING GRAVES’ DISEASE
In addition to hyperthyroid TSH levels (typically, a TSH level below 0.3) and high-normal or high levels of free T4 and free T3, the levels of TSH antibodies and TSI may be measured to diagnose Graves’ disease, the autoimmune condition that frequently causes hyperthyroidism.
A radioactive picture of the thyroid, made by ingesting a small amount of radioactive iodine, may also be taken to see if the gland is overactive. This overactivity is a hallmark of Graves’ disease.
DIAGNOSING GOITER
Several steps can be involved in diagnosing the enlarged thyroid known as goiter:
DIAGNOSING THYROID NODULES
Nodules are usually evaluated by
DIAGNOSING THYROID CANCER
The main diagnostic procedure for suspected thyroid cancer is FNA of the thyroid nodule. In FNA, a needle is inserted into the nodules or lumps. Fluid and cells are removed from various parts of the nodules, and these samples are then evaluated. Sometimes FNA is done with an ultrasound to help guide the needle into nodules that are too small to be felt. Between 60 and 80 percent of FNA tests show that the nodule is benign. Only about one of twenty FNA tests reveals cancer. The remainder of the cases are classified as suspicious, and frequently a surgical biopsy is needed in order to rule out or diagnose cancer.
Challenges to Getting Properly Diagnosed
While it’s common for doctors to say that thyroid disease is easy to diagnose and easy to treat, the reality is that diagnosis can be complicated. Many doctors don’t recognize thyroid symptoms, so patients mistakenly are prescribed estrogen, antidepressants, weight loss drugs, or cholesterol medications instead of given a thyroid test. Once thyroid problems are suspected, some doctors will perform only a TSH test, then base their diagnosis only on that result. This narrow approach misses patients who otherwise would be diagnosed by a thorough thyroid evaluation, such as one that takes into account clinical examination, review of symptoms, a thorough family and personal history, and other blood work and imaging tests as needed.
UNINFORMED DOCTORS
Surprisingly in this day and age, there are still practitioners who believe that they can simply look at a patient, or feel his or her neck, and rule out thyroid disease. Looking at the patient and feeling the thyroid for enlargement and lumps are only a small part of a clinical thyroid examination. As noted, a thorough clinical thyroid exam must also include a blood pressure and pulse check, weight check, evaluation of reflexes, and careful evaluation of clinical thyroid signs, such as loss of outer eyebrow hair, swelling in face and limbs, unusual skin patches, and other skin and hair disturbances. The doctor should then consider the findings, in addition to blood work and medical history, to make a diagnosis. If you are seeing a doctor who thinks he or she can rule out thyroid disease based on looking at you or feeling your thyroid, get another doctor.
“BY THE NUMBERS” DIAGNOSIS
Today’s conventional thyroid treatment tends to focus on blood test results to the exclusion of how patients feel. One prominent endocrinologist even declared that thyroid patients who had “normal” TSH levels after treatment but who continued to have debilitating symptoms were likely suffering from mental illness. This has to change. Practicing medicine is a lot more than just reading numbers off a chart.
Some doctors believe that, even in the face of obvious thyroid signs and symptoms, unless the numbers clearly demonstrate a problem, they won’t make a thyroid diagnosis. Holistic practitioner Dr. Jocelyne Eberstein has a problem with this approach:
Too many doctors just look at the numbers. They don’t even look up from their paper to see the patient is losing hair, constipated, and suffering from other symptoms. Practitioners aren’t looking, they aren’t touching.
It’s important to note that there is a major disagreement between those practitioners who believe that blood tests must be abnormal in order to diagnose thyroid disease and justify treatment and those who feel that blood tests are only a small part of the picture. The more holistic, integrative doctors typically consider a patient’s complete situation—including family history, personal history, symptoms, clinical examination, and blood tests—rather than relying only on blood test results.
Getting a proper diagnosis sometimes means you will need to remind your doctor that you are a patient, not a lab value. Spell out your symptoms and family history, insist on a thorough thyroid evaluation, and be sure that the doctor’s goal is resolving symptoms, not just looking at test results. When necessary, abandon a conservative, less innovative physician, and switch to one who will take a big picture view of thyroid diagnosis.
USEFULNESS OF THE TSH TEST
There are many practitioners who run the TSH—and only the TSH test—to diagnose and manage thyroid conditions. But some doctors feel that the TSH test alone is simply not very useful. Dr. Jocelyne Eberstein wonders about the usefulness of the test.
Why measure a stimulating hormone when you’re trying to check a hormone level? It’s like checking a man’s luteinizing hormone if you’re trying to evaluate his testosterone levels. This is why we need to actually check free T3 and free T4.
Again, some practitioners tend to rely on the TSH as the only test they need to diagnose and treat thyroid conditions. But to get a proper diagnosis, you may need to switch to a practitioner who will consider other tests (like free T4, free T3, and antibodies tests), as well as your clinical signs, symptoms, and history.
QUALITY/RELIABILITY OF THE TSH TEST
While many doctors assume that the TSH test is accurate, some have concerns about the reliability of the TSH test and feel it’s unwise to rely on this test alone for diagnosis and management.
Dr. Richard Shames, a noted thyroid practitioner and author of a number of books on thyroid disease, has found that many practitioners take TSH blood samples but allow those samples to sit for many hours before they are collected and shipped to the laboratory for analysis. Says Dr. Shames:
These samples are supposed to be cooled and packed in ice. But often they’re not. Or they have been sitting around for hours before even traveling to the lab. The TSH in the sample can degrade in transit. A TSH that might have been measured at a 6.0 or 7.0 can degrade so that by the time it’s measured, it actually ends up in the normal range.
Dr. Shames has seen situations where patients were being properly managed on thyroid medication and symptoms were relieved, then had a TSH test that showed that their TSH was too low. Says Dr. Shames:
It didn’t make sense. But when we retested, it turned out that their TSH was fine, and no dosage change was needed. But when doctors trust the TSH and don’t realize that some of these samples are degraded, patients may not get proper treatment.
There is also the issue of time of day affecting the TSH level. The highest TSH level is typically obtained from a fasting blood test administered first thing in the morning. One study found that TSH levels drop—by an average of 26 percent—when compared with the early morning level. This means that as many as 6 percent of patients would be reclassified from hypothyroid levels to “normal” TSH.
A patient who might have a high or high-normal TSH if tested earlier in the day could have a normal TSH if tested later in the day.
Getting a proper diagnosis sometimes means you will need to be careful when and where you have your blood work done and ask about how the sample will be stored before it’s sent to the lab for analysis. Given the significant questions about the TSH reliability overall, you may also need to see a physician who does not base his or her entire diagnosis on this test alone.
INTERPRETATION OF THE TSH TEST
Many practitioners consider the TSH test the gold standard for diagnosing thyroid disease. Unfortunately, as noted, there is still a major disconnect in the medical community over how to interpret the results of that test. Progressive practitioners tend to use the narrower, more recent range of 0.3 to 3.0, while others use the older reference range of 0.5 to 5.5. You could have a list of thyroid symptoms, a family history, and clinical signs of a thyroid condition, yet if your TSH test result came back at 4.9, one doctor might tell you your thyroid is normal, and another might tell you are hypothyroid. So much for the gold standard.
It’s estimated that if the new narrow range were adopted nationally, 30 million more people would be considered as having thyroid disease. But with the ongoing disagreement, the vast majority of these people remain in an undiagnosed limbo.
If you are told that your thyroid test is “normal,” you need to first find out the exact numbers and what range the doctor is using to define normal. Better yet, ask when you’re scheduling your appointment what range the doctor uses. And if you fall into the limbo of a TSH level between 3.0 and 5.5 and are told you’re normal, get another opinion from a more up-to-date practitioner.
FEAR OF OSTEOPOROSIS
Some practitioners have a fear that treating mild or borderline hypothyroidism will increase a woman’s risk of osteoporosis. This fear is based on research that has shown that extended periods of hyperthyroidism, in particular, extremely low, suppressed TSH levels, can be a risk factor for osteoporosis. There are also several inconclusive studies that suggest that long-term treatment of hypothyroidism may increase the risk of osteoporosis. At the same time, there are a number of other studies that show that thyroid treatment does not increase the risk of osteoporosis.
Some doctors, unfortunately, employ faulty logic and decide if a very low TSH level poses a risk, and treatment might pose a risk, then keeping perimenopausal and menopausal hypothyroid women at higher levels will avoid the risk.
An important review looked at sixty-three English-language studies of the thyroid-osteoporosis connection that were published from 1990 to 2001. Of the studies reviewed, levothyroxine was shown to have no overall effect in thirty-one studies, partial positive and/or partial negative effects were reported in twenty-three studies, only nine studies showed overall negative effects, and three studies reported no effects. Ultimately, this metareview found no association between the duration of levothyroxine therapy and an associated reduction of bone mineral density.
DOCTORS WHO WON’T ORDER TESTS/HMOS AND INSURANCE COMPANIES THAT WON’T COVER TESTS
Sometimes you will come up against a doctor who, for a number of reasons, simply refuses to order blood tests for your thyroid treatment. It may be a doctor who is trying to control costs (often in an HMO environment) or who has decided that, simply by looking at you, he or she can “tell” that you don’t have a thyroid condition and therefore don’t need testing. Or a doctor could become territorial and refuse to run thyroid tests unless it was his idea. (Ridiculous, I know, but far more common than you think.)
In some cases, HMOs and insurance companies simply won’t approve thyroid tests or will only approve TSH tests.
In these circumstances, you have several options.
Thyroid Treatments
HYPERTHYROIDISM/OVERACTIVE THYROID: THYROTOXICOSIS
If you are in the United States, the treatment most often recommended for hyperthyroidism and Graves’ disease is radioactive iodine (RAI), sometimes referred to as ablation therapy or chemical ablation. This involves taking a liquid or pill form of radioactive iodine, which is then absorbed by the thyroid. The RAI disables the thyroid, usually permanently. Most patients who have RAI treatment develop the opposite condition—hypothyroidism—and require thyroid hormone replacement for life. Some physicians in the United States take a less drastic approach and prescribe antithyroid drugs such as propylthiouracil (PTU) and methimazole (brand names Tapazole and Carbimazole), along with beta blockers like propanolol or atenolol, to calm down the thyroid, the immune system, and the heart rate/blood pressure. This approach is based on the chance of remission of hyperthyroidism and disease, which occurs in up to 30 percent of patients. (Interestingly, antithyroid drugs are the first choice in treatment for doctors outside the United States.) In rarer cases in the United States, and more commonly outside the United States, surgery to remove the thyroid may be advised. Holistic and integrative treatments prior to RAI or surgery focus on complementing antithyroid drug approaches with foods, supplements, and herbs that can slow down the thyroid but have few side effects. Some patients have also had success with calming and rebalancing the immune system through nutrition, herbs, supplements, movement therapy such as yoga, and energy work. Ultimately, most people with Graves’ disease and hyperthyroidism do end up hypothyroid for life as a result of RAI or surgery.
My book Living Well with Graves’ Disease and Hyperthyroidism provides more in-depth information on the various treatment options, both conventional and holistic, and also details a holistic and integrative protocol for Graves’ disease and overactive thyroid problems.
GOITER/ENLARGEMENT
Goiter can be due to an autoimmune condition that triggers an inflamed thyroid, or it can be caused by too much or too little iodine in the diet. In the United States, 10 to 20 percent of goiters are iodine-induced. Treatment for goiter depends on how enlarged the thyroid has become, as well as other symptoms. Treatment can include
NODULES/LUMPS
Benign nodules are often left alone and monitored periodically, assuming they aren’t causing serious difficulty. Some will be treated with thyroid hormone replacement to help shrink them, a treatment that is not considered universally effective.
Some emerging treatments, including percutaneous ethanol injections and ultrasound, are being used by cutting-edge practitioners to treat nodules.
Nodules are surgically removed if they are causing difficulties with breathing or swallowing.
Nodules that are considered suspicious, or that show evidence of cancer, are removed along with the thyroid gland itself.
THYROID CANCER
The treatments for thyroid cancer almost always involve surgery to remove the thyroid and cancer. In some cases, lymph node dissection also removes lymph nodes in the neck that contain cancer. RAI treatment is typically given as a follow-up to surgery. Because the thyroid takes up iodine, the radioactive iodine collects in any thyroid tissue remaining in the body and kills the cancer cells. Less commonly, external radiation therapy may be given. Hormone therapy, using thyroid hormone replacement medication, is often included.
Because the entire thyroid is removed as treatment for most thyroid cancers, almost all thyroid cancer survivors end up hypothyroid and need to take thyroid replacement hormone for life. Their thyroid medication needs to be at a high enough dose to ensure that their TSH levels remain low (nearly undetectable, actually) to help prevent a relapse of cancer. Survivors need regular checkups to watch for a reoccurrence.
HASHIMOTO’S DISEASE/THYROIDITIS
Typically, because Hashimoto’s disease most often causes hypothyroidism, the conventional approach is simply to treat the hypothyroidism with thyroid hormone replacement medication. Conventional medicine offers no treatment for the autoimmunity of Hashimoto’s itself.
Holistic and integrative approaches to Hashimoto’s tend to look at healing the underlying autoimmune imbalance, and may include nutritional support for the thyroid (selenium, tyrosine, B vitamins, etc.) and overall support for the immune system.
HYPOTHYROIDISM
The end result for most thyroid patients is hypothyroidism, an underactive thyroid condition that requires thyroid hormone replacement for life.
With the autoimmune disease Hashimoto’s thyroiditis, the thyroid typically burns itself out over time, becoming less able to produce thyroid hormone and leaving most patients hypothyroid.
With Graves’ disease and hyperthyroidism, most patients in the United States have RAI treatment, which usually leaves them without a functional thyroid. This means they end up hypothyroid, even if they started with an overactive gland.
With thyroid nodules and goiter, surgery may be performed to remove all or part of the thyroid. The end result is frequently hypothyroidism.
For thyroid cancer, almost all patients have their thyroid removed entirely, leaving them completely hypothyroid and reliant on outside thyroid hormone replacement.
So, whatever the thyroid disease or condition, patients are likely to end up hypothyroid in the end, unable to produce sufficient thyroid hormone on their own and requiring thyroid hormone replacement treatment.
Conventional treatment typically involves replacing the missing thyroid hormone, using prescription thyroid hormone replacement drugs. These medications are discussed in the next section. Holistic approaches to an underactive thyroid are also discussed later in this chapter.
Thyroid Medications
LEVOTHYROXINE
The most commonly prescribed thyroid hormone replacement drug is levothyroxine, the generic name for the synthetic form of thyroxine (T4). It is sometimes referred to as 1-thyroxine or L-T4, and some endocrinologists also incorrectly call it thyroxine, which is actually the name of the hormone produced in the body.
Most commonly, a levothyroxine drug is prescribed for hypothyroidism due to any cause, as conventional doctors consider it to be the standard treatment for hypothyroidism.
Many doctors will only prescribe levothyroxine for thyroid hormone replacement. The rationale is that people only need the synthetic T4, and the body will convert the T4 in the medication to T3 (triiodothyronine), the active thyroid hormone at the cellular level. Some people with hypothyroidism find that levothyroxine therapy is sufficient treatment for their hypothyroidism.
Many doctors do not recommend generic levothyroxine, preferring brand names instead. This is because the different generic versions of levothyroxine can vary in some cases from 95 to 105 percent of the stated potency, causing symptoms and testing irregularities. (For thyroid cancer survivors, erratic dosing can jeopardize therapy to prevent cancer recurrence.)
The different brand names of levothyroxine are for the most part equivalent in terms of effectiveness. The primary difference between brand names is that each has different fillers, binders, and dyes, and some patients may have allergies to those ingredients. The 50 mcg (microgram) dosage pills from the brand-name levothyroxine manufacturers are typically free of dyes and are more likely to be hypoallergenic.
Levothyroxine came on the market in the late 1950s, without approval from the U.S. Food and Drug Administration (FDA). It was grandfathered in under approval for natural dessicated thyroid, which had been available since the early 1900s. In 1997 the FDA required all levothyroxine drugs to go through the new drug application process and receive formal approval, given concerns over their stability, potency, and reliability. The drugs were to be approved by 2000, but only Unithroid (distributed as a generic by Lannett; formerly manufactured by Jerome Stevens) received approval within the FDA deadline. The other main brands—Levoxyl (Jones Pharma, a subsidiary of King Pharmaceuticals), Levothroid (Forest Pharmaceuticals), and Synthroid (Abbott Laboratories)—were eventually approved.
Synthroid, as a heavily marketed drug for more than four decades, enjoys a high degree of brand loyalty from physicians. Over the years, Synthroid’s manufacturer has been a heavy financial supporter of medical meetings and physician education, and has taken many opportunities to get Synthroid’s name in front of new and established physicians. As a result, Synthroid is sometimes used by doctors to describe the whole category of “thyroid hormone replacement drugs” (in the same way that the brand name Kleenex has, for example, become synonymous with “tissue” or Xerox with photocopying).
LIOTRIX (THYROLAR)
Thyrolar (Forest Pharmaceuticals) is the brand name for liotrix, a combination of synthetic T4 (levothyroxine) and synthetic T3 (liothyronine). This drug is not very regularly prescribed, but it is preferred by some physicians who wish to provide both T4 and T3 but prefer a synthetic versus natural desiccated thyroid.
It’s important to note how to properly store Thyrolar. Thyrolar needs to be kept at a refrigerated temperature between 36 and 46 degrees Fahrenheit (2 to 8 degrees Celsius). This refrigeration will ensure that Thyrolar remains potent and stable. According to the manufacturer’s pharmacists, refrigeration will actually help the product maintain optimal potency longer. If you need to travel, however, the product should remain stable for at least a week. So you don’t have to go to extraordinary lengths to keep Thyrolar refrigerated while traveling.
LIOTHYRONINE/T3
Liothyronine (brand name Cytomel, distributed by Jones Pharma Inc., a subsidiary of King Pharmaceuticals) is the synthetic form of triiodothyronine (T3), the active thyroid hormone at the cellular level.
Research has shown that some patients feel better with the addition of T3 in some form, so practitioners prescribe a form of liothyronine along with a levothyroxine medication, or natural thyroid medication.
Francesca, who is perimenopausal with a thyroid problem, started going to a new nurse practitioner, who put her on Cytomel. Says Francesca:
My only side effect was a minor headache for two days, which went away with aspirin. The third day I realized I was awake. I woke up in the morning and was “alert” for the first time in years. It didn’t take me an hour to drag myself out of bed. I was only taking 5 micrograms of Cytomel and had an immediate result. My body temperature has risen to 98.1 degrees Fahrenheit, and I am noticing little things changing in my body and health.
Liothyronine is also available from compounding pharmacies, who can make it available in regular or time-released capsules.
Dr. Richard Shames has found that T3 can be a helpful addition to a patient’s thyroid therapy. Says Dr. Shames:
When it comes to T3, some patients do well on Cytomel, but it seems that some patients do better on time-released T3. It seems that the compounded, time-released form prevents that spike of T3 that you get with Cytomel. For some patients, the time-released T3 provides the necessary gradient that helps to drive the T3 across the cell membrane barrier.
Sometimes thyroid cancer patients preparing for a scan are given Cytomel for several weeks, to help aid with hypothyroidism symptoms that result from withdrawal from other thyroid medication, which is needed for the scan’s accuracy.
A controversial form of thyroid treatment for hypothyroidism is T3-only treatment, and few doctors recommend this approach.
NATURAL DESICCATED THYROID
Natural desiccated thyroid is the original form of thyroid hormone replacement that first came into use in the early 1900s. It is thyroid medication derived from the thyroid gland of animals that is dried and measured to ensure proper potency. It contains natural forms of the thyroid hormones T4 and T3, as well as other, lesser known thyroid hormones, such as T2 and T1, the hormone calcitonin, and nutrients typically found in a natural thyroid gland. Decades ago, bovine (cow) thyroid was used, but prescription natural thyroid sold in the United States is currently porcine (pig).
From the early 1900s until the 1950s, natural desiccated thyroid was the only form of thyroid replacement drug available. In the late 1950s/early 1960s, the drug fell out of favor with many endocrinologists, as Synthroid’s extensive marketing promoted synthetic thyroid as a better, more “modern” option for thyroid treatment.
Marketing efforts aside, since the 1990s, Armour Thyroid (Forest Pharmaceuticals), along with other brands of natural thyroid, like Nature-Throid and WesThroid (both from Western Research Labs), have been enjoying a resurgence in popularity with increasing numbers of patients and practitioners. These doctors, more often osteopaths, naturopaths, and holistic practitioners, prefer to start their hypothyroid patients on a desiccated thyroid drug, because they believe that since the drug contains a full spectrum of thyroid hormones as well as nutritional cofactors, it more closely mimics the action of human thyroid hormone, and their patients generally respond better.
The top-selling brand of natural thyroid is Armour Thyroid, bound by microcrystalline cellulose. Westhroid is cornstarch-bound. Nature-Throid is bound with microcrystalline cellulose and is hypoallergenic.
Most endocrinologists and conventional practitioners tend to oppose the use of natural thyroid on principle, primarily based on outdated concerns about potency, or because they are unfamiliar with the current manufacturing processes for desiccated thyroid or how to properly dose these medications.
ANTITHYROID DRUGS
Antithyroid drugs have been in use since the 1940s. They are given to help achieve a remission in hyperthyroidism and its symptoms. One key antithyroid drug is methimazole (brand name Tapazole, distributed by Jones Pharma, a subsidiary of King Pharmaceuticals), sometimes also called thiamazole. This drug is used around the world. Carbimazole (brand name NeoMercazole, made by Nicholas Piramal) is a similar medication that metabolizes to methimazole. It is typically used in the United Kingdom and elsewhere in Europe.
The other main antithyroid drug is propylthiouracil, usually referred to as PTU. PTU is available only as a generic.
Methimazole inhibits the thyroid from using iodine to produce thyroid hormone. PTU has two effects. Not only does it inhibit the thyroid from using iodine to produce thyroid hormone, but it also inhibits T4-to-T3 conversion. PTU has a shorter half-life than methimazole and acts more quickly, so some people see the effects of PTU right away. Also, because PTU blocks T4-to-T3 conversion, it is thought to act faster and may more quickly reduce T3 levels, resolving symptoms more quickly, compared with methimazole. PTU, therefore, is sometimes given in thyroid storm (an emergency of the thyroid) or during severe hyperthyroidism because of its fast-acting characteristics. Because methimazole is longer acting, it is preferred by some doctors and patients because less frequent dosing is required.
THYROTROPIN ALFA/RECOMBINANT TSH
Thyrogen (Genzyme Therapeutics) is the brand name of thyrotropin alfa, also known as recombinant TSH. This drug, given only by injection, is for thyroid cancer patients. When thyroid cancer patients are preparing to have a scan to assess recurrence or leftover cancer cells, they usually need to stop taking thyroid hormone replacement drugs (usually, levothyroxine), in order to improve the accuracy of the scans. Unfortunately, the result of withdrawing thyroid hormone replacement is several weeks to months of hypothyroidism, including side effects such as severe fatigue, weight gain, depression, memory problems, confusion, and constipation. For certain patients, Thyrogen can be injected and will prevent the symptoms of hypothyroidism, without compromising the ability to conduct a scan. A scan using Thyrogen is considered slightly less sensitive than a scan on total withdrawal of all thyroid hormone replacement, so Thyrogen scans are often recommended for long-term survivors and for those who have had a few years of negative tests under conventional hormone withdrawal.
Optimizing Your Thyroid Hormone Replacement Treatment
Because most patients end up hypothyroid, it’s important to ensure that your treatment is optimized.
To optimize your treatment, you’ll want to consider the following important questions.
IF YOU’RE ON LEVOTHYROXINE, IS IT THE RIGHT BRAND FOR YOU?
Because of their differences in fillers, binders, and dyes, different formulations of levothyroxine may produce different reactions in patients. For example, Synthroid is known to digest very slowly, while Levoxyl is fast-dissolving. Synthroid contains acacia and lactose, which can cause problems in some people who are sensitive. With a number of FDA-approved brand-name levothyroxine drugs available, you may wish to discuss a change in brand with your physician. Do stick with a brand name, however, and not a generic, to ensure consistency from refill to refill.
DO YOU NEED T3?
Some people do not feel their best without the addition of the active thyroid hormone T3. Usually, the body converts T4 to enough T3, but nutritional deficiencies, toxins, and a variety of other physiological factors may prevent the body from effectively handling that conversion, which can leave you deficient in this most important thyroid hormone. While it’s a controversial topic that is under increasing study by various experts, some physicians find that supplemental T3 helps optimize thyroid treatment for some patients. They add T3 in one of several ways:
Check with your physician about whether or not supplemental T3 might be helpful for you. But realize that many conventional physicians will not be willing to even discuss T3, much less prescribe it, and you may need to seek a more open-minded practitioner.
WOULD NATURAL THYROID HELP?
Some practitioners find that, in general, their patients do best on natural desiccated thyroid, derived from the thyroid gland of pigs. These products, including Armour, WesThroid, and Nature-Throid, are prescription thyroid drugs that have been in use as long as one hundred years. Many patients who have switched from synthetic to natural thyroid swear by the improvements in health and symptoms they’ve enjoyed after taking the natural medication.
Keep in mind that many conventional physicians feel that these drugs are “out of date” or hard to regulate or prescribe, and so won’t prescribe them.
Jeffersonville, Pennsylvania–based holistic physician Dr. Martin Mulders has changed his own opinion of Armour Thyroid:
I find that patients generally do better on desiccated thyroid…. I use it all the time. Back in the early 1990s, however, I was saying that “Armour Thyroid is hard to regulate,” like some doctors say. But I’ve since learned that it’s absolutely not true. In my opinion, doctors who say that it’s difficult haven’t tried it with their patients.
IS YOUR TREATMENT OPTIMIZED?
Kensington, Maryland–based holistic physician and thyroid patient Adrienne Clamp, MD, believes that each patient needs to be on the medication that safely works best for him or her:
That being said, I usually begin with natural desiccated thyroid because it most closely mimics the normal thyroid gland. If this is not what the patient feels best on or has objections (for example, those who keep Kosher, or who are vegetarians—since natural desiccated thyroid is a pork-derived product), I use synthetic T4 and T3 alone or in combination. Often compounded T3 is a useful adjunct to T4 when quick-release [manufactured] T3 is not well tolerated or needs to be dosed multiple times a day. I myself feel best on a combination of natural desiccated thyroid and compounded slow-release T3. Everyone is different, and it often takes some experimentation to find the agent or combination of agents that gives the best result.
ARE YOU AT THE OPTIMAL DOSAGE/TSH LEVEL FOR YOU?
While the “normal” range for TSH lab tests is established for each lab, where you personally feel best can vary. A study reported in the Journal of Clinical Endocrinology and Metabolism found that the mean TSH level for people who don’t have a thyroid condition is 1.5. The American Association of Clinical Endocrinologists stated that the normal range for TSH tests is 0.3 to 3.0, despite the fact that many practitioners and labs are still using the outdated 0.5 to 5.0 range, leaving millions of people in the 3.0 to 5.0 range undiagnosed, untreated, and at risk of a host of symptoms.
It’s no wonder that if your TSH level is on the higher end of normal for you, you may have symptoms. Check your most recent blood test results and consult with your physician about whether a slight increase in dosage and a reduction in your TSH level would be better for your health.
Ultimately, until you take your thyroid medication for a while, you won’t know the TSH level at which you will feel your best. It could be 0.3, 3.0, or somewhere in between. But the idea that people feel their best at different TSH levels has not gained widespread acceptance among many endocrinologists or conventional physicians.
So if you are seeing a doctor who still goes by the old 0.5 to 5.5 range, he or she may treat you but provide you with only enough thyroid hormone to get your TSH level to the higher end of the normal range (that is, to 4.0 to 5.0). The doctor may also tell you that if you don’t feel well at the high end of normal, then something else is wrong with you because it’s not your thyroid, since it’s normal. This is a sign that it’s time for another doctor.
DO YOU NEED A SEASONAL ADJUSTMENT IN DOSAGE?
One little-known issue for thyroid patients is the seasonal variation in thyroid function. A number of studies show that TSH naturally rises during colder months and drops to low normal or even hyperthyroid levels in the warmest months. Some doctors adjust for this by prescribing slightly increased dosages during colder months and reducing dosage during warm periods. Most doctors and patients are not aware of this seasonal fluctuation, however, leaving patients suffering with worsening hypothyroidism symptoms during colder months or going through warmer months suffering with hyperthyroidism symptoms due to slight overdosage. This seasonal fluctuation becomes more pronounced in older people, particularly those in cold climates. Twice-yearly tests, at minimum, during winter and summer months can help assess fluctuations and guide any seasonal dosage modifications that are needed.
SHOULD YOU TAKE YOUR THYROID MEDICATION MORE THAN ONCE A DAY?
If you are taking a levothyroxine drug, there is no benefit to splitting your dose and taking it multiple times a day. The drug is dissolved so slowly, and has such a long half-life in your body, that there is no benefit to be had by taking it in staggered doses.
For drugs that contain T3, including Cytomel, Thyrolar, Armour, and the other desiccated thyroid drugs, as well as compounded drugs that contain T3, you may in fact want to stagger your dosage throughout the day, to help maintain a steady level and offer the best possible relief of symptoms. T3 is faster-acting and has a short half-life in the body, and some people report better results when they take their thyroid medications two or three times a day. Some patients take a dose in the morning and at bedtime; others take a morning, lunchtime, and bedtime dose. Time-released compounded drugs eliminate the need for split dosages by gradually releasing T3 throughout the day.
(You should always discuss any change in the way you take your medication with your physician.)
IS YOUR MEDICATION FLUCTUATING IN POTENCY?
If you’ve had your brand of thyroid medication changed or a generic prescription refilled since your last thyroid test, you may have a change in symptoms and a fluctuation in your thyroid levels. From brand to brand, there is a significant difference in potency, even among pills of the same dosage, so switching from an 88 mcg pill of one brand name levothyroxine to another can actually result in a change in your symptoms.
There is a risk that if you are prescribed generic levothyroxine, each time you get a prescription refill, you may be given a thyroid medication from a different manufacturer. This is the key reason why most practitioners recommend that you not use generic levothyroxine. If you have no choice and must get generic levothyroxine, try to personally work with a pharmacist who will ensure that you get the same product from the same manufacturer.
ARE YOU DELIBERATELY BEING UNDERDOSED?
Some physicians make it a practice to underdose thyroid medication. This means that they will prescribe a patient just enough thyroid medication to get the TSH level into the top end of whichever normal range they use, even though many practitioners recognize that the majority of patients feel best at a level more like the general population’s average TSH of 1.0 to 2.0.
The main reason for this policy of underdosing is the fear of osteoporosis, which was discussed earlier in the chapter. Practitioners are mistakenly concerned that maintaining a woman’s TSH level at a level of, say, 1.0 to 2.0, rather than above 4.0, is a risk factor for osteoporosis. Meanwhile, if you’re being treated but your TSH is still in the high normal range (and I consider that to be 3.0 and above), then you may not feel well.
If your doctor has this philosophy, you may be able to get him or her to work with you on increasing the dosage by agreeing to have periodic bone densitometry testing to assure your doctor that the medication is not having an adverse effect.
ARE YOU TAKING YOUR MEDICATION PROPERLY AND CONSISTENTLY?
There are a number of guidelines on how to properly take thyroid hormone, to ensure that you are absorbing the drug and receiving the maximum possible benefit.
Any time you have a dramatic dietary change, for example, starting or stopping a high-fiber diet or starting or no longer taking your thyroid medication with food, get your thyroid levels retested about six to eight weeks later, to ensure you’re receiving the proper amount of thyroid hormone.
ARE OTHER MEDICATIONS INTERFERING WITH OR INTERACTING WITH YOUR THYROID MEDICATION?
Use of tricyclic antidepressants such as doxepin, amitriptyline, desipramine, and imipramine (brand names include Adapin, Elavil, Norpramin, and Tofranil) at the same time as thyroid hormone may increase the effects of both drugs and may accelerate the effects of the antidepressant. Be sure your doctor knows you are on one before prescribing the other.
Also, researchers have found that taking thyroid hormone replacement while taking the popular antidepressant sertraline (brand name Zoloft) can cause a decrease in the effectiveness of the thyroid hormone replacement. This same effect has been seen in patients receiving other selective serotonin reuptake inhibitors such as paroxetine (brand name Paxil) and fluoxetine (brand name Prozac).
If you are taking an antidepressant and your doctor prescribes thyroid medication (or vice versa), be sure to get your thyroid retested six to eight weeks after starting the new medication to evaluate any possible interactions.
A number of other drugs may interact with thyroid hormone or affect thyroid function:
ARE YOU FORGETTING TO TAKE YOUR MEDICATION?
Surprisingly, one of the key reasons patients don’t feel well on thyroid treatment is that they are failing to take their medications regularly, as prescribed. When you are on thyroid hormone replacement, it’s critical that you take your medication every day as prescribed. Even a day or two’s failure to take thyroid medication can throw off your treatment regimen and have a dramatic effect on your overall health. Here are some tips on how to remember to take your medication.
Nutrition and Supplements for Thyroid Function
You’ll want to make sure that you are getting proper nutritional supplements to help support your thyroid.
MULTIVITAMINS
A high-potency multivitamin is essential for thyroid patients. Look for one that has high amounts of B vitamins, vitamin C, vitamin E, and a good range of minerals. One that I particularly like is Dr. Jacob Teitelbaum’s formulation known as Daily Energy Enfusion. Dr. Teitelbaum’s multivitamin formula does contain some iodine, however, so you may want to slightly reduce your daily dosage if you are iodine sensitive. It comes as a flavorful powdered drink along with one vitamin B capsule, and is the equivalent of more than thirty vitamins and supplement pills that would need to be taken each day. Daily Energy Enfusion does not include iron or calcium, so it can be taken at the same time as thyroid hormone.
Specifically, you want to make sure you are getting
VITAMIN C
Many experts recommend that in addition to your multivitamin, you take 2,000 to 3,000 mg of vitamin C each day. You can use capsules or powdered forms of vitamin C.
One particular favorite of mine is Emergen-C drink mix. It’s very low in calories and sugar but very flavorful (I particularly like the raspberry, cranberry, and tangerine flavors.) Each envelope makes one drink, and the drink has a bit of fizz to it, so it functions like a soda. But it’s packed with 1,000 mg (1 gram) of vitamin C, as well as B6, B12, potassium, and a variety of other useful vitamins.
VITAMIN D
Vitamin D functions as a hormone and is necessary for the pituitary gland to produce thyroid hormone; it may also play a role in T3 binding to its receptor. It enables the deiodinase enzyme to convert T4 (inactive thyroid hormone) to T3 (the active type). It is also thought that vitamin D is necessary for health immune system functioning.
PROBIOTICS
Probiotics are supplements that contain live bacteria—the “good” bacteria found in fermented foods such as miso and in dairy products such as yogurt and some cheeses. These bacteria are needed in sufficient quantities in the intestinal system. One probiotic bacterium is Acidophilus, the live culture found in yogurt.
The probiotic bacteria known as Bifidobacterium lactis HN019 reportedly boosts the activity of various disease-killing immune system cells in healthy adults. Probiotics aid proper digestive functioning, which enhances the immune system. They also kill off harmful bacteria, having an antibiotic effect by fighting off various types of infection. You can eat yogurt, but the concentration of live cultures in yogurt is not high enough to get a substantial enough effect, so a probiotic supplement is your best option. Some probiotic supplements can be expensive and require refrigeration, but I recommend a patented formula from Enzymatic Therapies called Acidophilus Pearls. This tiny pearl-shaped supplement contains a guaranteed level of live bacteria in the millions, is very inexpensive, and requires no refrigeration.
ZINC
Zinc is needed by the thyroid for both hormone production and T4-to-T3 conversion. It is also necessary for proper hypothalamic functioning, an essential part of thyroid function. Zinc, along with selenium, can help prevent the decline of T3, which can occur on a low-calorie diet.
SELENIUM
Perhaps the most important mineral for thyroid function is selenium. Selenium activates hepatic type I iodothyronine deiodinase, which is responsible for controlling thyroid function by the conversion of T4 to T3. This enzyme is a selenoprotein that is sensitive to selenium deficiency. Stress and injury appear to make the body particularly selenium-deficient. After severe injury, the conversion of T4 to T3 is decreased, leading to low T3 syndrome. One study found that selenium levels are low after trauma, which correlates to low T3 levels, along with a decrease in the T4-to-T3 conversion.
Some researchers and practitioners are beginning to believe that selenium deficiency alone can trigger autoimmune thyroid disease in some people. One study published in 2002 showed that in areas with severe selenium deficiency, there is a higher incidence of autoimmune thyroiditis. In the study, patients with thyroid antibodies received 200 mcg of selenium supplementation over three months. At the end of the test period, antibody levels had decreased by as much as 40 to 63 percent; a small percentage of patients in the selenium-treated group had antibody levels that completely returned to normal. The researchers concluded that selenium supplementation may reduce inflammation in patients with autoimmune thyroiditis.
A 1997 study found that high intake of iodine—when selenium is deficient—could trigger thyroid damage. But sufficient intake of selenium appeared to offset the dangers of high iodine intake.
Experts recommend 200 mcg of selenium a day but caution that selenium is one of those supplements where more is not better. Overdosage on selenium can be harmful, so keep your intake to 200 to 400 mcg, maximum.
MAGNESIUM
Magnesium is an essential mineral that is often deficient in thyroid patients. It helps maintain normal muscle and nerve function, keeps heart rhythm steady, and strengthens bones. It is also involved in energy metabolism. If you aren’t getting enough magnesium, you may have more muscle cramps and pain than usual, as well as tingling, numbness, and abnormal heart rhythms—all symptoms that are also more common in thyroid patients.
TYROSINE
Tyrosine is considered the precursor to T4 thyroid hormone. The thyroid takes in iodine and combines that iodine with the amino acid tyrosine, converting the iodine/tyrosine combination into T3 and T4. So a deficiency in tyrosine means a basic building block of good thyroid function is missing.
GUGGUL
Z-guggulsterone (known as guggul), a component derived from the plant Commiphora mukul, has been used in Ayurvedic medicine as an anti-inflammatory, antiobesity, thyroid-stimulating, and cholesterol-lowering agent. Guggul is considered particularly important for prevention of a sluggish metabolism, and may increase the thyroid’s ability take up the enzymes it needs for effective hormone conversion and also increase the oxygen uptake in muscles. Some people find that guggul is overstimulating, so you need to be careful using this supplement.
ASHWAGANDHA
Ashwagandha (Withania somnifera), also known as Indian ginseng and winter cherry, is an adaptogenic herb traditionally used to improve fertility, increase sex drive, and enhance the immune system. Some studies have shown that ashwagandha stimulates thyroid activity and may help fight fatigue in thyroid patients.
ESSENTIAL FATTY ACIDS
Essential fatty acids are critical for thyroid patients. Many practitioners recommend them to reduce inflammation—particularly important in autoimmune-triggered hypothyroidism. Essential fatty acids cannot be produced in the body, so you must get them through diet or supplements. The key essential fatty acids include
Besides adding more of the foods that contain these essential fatty acids to your diet, you can add the following:
IODINE
Iodine supplementation is a controversial topic for thyroid patients. On the one hand, too little iodine can cause a variety of thyroid problems. On the other hand, too much iodine can trigger or worsen thyroid problems.
The key is knowing if you need iodine supplementation, and if so, how best to take it.
Holistic and nutritional practitioners sometimes assume that every thyroid patient needs iodine or an iodine-containing herb like bladderwrack (Fucus vesiculosus), seaweed, or kelp. But there is controversy over the amount of iodine deficiency in the United States. Statistics show that one-fourth to one-third of Americans may have some degree of iodine deficiency. Some practitioners, however, like Michigan’s Dr. David Brownstein, one of the pioneers in iodine testing and therapy, say that the vast majority of thyroid patients test positive for iodine deficiency. According to Dr. Brownstein, patients who show suboptimal iodine levels and receive iodine supplementation treatment usually find that their symptoms improve.
Should you take iodine? Answering that question requires that you be tested and, if you are deficient, carefully trying iodine supplementation under the direction of a practitioner.
The best tool for evaluating iodine levels is the urinary iodine clearance test. Dr. Brownstein uses Hakala Research, a laboratory that has pioneered the urinary iodine clearance testing process. For those patients who are iodine deficient, Dr. Brownstein has them follow a protocol for iodine supplementation that uses a specialized combination and dosage of iodine and iodide, designed for best absorption of the nutrient. The combination is found in a pill format, known as Iodoral, and in a liquid called Lugol’s solution.
Dr. Brownstein has outlined an entire program for iodine testing and supplementation in his book Iodine: Why You Need It, Why You Can’t Live without It and I highly recommend that anyone interested in iodine testing and supplementation read this book to learn how to get properly tested and safely supplement with iodine.
Some Cautions
Ensuring that you are getting proper thyroid treatment also means that you must keep certain cautions in mind.
WATCH GOITROGENS
Goitrogens are chemicals in certain products and foods that promote formation of goiters. They can act like antithyroid drugs in slowing down the thyroid and causing hypothyroidism. Specifically, goitrogens inhibit the body’s ability to use iodine, block the process by which iodine becomes the thyroid hormones T4 and T3, inhibit the actual secretion of thyroid hormone, and disrupt the peripheral conversion of T4 to T3 in the thyroid gland.
If you don’t have a thyroid due to surgery or RAI treatment, you don’t have to be particularly concerned about goitrogens. If you still have an even partially functional thyroid, however, you need to be more concerned and careful not to eat goitrogens uncooked in large quantities. The enzymes involved in the formation of goitrogenic materials in plants can be partially destroyed by cooking. Eating moderate amounts of goitrogenic foods, raw or cooked, is probably not a problem for most people.
A list of goitrogenic foods is featured in Chapter 2.
REDUCE TOXIC EXPOSURES
Reduce exposure to fluoride by drinking bottled water that is not fluoridated. Use a fluoride-free toothpaste, and do not get dental fluoride treatments. These have not been clearly demonstrated to be helpful at reducing or preventing cavities in adults.
There’s not much you can do to avoid eating perchlorate-contaminated foods, except to grow your own produce and use water that you’ve had tested for perchlorate contamination. If you drink well water, you should also have that water tested, and if you live in an area near a current or former facility for rockets, explosives, or fireworks production, consider having your water independently tested. Most importantly, become aware of the issues, and monitor the status of perchlorate legislation, by monitoring the comprehensive site www.perchlorate.org.
Regarding mercury, some patients have reported that their thyroid problems and other symptoms were greatly relieved with supplements to help chelate the mercury, and by removing mercury fillings in their teeth. A holistic physician can guide you in evaluating your mercury levels and in deciding what to do in response to elevated levels.
TREAT INFECTIONS
Infection is thought to trigger some thyroid problems. The food-borne bacteria Yersinia enterocolitica, for example, has been associated with production and elevated levels of thyroid antibodies, a sign of autoimmune thyroid disease.
A Genova Diagnostics (formerly Great Smokies) laboratory analysis can help detect intestinal bacterial overgrowth that may be contributing to underlying immune system problems and fueling the thyroid condition. These are typically treated with antibiotics, or, if you are working with a more holistic practitioner, diet, nutritional supplements, and herbs that function in an antibiotic-like capacity.
BE CAREFUL OF SOY, ISOFLAVONES, AND PHYTOESTROGENS
Experts can’t seem to agree on the subject, and there is much debate regarding the pros and cons of soy. But there is increasing agreement that overconsumption of isoflavone-intensive soy products may trigger or aggravate a thyroid condition. I discuss soy at greater length in Chapter 6, but be aware that overconsumption of isoflavone-intensive soy products (most often this is due to the use or overuse of soy supplements, protein powders, and other processed soy products) may trigger hypothyroidism or worsen an existing thyroid condition. If you are going to use soy, better to use fermented forms of soy foods, like tempeh, tofu, and miso, and only occasionally. A daily diet of soy milk, soy burgers, edamame, soy shakes, and soy foods at every meal elevates soy from mild phytoestrogen to potent hormone that has the ability to harm your hormonal health.
An Important Note for Women Taking Estrogen and Thyroid Hormone Replacement Medication
If you are taking thyroid medication, and you start taking any estrogen medication—that includes birth control pills and all forms of estrogen therapy—you may need to adjust your thyroid dosage as a result of the estrogen.
Estrogen can block thyroid receptors, making your thyroid medication less effective, which may result in the need for an increased dosage.
The drop in estrogen after surgical or natural menopause can also destabilize thyroid dosage requirements. Amanda was on thyroid medication for hypothyroidism when she had a total hysterectomy at age forty-eight. Says Amanda:
Prior to my surgery, I asked my gynecologist if I would have to have my thyroid medication adjusted after surgery, because I know that all of our hormones are well synchronized, and if all of a sudden there is a sudden drop in estrogen (surgical menopause), surely there would be other changes. She assured me that there was no connection and I needn’t worry! Needless to say, there is a connection, and I had terrible hormonal problems for a year and many medication adjustments. My thyroid medication had to be increased significantly.
If you add any estrogen medication, be sure to have your thyroid function thoroughly reevaluated (that means not just TSH, but also free T4 and free T3) to see if you require a dosage adjustment.