Thyroid Symptoms Are Often Dismissed
So many patients come in to see me with what they feel are thyroid issues. They are tired, gaining weight, constipated, have mental fogginess, forgetfulness, menstrual period irregularity and are cold all the time. Many of these patients have gone in to their family practice doctor only to find out, after very basic thyroid labs are drawn, that they are “normal”, and their thyroid is fine. They are frustrated and feel hopeless.
The above symptoms remind me of a cold car in the garage, sitting there, gathering dust. And if you think about it, a car is a great analogy to the thyroid. The thyroid is the car of our body. It literally dictates the rate of metabolism (speed) of our body. Thyroid hormone receptors are literally everywhere, in every tissue, and when thyroid hormone levels are suboptimal, our body can’t “turn on and go”.
How Is Thyroid Dysfunction Properly Diagnosed?
The first thing that must be done when assessing thyroid function is a proper physical examination. We start with vitals. Temperature is so overlooked these days unless there is are signs of a fever. Body temperature is a continuum. 98.6°F is optimal, right? And if someone has a fever of 99°F or 100°F, it is enough for us as doctors to justify their symptoms of feeling achy and miserable. Maybe they have an infection, maybe a virus, maybe they should stay home from school or work. But what if someone has a lower than normal temperature, like 97°F or 96°F or even, as I have seen, as low as 94°F? Most patients with very low temperatures have been told that it is normal for some people to have low body temperature and that low temperature has nothing to do with their symptoms. So why is it that we have an optimal temperature, and that higher than optimal is too high and can cause symptoms, whereas lower than optimal is no big deal? Will the body exhibit distress when the temperature is too low? Of course it will! When the body temperature is too low, it is like your car is sitting in a cold garage collecting dust! All of your systems slow down, there is no gas in the tank, and you can feel miserable and symptomatic!
Body Temperature Is an Indicator of Thyroid Health
The best way to truly assess body temperature as it relates to thyroid function is to take your morning temperature about three hours after waking. Use a mercury or other metal thermometer, and hold it under your tongue for 6-10 minutes. I also suggest that my patients check their temperature a few more times during the day using the same method and document those temperatures for a few days. If you have a low body temperature, you also have slower metabolism and lowered body function. In this case, the goal needs to be to bring your body temperature up to normal.
Physical Examination of the Thyroid
Another important part of the physical examination is palpating the thyroid. The thyroid gland lies just above the collarbone like a butterfly across the windpipe. It has two lobes (wings) with a connecting piece in the middle called the isthmus. The thyroid should not be palpable, and your doctor should not really be able to feel it. If your thyroid is palpable, it should feel rubbery and smooth and barely noticeable. Most of the time, when I am palpating a patient’s thyroid who is experiencing thyroid-like symptoms, it feels spongy, like a sponge feels when it is filled with water and you press on it. Sometimes I may feel lumps that are more distinct and obvious, but most of the time it feels diffusely enlarged. Even a slight enlargement of the thyroid can be a sign of thyroid dysfunction.
Blood Work to Measure Thyroid Function is Essential
The Thyroid Hormones
Thyroid laboratory values are hotly debated. Most traditional doctors will only look at thyroid stimulating hormone (TSH). TSH is the message your pituitary sends to your thyroid that you are running low on thyroid hormone. But TSH is also the hormone that controls a certain exchange in the thyroid tissue called the sodium Iodine symporter (NIS). TSH goes up to say there is not enough thyroid hormone, so lets get more cabs available that can drive iodine and sodium into the thyroid tissue to make more hormone. When the iodine gets into the thyroid, more T4 is produced, and then the body converts that T4 to T3, the form of thyroid hormone that can be used by the tissues of the body. T3 is our active form of thyroid hormone. When T4 gets too high, and the body can’t keep up with the conversion of T4 to T3, it will store the T3 as reverse T3 (rT3). This rT3 is like T3 in “jail” and is not able to be accessed readily. The body will do this when it is under a significant amount of stress. Stress can be from inflammation, nutrient deficiencies, stomach acid imbalances, low cortisol or trauma.
Cortisol is important because when it is high (think stress both physical and emotional), it will raise your blood sugar, which works with your cells to bring T3 from your blood into the cells. This can cause high amounts of thyroid hormone to remain in the blood (this is called “pooling”), and this makes your free T3 look very high. Symptoms of high T3 are heart palpitations, jitteriness, anxiety and insomnia.
So, the adrenals and the thyroid are like the gas and the breaks so to speak. You need to have both of them activating at the proper time.
It must make sense to you now why just looking at the TSH in the blood will not really tell us anything. The range for TSH is 0.5-5.2 mIU/L. That is like saying you could walk around in a size 1 or size 5 shoe and be comfortable, which is ridiculous. There are many people who feel awful when their TSH is higher than 2.0. They may exhibit a thyroid that is enlarged along with symptoms of thyroid dysfunction like fatigue and mental fogginess. Nevertheless, their traditional doctor has told them that their thyroid is fine. At this point, it is probably clear to you why the TSH levels alone do not provide enough information to properly diagnose thyroid issues. We need to assess your levels of free T4, free T3, cortisol, and iodine to properly understand thyroid function.
Iodine you say? “I am sure I get enough iodine. I eat iodized salt on my food.”
You might be surprised to learn that iodine deficiency is one of the most pervasive nutrient deficiencies in the United States. Yes, we have iodized salt. However, the refined iodized salt that we use is also full of other halides such as bromine, chlorine and fluorine and other chemicals used in order to process that salt, remove it’s natural minerals, and turn it into the pretty white homogenous texture that characterizes the salt we know. In fact, most of those chemicals in salt are known goitregens. A goitrogen is a substance that interferes with thyroid health by disrupting the ability of the thyroid to take up and utilize iodine. So we have iodized salt, but it is also filled with goitrogens that inhibit the iodine from being used by the body. Bromine is one of the most common goitrogens we know of. Bromine binds to the thyroid through the same mechanism that iodine does, as all the halides look the same to the body. In effect, bromine competes with iodine for binding in the thyroid, but we can’t use it. Fluorine behaves in a similar way. We get fluorine in toothpastes and mouthwash and even drinking water. We are giving our babies fluoridated water! And bromides are found everywhere. In fact, brominated flour is used in almost all traditional baking in the United States and is even in Gatorade, Mountain Dew, and other soft drinks.
The recommended daily allowance (RDA) for iodine is inappropriately low at 150 mcg which is enough to prevent an obvious goiter, but is insufficient for optimal health. It is estimated that we need between 15-20 mg of iodine daily for optimal body health. And body health is the operative term here, because iodine is used in all tissues of the body and is highest in all of our glandular tissues such as breast, prostate, ovaries, pancreas and adrenal glands. In fact, the breast tissue has the highest concentration of iodine of all the glands in the body. It is interesting that the prevalence of glandular cancers is on the rise while iodine deficiency is widespread. Iodine is not only crucial for thyroid health, but it is also an antioxidant and is anticarcinogenic.
How is Iodine Measured?
Iodine can be measured in the blood or urine. We can get a spot urine test for iodine and then give a loading dose of iodine and have urine collected over 6 hours to see where iodine levels lie. The less iodine we see in the urine after giving a large dose, the more the body is retaining it and the greater the body’s iodine requirement. When we give large doses of iodine, we can also see a large amount of bromine and fluorine excreted in the urine as iodine displaces these other halides in the tissues. This can provide a clearer picture of overall body toxicity.
So lets go back to TSH, and what TSH levels tell us. If the TSH levels are high, it could indicate that there is not enough thyroid hormone (T4), or that the body is increasing iodine transport to bring more into the cell. So, we must also assess free T3 and free T4 to determine if the high TSH levels are related to low thyroid hormone, or if thyroid hormone appears optimal. It is also imperative that we measure anti-thyroid antibodies, which are an indication that the thyroid is under siege by the immune system. Getting diagnosed with autoimmune thyroid conditions does not have to be a “forever” diagnosis. But, we have to understand the imbalance and correct it so that the body doesn’t have to work at it alone.
Once we have a thorough history, temperature and vitals, and thorough blood work, including iodine levels, all thyroid hormone levels, and anti-thyroid antibodies, we can make a good determination of the health and function of your thyroid and provide a treatment plan to get you feeling better.
Treatment Plans to Restore Thyroid Health
Any thyroid plan is going to start with assessing your environment. For the thyroid and endocrine system to work well, we need to get rid of as many endocrine-disrupting chemicals as possible. Not only do we need to eliminate the iodine-competitive halides (bromine, chlorine and fluorine) from your diet, but we need to focus on organic food, grass-fed meat, and discontinue the use of certain chemicals found in cleaning products for our home. All of these chemicals can disrupt thyroid function.
Next, we focus on diet. In addition to emphasizing organic foods and grass-fed meat, elimination of gluten is also important, especially if there is an autoimmune component to the thyroid imbalance. Gluten contains gliadin, which is a protein that looks very much like transglutaminase, an enzyme needed for many metabolic processes to run correctly and is found in high concentration in the thyroid. The immune system cannot easily distinguish gliadin from transglutaminase, and thus gliadin can trigger an autoimmune reaction that also attacks the thyroid. Complete elimination of gluten can reduce autoimmune antibodies that target the thyroid.
Finally, we need to make sure you are getting all the nutrients you need in proper doses for the thyroid to work efficiently. It is important to maintain healthy levels of selenium, magnesium, iodine, iron and vitamins A, C, E, D as well as complex B vitamins. Returning to our car analogy, we need to balance the adrenal glands so that the gas and breaks aren’t being applied at the same time. And then, we need to re-measure and reassess the biomarkers of thyroid function. Have our interventions corrected the thyroid profile? How is the patient feeling? If the issues are still not correcting, we can prescribe bioidentical thyroid hormone to remedy the imbalance.
The Use of Bioidentical Thyroid Hormones
When determining whether the use of bioidentical thyroid hormone is appropriate, we have several options that include using synthetic thyroid hormone (e.g., Synthroid or synthetic T4), T3 alone, or a combined formulation of bioidentical T3 and T4 (e.g., Armour Thyroid or Nature-Throid) in a ratio that is similar to that made by the body. Finally, there is also dessicated thyroid hormone that is porcine-based and not only contains thyroid hormones in an optimal ratio, but also other nutrients that the body needs to produce adequate hormones. The decision about which form of thyroid hormone is appropriate to use is based on the blood work results and progress made through nutrition and supplementation. There are some patients who really need thyroid hormone prescribed from the start in addition to nutrient supplementation and a dietary plan, and that is fine.
Thyroid hormone balancing is crucial for optimal body temperature and optimal health. Only when thyroid function is assessed in a comprehensive fashion can we pinpoint deficiencies and correct them to restore full thyroid health.