Hypothyroidism 25 August 2009
The thyroid gland is a butterfly shaped endocrine gland found just below the Adams apple in the neck. It produces two main hormones:
- T3 (triiodothyronine)
- T4 (thyroxine)
Approximately 90% of the thyroid hormone produced is thyroxine and 10% is T3. Thyroxine is not readily available and is stored by the body, only to be released when T3 levels are low. Thyroxine is converted into T3 in the liver. T3 is approximately 4 times more powerful than T4 and is the active thyroid hormone in the body. Having appropriate levels of thyroid hormone is critical for good health. These hormones control the body’s metabolic rate and help regulate body temperature. They act as the spark plugs of the cells by stimulating the mitochondria of the cell to burn fuel producing heat and energy.
Diseases of the thyroid gland can be broadly categorised into hyperthyroidism (too many hormones are produced) and hypothyroidism (too little hormones are produced). Hypothyroidism is much more common. In fact, it’s an unrecognised epidemic. It is often not diagnosed because it is not suspected and because of a dependence on unreliable blood tests.
Recognising hypothyroidism is crucial because of the broad range of responsibilities of thyroid hormones. These include:
- proper maturation and function of other hormone glands
- stimulation of the cellular energy production necessary for life
- maintenance of body temperature
- stimulation of protein synthesis necessary for normal growth and cellular renewal
- removal of cellular waste products
- stimulation of the immune system
- stimulation of carbohydrate and fat metabolism
The cardinal symptoms of hypothyroidism are:
- low-energy which does not improve easily with rest
- cold intolerance
- susceptibility to infection
However every cell in the body needs small amounts of thyroid hormone to function optimally so there are a wide range of symptoms which may occur. Common symptoms include morning fatigue, dry skin, eczema, psoriasis, chronic pain (including back pain), hyperactivity, poor memory, headaches, menstrual irregularities, endometriosis, miscarriages, candida infections, paresthesiaes, carpal tunnel syndrome, depression, infertility, fibrocystic breast disease, ovarian cysts, weight gain, sleep disturbance, sleep apnoea, migraines, musculoskeletal stiffness, aches and pains especially in the morning, allergies, eye fatigue, puffy eyelids, low libido, poor digestion, early greying of hair, hair loss, constipation, palpitations, elevated cholesterol levels, recurrent upper respiratory tract infections, muscle cramps, osteoporosis, anaemia and anxiety. Dr Mark Starr, a US chronic pain specialist and author of Hypothyroidism Type 2, The Epidemic states that, unrecognised subclinical hypothyroidism is the root cause of almost all cases of chronic pain. Hypothyroidism prevents the body from repairing itself.
In children, low thyroid levels can retard normal growth and development. It has also been found to be the cause of hyperactivity and other behavioural problems in some children. In teenagers it can cause anaemia, diminished endurance, menstrual difficulties and digestive disturbances.
Interestingly, paradoxical symptoms can also occur. A few patients with hypothyroidism may be underweight, have rapid heart rates and tremors. They are usually running themselves hard on adrenal hormones to compensate for their low thyroid function. Metabolic rates are therefore frequently elevated and unfortunately the symptoms are commonly mistaken as being due to hyperthyroidism. Basal temperature testing (see below) is best used to confirm hypothyroidism.
Thyroid hormones contain iodine and therefore iodine deficiency can cause hypothyroidism. In severe cases it is characterised by a large thyroid gland called a goiter. Other causes of hypothyroidism are due to autoimmune disease, environmental toxins, infection, radiation, hormone imbalances or genetics. A family history of hypothyroidism is a very powerful risk factor. Unfortunately, subclinical hypothyroidism is frequently undiagnosed. Standard blood tests are not necessarily a good indicator of thyroid status. Thyroid hormone must be secreted by the thyroid gland, travel in blood bound tightly to carrier proteins to target cells, extricate itself from the proteins, penetrate the cell wall and nuclear membrane and then attach to receptors on the cells DNA to have its effects. Just because blood levels are normal does not mean the rest of that sequence occurs flawlessly. Processes that can go wrong in this complex sequence include:
- the hormones may be prevented from reaching the receptors by thyroid antibodies
- the receptors may not work properly
- a toxic substance may be occupying the receptors, preventing the hormones from binding with them
- thyroid hormones may all be bound by blood proteins and not released to the cells. For example, the body protects itself from elevated levels of oestrogen by making more of a protein called sex hormone binding globulin. This binds excess oestrogen but unfortunately also binds other important hormones such as thyroid hormone.
- there are actually four different receptors throughout the body for thyroid hormones. However it is the receptors attached to the hypothalamus of the brain which regulate the secretion of thyroxine from the thyroid gland. Therefore the body may be producing sufficient thyroid hormone for the hypothalamus but not for skeletal muscle. Imagine going for a long drive in the car where the driver adjusts the air-conditioning only for his or her comfort. The driver may have a very comfortable trip while everybody else is miserable.
Hypothyroidism can now be sub classified into type 1 and type 2. Type 1 hypothyroidism occurs when the thyroid gland produces insufficient amounts of thyroid hormone. This can be detected on blood tests. Type 2 hypothyroidism occurs when there is a resistance to thyroid hormones at the receptor level. Levels of thyroid hormones are normal. Blood tests do not detect type 2 hypothyroidism. Multiple studies have shown many patients with symptoms of hypothyroidism who had normal blood tests but had low basal temperatures, improved dramatically when given thyroid hormones.
Additionally, the normal range of thyroid hormones is huge. Normal ranges are designed to diagnose severe disease and frequently do not recognise that diseases are not black and white but come in a full spectrum. Anti-aging medicine is all about living life towards the upper end of the acceptable range, rather than the low end. It’s about achieving the optimal level for the individual, not just the normal range for the group. Think of it as a numerical scale*0 1* 2 3 4 5 6 7 8 9 10 *11 12* Low high
where 0 to 1 represents severe hypothyroidism and a struggle for survival. Eleven to twelve represents severe hyperthyroidism where you are running on too many cylinders. Anywhere in between 2 and 10 and you will be diagnosed as “normal”. The problems with using this system to diagnose disease include:
- If your test comes back as a 1, you are diagnosed with the disease. If your test comes back as 2, you are told you are normal. The trouble is, in terms of how you feel, there is not a lot of difference between 1 and 2.
- Maybe you don’t want to struggle through life as a 2 or 3 with increased infections, increased heart disease and low energy. Perhaps you would prefer to live life as an 8 or 9, have lots of energy, a dramatically reduced risk of heart disease and decreased susceptibility to infections.
- Maybe last year when you felt well, you were actually an 8, this year when you have your blood test you are a 3. So officially you are within the normal range but for you, there is an enormous difference between 8 and a 3. Three maybe within the normal range, but it’s not normal for you.
- The normal range is the normal range for your local population, many of whom have undiagnosed hypothyroidism. Maybe you don’t want to be at the low end of that normal range.
So, if you have symptoms consistent with hypothyroidism, don’t be put off by normal blood tests and find a doctor who is prepared to look beyond blood tests in the diagnosis and treatment of hypothyroidism. Basal temperatures are another way of assessing thyroid function. They are done by taking an oral temperature first thing on waking and last thing before going to sleep at night. Premenstrual women should only do this test on days 2 to 5 of their period. At other times, other factors can affect the temperature. If you average less than 36.6C, then hypothyroidism is likely. The low temperature is a direct reflection of decreased metabolism. Click here to see the text of a television interview I did discussing this. The current disregard of this diagnostic strategy is remarkable considering Dr Broda Barnes, the premier thyroid specialist of the 20th century, used basal temperatures as the key parameter for assessing thyroid function.
Thyroflex computer testing is another way to confirm the diagnosis. Thyroflex measures the duration of the brachioradialis muscle reflex. If delayed, hypothyroidism is confirmed.
Checking your basal temperature regularly is an important way to take responsibility for your own health. Thyroid hormone is a very important anti-aging hormone and premature aging as one of the main symptoms of hypothyroidism. Physiological replacement of thyroid hormones is a surprisingly underutilised anti-aging tool.
Hypothyroidism is often associated with other diseases.
- Cardiovascular disease
Research by Dr Broda Barnes suggested that the incidence of coronary artery disease is dramatically increased in people with hypothyroidism and is reduced with thyroid replacement therapy. He hypothesised that thyroid deficiency is the common denominator in susceptibility to infection and heart disease. He felt that hypothyroidism was the underlying cause of the massive increase in heart attacks during the 20th century. The associated increase in susceptibility to infections meant that before the discovery of antibiotics in 1944, people with hypothyroidism died at a young age of infections such as tuberculosis. The widespread use of antibiotics has resulted in a significant increase in life expectancy in patients with hypothyroidism. They are now surviving long enough to die of heart attacks.
We now know that free radicals are a major component in the development of coronary artery disease. From my newsletter on fats:
As we know, a diet high in saturated fat and trans fatty acids will overwhelm the ability of HDL to return the triglycerides in LDL back to the liver. The excess LDL therefore gets deposited in the walls of arteries and is free to cause atherosclerosis. The word atherosclerosis comes from the Greek word athere (porridge) and sclerosis (stiffening). Here is the really important piece of information. LDL cholesterol does not damage arteries in its natural form. It is only when LDL is attacked by free radicals and becomes oxidised that it causes atherosclerosis. This is why heart disease is largely preventable. The oxidised LDL triggers inflammation in the arterial wall and inflammatory cells subsequently arriving eat the oxidised LDL. Unfortunately this causes the inflammatory cells to rupture which increases the inflammation. The inflammation causes a plaque to form on the arterial wall and muscle cells in the arterial wall to enlarge. This process leads to narrowing of the arteries to the heart muscle. Eventually the plaque ruptures and results in a blood clot forming in the artery. This completely blocks blood flow to the heart muscle and results in some of the heart muscle dying (otherwise known as a heart attack.)
Our bodies are protected against free radicals by antioxidants. Unfortunately, the lower our thyroid function, the lower our antioxidant production and therefore the increased susceptibility to heart disease. Recurrent infections associated with hypothyroidism may also be the cause of the underlying arterial inflammation. LDL cholesterol may even be layered on the arterial wall initially in an attempt to heal the inflammation. Normal thyroid metabolism prevents recurrent infections and inhibits chronic inflammation.
Historical research has shown all patients dying of hypothyroidism had severe hardening of arteries throughout their bodies. This was confirmed in animal studies and interestingly the animals treated with thyroid replacement did not develop atherosclerosis. Additionally, patients who have had thyroid surgery for hyperthyroidism inevitably develop high cholesterol levels. It’s always a good idea to have your thyroid function assessed if you have unexplained high cholesterol levels which are not responsive to lifestyle changes. If hypothyroidism is confirmed, thyroid replacement hormones will result in a significant decrease in both total cholesterol and LDL. People with low thyroid function also tend to have high levels of homocysteine (see homocysteine and atherosclerosis). People with high thyroid levels have low homocysteine levels. Again, if your homocysteine is inappropriately elevated, and does not respond to treatment, make sure you have your thyroid status checked.
Dr Barnes ran a heart disease study concurrent with the famous Framingham heart study (which was looking at coronary risk factors). He enrolled 1569 of his patients, all of whom were on thyroid replacement therapy. The Framingham study would have predicted that 72 of his patients would have had heart attacks. Only 4 did. This means he prevented over 90% of the predicted heart attacks in his patients. The failure to address or recognise type 2 hypothyroidism is why heart disease remains such a huge problem.
Congestive heart failure is also associated with hypothyroidism and responds well to thyroid hormone replacement.
- Recurrent infections.
Low thyroid function impairs the immune system and predisposes us to infections. Dr Barnes extensive experience suggested that 99% of children who suffer frequent infections are hypothyroid. The upper respiratory tract and the urinary tract are particularly common site of infection. Resistance against viral, fungal and yeast infections is low.
Type 2 diabetes improves significantly if an under active thyroid gland is treated simultaneously. Hypothyroidism often coexists with diabetes but is frequently not looked for. Complications of diabetes are dramatically reduced in patients with coexisting thyroid disease who have appropriate thyroid replacement. None of Dr Barnes patients with diabetes had developed any of the typical or more advanced complications of diabetes. My take-home message is that if you have been diagnosed with diabetes, make sure you don’t have coexisting hypothyroidism.
If the body’s metabolic rate drops, bone marrow has difficulty producing red blood cells.
- Delayed healing of wounds.
Slowing metabolism also causes delayed healing of wounds.
- Systemic candida
Hypothyroidism lowers resistance to yeast.
See Iodine, Thyroid and Cancer.
- Skin diseases
Cellulitis, eczema, acne and psoriasis occur frequently in hypothyroidism. Increased susceptibility to skin infections is a hallmark of hypothyroidism. About 90% of Dr Barnes acne patients responded to thyroid therapy.
- Menstrual disturbances
Hypothyroidism can cause both premature and delayed puberty. It can also cause PMS, cramping, irregular heavy cycles and amenorrhoea. Endometriosis, fibroids and ovarian cysts are also frequently associated with hypothyroidism.
The majority of patients with infertility and recurrent miscarriages also suffer from hypothyroidism. Way back in 1914 a famous endocrinologist, Dr Eugene Hertoghe stated “we may assess that thyroid extract has proved in scores of cases an excellent remedy for otherwise inexplicable sterility.” Unfortunately this has largely been forgotten.
Dr Barnes believed decreased blood flow to the kidneys due to hypothyroidism was the cause of most high blood pressure. 80% of his hypothyroid patients with hypertension had their blood pressure normalise with thyroid hormone replacement alone. This can take from months to years to occur. No cases of chronic kidney failure developed in Dr Barnes thyroid treated group.
- Chronic fatigue syndrome (CFS)
Many patients with chronic fatigue syndrome actually have type 2 hypothyroidism but go unrecognised because their blood tests are normal. Even if they are being treated for hypothyroidism treatment may be inadequate if it is being guided by the TSH test alone. Chronic fatigue patients often have systemic yeast infections. This is frequently because of the effects of hypothyroidism on the immune system.
- Attention deficit hyperactivity disorder (ADHD)
Hypothyroidism can cause paradoxical effects. One study showed that ADHD was present in 72% of males and 43% of females with genetically inherited hypothyroidism. The short attention span and hyperactivity may be secondary to low metabolism and fatigue. If basal temperatures are low, treatment with thyroid replacement to elevate metabolism is much more natural than treatment with amphetamines.
Children with type 2 hypothyroidism are much more susceptible to environmental toxins, allergies, chemical sensitivities and depression.
The liver is responsible for maintaining a constant level of glucose in our blood. The liver functions poorly in hypothyroid patients. The overwhelming majority of hypoglycaemia is due to hypothyroidism and almost always resolves with thyroid hormone replacement and correction of any adrenal fatigue.
- Autoimmune disease
Autoimmune diseases such as lupus, fibromyalgia, polymyalgia and rheumatoid arthritis are associated with hypothyroidism. No new cases of lupus developed in any of the thousands of hypothyroid patients Dr Barnes treated. None of his patients who did have lupus developed any further progression of their disease. Roles of thyroid hormone include intracellular cleansing and activation of enzymes, both of which are impaired in autoimmune disease.
Additional management principles of autoimmune disease include addressing any adrenal dysfunction, the use of bioidentical cortisol and physiological doses and mercury chelation. Mercury attaches to the outside of cells causing the body to identify the cells as foreign and therefore attack them with its own immune system.
Subclinical hypothyroidism is a frequent cause of recurrent migraines. Even headaches associated with the menstrual cycle respond well to thyroid hormone replacement if associated with type 2 hypothyroidism.
The principles of management of hypothyroidism should include:
- Looking for and treating the cause of hypothyroidism e.g. over acidification of blood and tissue, mercury poisoning, uranium 238, genetic, autoimmune disease, iodine deficiency, protein deficiency, chronic infection (particularly with mycoplasma), leaky gut syndrome, environmental chemical toxicity, parasites, yeast, food allergies and stress.
- Detoxification. Medical studies at the Environmental Health Centre of Dallas have demonstrated resolution of many symptoms of hypothyroidism after detoxification from environmental toxins and heavy metals. Zeolites in particular can remove uranium 238 which is a thyroid poison. Reishi mushroom extracts are also useful.
- Checking for and correcting any iodine deficiency. See Iodine, Thyroid and Cancer.
- Avoiding substances known to inhibit thyroid function- fluoride, chlorine, bromide, phthalates in plastic and large amounts of refined soy.
- Addressing coexisting endocrine problems such as adrenal fatigue or progesterone and testosterone deficiencies. A certain amount of adrenal hormone is required to convert T4 into T3. Oestrogen dominance (high levels of oestrogen unopposed by adequate levels of progesterone) results in an increase in thyroid binding proteins in the blood. Ultimately there is less free thyroid hormone available to cells.
- Improved nutrition and supplementation with nutrients required for thyroid hormone synthesis. Iron, zinc, magnesium and selenium are particularly important. Selenium is required for the conversion of T4 into T3 and also reduces thyroid antibody levels in autoimmune thyroid disease. Without adequate magnesium, thyroid hormone is more likely to cause rapid or regular heartbeat. For more information, see Magnesium and Selenium.
- Ensuring adequate protein intake. Without adequate protein, the thyroid gland produces less thyroid hormone as it puts the body into “hibernation mode” to conserve protein. Artificially raising the metabolic rate by giving thyroid hormone without addressing any protein deficiency may cause the body to start breaking down is own protein stores.
- Herbal support for the thyroid. My preference is for Ashwagandha which increases the conversion of T4 into T3. For more information, see Ashwagandha.
- Thyroid hormone replacement. This can be done with either:
- synthetic T3
- synthetic T4 (thyroxine)
- a combination of synthetic T3 and T4
- desiccated (natural thyroid) which is derived from animal thyroid and contains T3, T4 and all the prohormones required for their synthesis. Natural thyroid is both FDA and TGA approved. Criticism of natural thyroid revolves around the slight variation in dose in each capsule however a large study published in the April 16 1997 edition of the Journal of the American Medical Association showed that this was the same or worse for synthetic thyroxine.
The most common treatment is with thyroxine alone. The problem is that thyroxine alone is frequently the least effective option. T4 alone has never been proven to be effective for treating the symptoms of hypothyroidism in any long-term study. It was approved as a treatment for hypothyroidism in 1917 before testing for effectiveness of a drug was required. Several studies have shown increased effectiveness of natural thyroid over synthetic T4 alone.
Response to all of the thyroid hormones is very variable. What works well for one person may not work well for another. Trying different combinations is often necessary. I generally begin with small doses of natural thyroid and slowly increase. Follow the video link to see the CNN interview with Dr Stephen Hotze about the use of natural thyroid in hypothyroidism. Video. It should be taken on an empty stomach, at least 30 minutes before a meal and well away from any iron or calcium supplements. Most people find that twice daily administration is more effective than once a day.
Failure to respond or increasing fatigue usually suggests coexistent mild adrenal deficiency and/or the presence of toxic environmental chemicals or heavy metals. These chemicals and metals can block the cascade of chemical reactions involved in thyroid and other hormone metabolism. Mercury toxicity in particular can make thyroid hormone replacement intolerable. For more information, see Mercury. Adequate levels of cortisol from the adrenal gland are required for thyroid receptor manufacture and for the conversion of T4 into T3. Iron and calcium tablets reduce the absorption of thyroid hormone by 70% so should not be taken at the same time.
Doses of thyroid hormone may also need to be greater than suggested by monitoring of the TSH level alone. The TSH test is quite sensitive. hen it was first introduced in 1975 for the diagnosis and monitoring of thyroid disease it was a decision made by consensus of endocrinologists. No studies have ever been done to compare the “TSH approach” to the clinical approach (actually asking the patient how they feel) used for the previous 83 years. Thyroid expert Dr David Derry writes “Unfortunately the TSH test approach lowered the dose used to treat patients considerably. The effective dose physicians used by clinical judgment before 1975 was around 2-3 times higher than the dose used by TSH blood test monitoring.”
Response to thyroid hormone can also be slow and may require as much as six to 12 months before a significant effect. Monitoring basal temperatures is a good way to monitor dose requirements. Consistent temperatures above 36.8°C require a reduction in dosage.
The good news is that taking thyroid hormone is simple, safe and inexpensive. As the famous endocrinologist Dr Eugene Hertoghe once said, “it is necessary to stress that the clinical evaluation of a patient’s condition must precede interpretation of laboratory tests and not follow it.”