Low Thyroid Diagnosis and Treatment – Nuts and Bolts
The Hypothyroid Problem
Millions of patients, especially women, suffer from hypothyroidism (low thyroid levels) and are completely unaware of it. They just know they feel ‘crappy” (is it politically correct to say that?)
- They notice that they can’t keep weight off the way they used to.
- Their energy levels are low and they tend to crash every day around 3 p.m.
- They find themselves crawling, not springing out of bed in the morning.
- They complain of always being cold and they bug their spouses or co-workers to turn up the heat.
- Their memory is a little sketchy at times and concentration not as focused as it used to be.
- Their finger nails get brittle and their hair gets thin and stringy.
- They generally feel that their battery is just running low.
These complaints are often attributed to the demands of being a parent, a spouse, demands of the workplace, or the old standby – just getting older. Does this sound like you? This problem of hypothyroidism is extremely common, and the solution is elegant and simple. Yet so many people suffer needlessly. Simple awareness of the signs and symptoms of hypothyroidism is the first step.
What Makes Our Thyroid Gland Go Crazy?
As we age there is a steady decline in our thyroid hormone levels. There are many reasons for this. Sometimes the brain quits stimulating the thyroid gland to produce thyroid hormone. Sometimes our diet is deficient in the critical nutrients needed to make the hormone in the first place. Chronic stress, illness and many medications also can take their toll on thyroid function.
Occasionally the cells of our bodies can become resistant to the effects of thyroid hormone – something called thyroid resistance. Additionally, some of us develop auto-immune antibodies against the thyroid gland or thyroid hormone, impairing thyroid activity. Interestingly, low thyroid levels can affect other hormones in our body – AND low hormones elsewhere can mess up the thyroid! How’s that for codependence?
The problem can be very convoluted, confusing, circular and complex to the uninitiated. Yet once the causes are teased out, the solutions are relatively straightforward. Awareness of the common symptoms by the patient and vigilance on the part of the physician are the keys to success.
The Thyroid ‘Demographic’
Low thyroid hormone levels, or hypothyroidism, is reported to be present in one out of every seven adults. Women seem to be at greater risk for developing low thyroid hormone levels than men, although men are by no means excluded. Thyroid deficiency can occur at any age, yet frequently raises its nasty head in the late 30’s and early 40’s. It frequently goes undetected in women as they approach menopause since the symptoms of both conditions are often intertwined and “generic.”
What Does the Thyroid Gland Do?
The short answer is a lot! The thyroid gland is a little butterfly shaped gland located in the middle of the neck. Secreting thyroid hormone helps to regulate your body’s metabolism. It also manages your energy levels and influences your body temperature (sets your internal thermostat). It plays a role in increasing the breakdown of fat, resulting in weight loss and lower cholesterol. It is critical in protecting you against cardiovascular disease. Normal thyroid levels facilitate optimal brain function and help prevent cognitive impairment, improving memory and focus. Every cell of the body has thyroid hormone receptors on them, and thus every cell in the body is negatively influenced when thyroid hormone doesn’t show up for work.
The brain produces a chemical which travels in the bloodstream to the thyroid gland and tells it to make thyroid hormone. This chemical is called TSH (thyroid stimulating hormone). If thyroid levels get a little low the brain makes more TSH to nudge the thyroid gland into making more hormone. If the thyroid gland doesn’t, or can’t, respond to its marching orders, the TSH levels remain elevated, continually trying to coax the thyroid gland to get with the program.
Once stimulated by TSH, a healthy thyroid gland produces two “flavors” of thyroid hormone. T4 is the predominant hormone produced. T4 is essentially inactive and needs to be converted elsewhere in the body to the ‘active’ form which is called T3. The thyroid gland also produces a little T3 of its own. T4 and T3 ride around the bloodstream attached to little carrier proteins. Once they reach their destination, they “hop off the bus” and the inactive T4 is converted to active T3. This ‘free’ T3 then enters the cell to perform its magic.
It’s the free T3 that is essentially driving your entire metabolic engine. That is the reason measuring free T3 levels in your blood is the most important element in determining your overall thyroid function. TSH and T4 are also important, but to a lesser degree. (There are some instances when this simple pathway can get a bit convoluted and we will discuss that shortly).
Symptoms of Hypothyroidism (Low Thyroid)
Since thyroid hormone affects every cell in the body, deficiency of thyroid hormone can have several seemingly unrelated symptoms. They can be vague and nonspecific and confused with other problems. They can overlap with other issues that also need to be addressed. The list is long but very important. Symptoms include:
- dry skin, brittle nails
- hoarse voice
- thinning hair or hair loss
- cold hands and feet
- muscle fatigue, pain, weakness
- poor memory and concentration
- heavy menstrual bleeding, worsening PMS, infertility
- loss of sex drive
- severe menopausal symptoms such as hot flashes and mood swings
- fluid retention, swelling of hands and feet, puffy eyes
- low blood pressure and heart rate,
- elevated cholesterol and triglycerides,
- memory and concentration problems or brain fog,
- fatigue, trouble getting out of bed in the morning,
- loss or thinning of the outer third of your eyebrow,
- trouble losing weight or recent weight gain
- depression, apathy, anxiety
Diagnosis of Hypothyroidism
Many people who present to their doctor with these complaints and have their thyroid function evaluated are told that their thyroid is normal. Many times,however, they are suffering from significant hypothyroidism. How can this be? Most physicians only use TSH as a guide to determining whether or not the patient has a thyroid issue. For hypothyroidism, they are looking for a high TSH – made by the brain in response to low thyroid levels. But here is the problem – by only measuring TSH, over 80% of people with low thyroid are misdiagnosed!
It is possible (and fairly common) to have a normal TSH but have low thyroid hormone levels. Similarly, T4 and T3 levels can also be “normal” in hypothyroid people.
What’s going on here? The problem is that most physicians use the wrong tests to assess the thyroid. That is the way they were trained. They are searching for thyroid disease, not looking for optimal thyroid performance.
Unfortunately, you can be disease free yet still be suffering from several symptoms of low thyroid levels. This is a common mistake and the reason many patients suffer needlessly. This is an education issue for physicians and many are slow to embrace this knowledge. Additionally, a TSH level is the only screening lab value that many insurance companies will cover. This is another of how letting insurance companies dictate patient care is bad medicine.
Once again…What constitutes “normal”? Normal ranges used by laboratories are determined by the average of a large number of very diverse people in terms of age, gender, ethnic and cultural background, diet, activity level and presence or absence of other illnesses. Common sense tells us that what is normal for an 80-year-old sedentary female may not be normal for a 27-year-old active, healthy male. Normal “for your age” does not translate into optimal for any age.
In order to properly assess thyroid function we need to know several things. We need to know how your adrenal glands are functioning and what kind of stress you are under. High stress causes high cortisol levels which is well-known to squash thyroid function.
We know that estrogen dominance experienced by many females suffering from PMS or experiencing perimenopause also adversely affects thyroid function.
We need to ensure that critical elements such as selenium, iodine, zinc and vitamin D are present in adequate amounts to support thyroid function.
We need to know if gastrointestinal problems, which frequently cause chronic inflammation and can trigger autoimmune disease of the thyroid gland, are an issue.
All of these things contribute to a broken thyroid and must incorporated into the decision tree before treatment will work.
More Thyroid Stuff
The Brain and TSH
The brain’s ability to secrete TSH can be impaired for many reasons. A normal or low TSH level by no means insures good thyroid function. Sometimes the brain’s ability to crank out enough TSH is broken and, like Scotty likes to say on Star Trek, ‘she’s giving it all she’s got’.
The thyroid gland may require more ‘motivation’ than it is receiving from the brain (TSH). In reality, it is responding appropriately to the weak signal it is receiving. Only by measuring free T4, free T3, reverse T3 (for later discussion), and thyroid antibodies can we have a comprehensive snapshot of what the thyroid gland is up to.
Sometimes conditions such as chronic stress, illness, fasting and even certain medications can impair the conversion of T4 to T3 (the active form of thyroid). This results in low T3, and adding more T4 obviously won’t fix it.
Additionally, under times of psychological or physiologic stress, the body can put the brakes on the effects of thyroid hormone. This will protectively throttle down the metabolism by making something called reverse T3, instead of T3. Reverse T3 will snatch the receptor sites for thyroid hormone and won’t let the all-important T3 into the cells to do its job.
So, although you may have a normal free T4 and free T3 level, elevated reverse T3 spoils the party by not letting T3 in to do its job. This needs to be identified before thyroid hormone optimization can work. That is why giving just Synthroid (which is straight T4), as many practitioners do, can be ineffective. The T4 either can’t convert to T3 (the good stuff), or makes reverse T3, which doesn’t work.
But wait! There’s more. If anti-thyroid antibodies are floating around, the picture can get very complicated because the lab values for thyroid hormone may appear normal (or even elevated). I see anti-thyroid antibodies all the time in my practice. It’s always something!
What does all this mean to you, the patient?
This means that proper testing of thyroid function must be performed before adequate therapy can be delivered. A normal TSH level is of no value to us. We need to take a comprehensive look at the effects diet, nutritional status, hormone balance and presence of other illnesses or medications to nail down this diagnosis. This requires, at a minimum, the following: TSH (we want this to be below 2, not the traditional 4.5), free T3, free T4, reverse T3 and anti-thyroid antibodies.
Treatment of Hypothyroidism
As mentioned, the traditional approach to treating hypothyroidism, when diagnosed, is usually through the use of Synthroid (T4). We discussed earlier that straight T4 frequently can’t get to where it needs to be to improve thyroid hormone blood levels (specifically T3) to relieve symptoms. Using a combination of both T4 and T3 (such as Armour thyroid), and specifically targeting the free T3 levels, is very effective in alleviating the symptoms of hypothyroidism. In many cases, a sustained-release preparation of straight T3 is necessary for symptomatic relief if several of the T4 to T3 blocking mechanisms are in play.
Once the diagnosis is made and appropriate treatment begun, most patients begin to feel much better within two weeks. We will generally retest blood levels within six to eight weeks and assess symptoms to make dose adjustments. After that, retesting once or twice a year is sufficient.