The prevalence of thyroid disorders in the nation are increasing. It is estimated that 20 million Americans have some form of thyroid disease, some say it is higher than that. Many are unaware that they have a problem. They think what they feel is “normal.” Women are much more likely to develop thyroid disease than men. Over 12% of Americans will develop a thyroid disorder in their lifetime. (1)
One of the most common autoimmune diseases, Hashimoto’s disease, is a disorder of the thyroid. It is number 1 cause of hypothyroidism in the US. (2) Another study has found that approximately 8% of the US have antibodies against their thyroid gland. (3) Many of these people do not have symptoms and because these antibodies are not checked their thyroids’ are slowly destroyed over a period of time until they develop symptoms. The key to autoimmunity is prevention and early detection.
There are many variables as to why the thyroid gland is under such strain causing a disorder. I will present a few different ones in this article. But first let me discuss a little about the thyroid gland and how it functions. Then I will discuss the common signs and symptoms, blood work, thyroid patterns and diagnoses, and treatment options.
What is the Thyroid Gland and What is its Function?
The thyroid is an endocrine gland that resides in the lower part of your neck. It has two lobes and is shaped like a butterfly. To understand this gland like all other structures we need to pull back and get a good look at the bigger picture specifically the hypothalamic-pituitary-thyroid axis (HPT axis). Our brain is essentially the master of the body, it controls many of the processes that happens within. Some are automated, others are not. This is not to say the brain is the most important part but it is integral to the entire body.
In the brain is a structure called the hypothalamus. It regulates endocrine output and it is modulated by dopamine and serotonin, two important neurotransmitters. Important to remember because anything that affects dopamine and serotonin will also affect the thyroid. They hypothalamus releases thyrotropin-releasing hormone (TRH) which acts upon the pituitary gland. The pituitary responds by releasing thyroid-stimulating hormone (TSH). TSH then stimulates metabolic activity and an enzyme called thyroid peroxidase (TPO). This enzyme produces thyroxine or T4 and triiodothyronine or T3 by transporting iodine into the thyroid and catalyzes it with hydrogen peroxide.
The majority of your T4 is made in the thyroid. T4 is essentially the inactive form of it. T3 is the active form. T4 is converted into T3 via 5’-deiodinase enzyme, mostly by the liver. About ~60% of T4 is converted into T3, an additional ~20% is converted into reverse T3, which is inactive. Another ~20% is converted into T3 sulfate (T3C) and triiodothyroacetic acid (T3AC). T3C and T3AC are converted into T3 in the gastrointestinal tract and this is dependent on a healthy microbiota.
And between all these structures are regulatory mechanisms to keep things balanced. The thyroid hormones affect basal metabolic rate, aid in development, and regulate fat, carbohydrate, and protein metabolism among other things. Every cell in the body has receptors for thyroid hormone. Suffice it to say, that it plays a critical role in the body.
There could be a break in the HPT axis at multiple points ending in a thyroid disorder. That is why it is important to understand the bigger picture. The picture can widen more when we bring in other systems that can play a role into thyroid such as the digestive system. It is important to keep this all in mind in regards to figuring out what is going on and treatment.
Ok, let’s talk about some common signs and symptoms hypo- vs hyperthyroidism.
Signs & Symptoms of Hypothyroidism
- Lack of motivation
- Thinning hair or hair loss
- Dry skin
- Puffy or swollen face
Signs & Symptoms of Hyperthyroidism
- Increased heart rate and blood pressure
- Muscle weakness
As you can see there are a lot of signs and symptoms and it depends on what type of thyroid disorder you have. These are meant to be just examples. Also, it may have nothing to do with your thyroid at all. So it is important to get proper testing done. However, that is easier said than done.
There a couple of reasons why it is difficult to get proper testing. First of all, the most common labs ran are TSH and total T4. Often times it is only TSH. However, if you remember from my explanation above TSH is only one small part of the big picture same with total T4 if it is ran. Several thyroid patterns will not be picked up running these two labs.
My wife had labs ran on her thyroid years ago when I was working on my bachelors. They ran only TSH which was normal. After completing my doctorate degree, I was able to run my own labs and found that she had high reverse T3 which often points to some sort of chronic inflammation or micronutrient issue and an entirely different avenue. But hopefully you get my point. Without running extensive labs you can miss the mark.
The other issues has to do with the “normal” range. These ranges vary from company to company and they are often based on people who get blood work done. But who tends to get blood work done? Those who are not feeling well. Furthermore, if they were based off of a common pool of “healthy” people it can also be problematic. Many people do not know there is something wrong because the symptoms have not developed yet. We use the ranges the lab gives use but we also narrow the range too. The narrowing of the range is called a functional range. This way we can catch something early on.
Typically we run a full thyroid panel in our office. In addition to TSH and total T4, this panel includes total T3, free T4, free T4 index, free T3, T3 uptake, reverse T3, thyroid-binding globulin, thyroid peroxidase antibody, and antithyroglobulin antibody. We will also run a full comprehensive blood panel. We got to know what is going on in the body and these labs help with that. As you can see there are a lot more markers than just TSH and T4. And depending on what is going on it will help us understand what type of thyroid disorder it is.
Thyroid Patterns and Diagnoses
Typically we think of two types: hypothyroidism and hyperthyroidism, but this is an oversimplification. However, it is a good jumping off point in explaining the different issues. Hypothyroidism is someone who is low in thyroid production or function. Hyperthyroidism is someone who is high. Each have different symptoms. If your thyroid has to do with metabolism then low means you have low or sluggish metabolism and high means you have high or fast metabolism. So someone with hypothyroidism tends to be fatigued, gains weight, and cold. Whereas, someone with hyperthyroidism tends to lose weight, warm, and increased heart rate.
That is the simplified version, now I will talk about 6 patterns which may have more than one diagnosis with each of them. Also this is not meant to be exhaustive list of every known disorder just the more common ones. I will start at the the top with the pituitary.
1. Hypothalamic-Pituitary Driven or Secondary Hypothyroidism
This is characterized by low TSH and T4. This is an issue at the the top of the HPT axis. If the pituitary doesn’t release TSH then thyroid hormone production will not happen. As I said earlier this area of the brain is modulated by serotonin and dopamine. So if you are deficient in those two neurotransmitters it will greatly affect the ability of the hypothalamus and pituitary to work properly
Serotonin and dopamine depend on adequate amino acid supply of tryptophan and tyrosine. So if you do not get enough protein this can become a problem. Also these neurotransmitters depend on several vitamins and minerals as cofactors such as vitamin B6, magnesium, and iron. I am going to single out two other vitamins, B9 and B12, because they are a crucial part to our methylation pathways. Methylation happens all over the body and it is an important part of our glutathione production and clearing homocysteine. Some people have genetic SNPs that makes a proper methylation difficult. Others just do not get enough of the methylated forms of B9 and B12. Nevertheless, these two also come into play with the dopamine and serotonin.
The biggest issue here is inflammation. Inflammation of the brain can cause a host of problems and often presents with brain fog, depression, loss of memory, not feeling refreshed after sleep, anxiety, and many other things. Neuroinflammation can be caused by a lot of things bringing it back to the Big 5: infections (4), food sensitivities, heavy metals, environmental toxins, or physical and emotional trauma. Our brain does not like inflammation (5) and it will take its toll on the endocrine system, specifically the thyroid. The key is find and resolve the underlying causes by treating infections, removing foods patients are sensitive to, regulating blood sugar, and testing for and removing any other toxin.
2. Primary Hypothyroidism
Primary hypothyroidism is characterized by lab high TSH. This is one that may not be seen super often if you run the proper labs. Let me explain. If TSH was the only thing ran and it was high. Then you would combine that with the physical exam and history for a diagnosis of primary hypothyroidism. Unfortunately it is still vague, you don’t know what is causing it. So further testing is required.
In many areas of the world it can be caused by iodine deficiency. The body uses iodine to make the thyroid hormones. It is actually in the name of T3 that I wrote out above, triiodothyronine. In the US that tends to be more rare. What is common falls under the next pattern, Hashimoto’s thyroiditis.
Autoimmune diseases are among the most prevalent diseases in the world. Some argue that they are the number one cause of death because heart disease is being shown to have autoimmune connections. In the case of the thyroid we typically see two autoimmune diseases, Hashimoto’s thyroiditis and Grave’s disease.
Hashimoto’s is the most common and typically people present in the beginning with a fluctuation in thyroid hormone production. But ultimately once enough of the thyroid is destroyed they will have hypothyroidism. There is one study that suggests that the vast majority of hypothyroidism is Hashimoto’s. (6,7) Grave’s disease also occurs with thyroid destruction only it is characterized with an increase in thyroid hormone production leading to hyperthyroidism. (8)
Symptoms do not present until the disease is well underway often times. And we know prevention is key in all diseases. This is why it is important to have blood work done, a check up, and eat a good diet regularly. A complete thyroid panel should be run that includes the antibody testing. I had one patient with normal labs except for the antibodies. They were very high. So the thyroid was still functioning, but it was being destroyed. Thyroid peroxidase and antithyroglobulin antibody tests must be included in the blood work. I don’t think I can say this enough, it is crucial in diagnosing a thyroid disorder. (9)
One of the major causative factors is gluten intolerance with Hashimoto’s. Due to the similar protein structures between gliadin (protein within gluten) and the thyroid cross-reaction occurs, in other words the immune system starts attacking both the thyroid and gliadin. (10,11,12) I have found this to be the case with Hashimoto’s as well. Complete removal of gluten from the diet and an adoption of anti-inflammatory diet is critical to reduce the inflammation and help the body heal. Depending on how much damage has been done will indicate if thyroid hormone replacement will be needed.
4. Thyroid-Binding Globulin
Thyroid-binding globulin is the reason we have total T4 and T3 markers versus free. This can be measured by T3 uptake as well as the free T4 and T3. Increased thyroid-binding globulin leads to a drop in free thyroid hormones which would give symptoms of hypothyroidism. (13) This is typically caused by excess estrogen from xenoestrogens and phytoestrogens or birth control and hormone replacement therapy. (14,15)
Low thyroid-binding globulin increases the free thyroid hormones. However, there are often no symptoms with this one. This can also be caused by excess estrogen, but typically this is seen in metabolic syndrome with females leading to high levels of exogenous testosterone. (16)
5. T4-T3 Conversion
This is not necessarily a thyroid gland problem. The issue occurs in the peripheral cells, liver, and gut. There is an issue with converting T4 into T3. The enzyme 5’-deiodinase is supposed to remove 1 iodine from the T4 to make T3 but it requires selenium and zinc. Dysbiosis leading to a decrease of beneficial bacteria that perform this conversion is one underlying cause. (17,18) Lipopolysaccharides produced by pathogenic bacteria can inhibit 5’-deiodinase causing underconversion. (19) Ultimately, anything that causes inflammation will inhibit this conversion as well. (20)
This pattern is sometimes called low T3 syndrome. T3 is low but T4 and TSH are normal. So it can be difficult to catch. But treatment needs to be directed to micronutrients and why the inflammation is there.
6. Thyroid Resistance
Lastly, is thyroid resistance. Much like the insulin resistance of type 2 Diabetes where glucose is unable to get into the cells, thyroid resistance is where thyroid hormones are unable to get into the cells. TSH, T4, and T3 are normal with this. So obviously this is a tricky beast to test for. There are a few factors that cause it that we know of: inflammation, high cortisol, homocysteine, genetic factors, and vitamin A deficiency. (21,22,23)
From a holistic standpoint, we approach with a thorough history. We want to know everything that has happened with your health, every major event including surgeries, medications, family history of illness, supplements, diet, health questionnaires for specific issues, etc. Through a physical exam and muscle testing we can figure out more of the puzzle. I have mentioned earlier some of things we look for such as goiters, nodules, exophthalmos (bulging of the eyes), and onycholysis (loosening or separating of the fingernail from its bed).
Lab tests are crucial in determining what is going on as well. In addition to a full comprehensive blood analysis with 10 different thyroid markers we may also run a dried urine test called a DUTCH test to dig deeper into hormone function. We may also do diagnostic imaging on the thyroid gland such as ultrasound depending on what is going.
In the end, we don’t want to leave one stone unturned. We know many of our patients have seen numerous professionals without any help and we want to make sure that we are the last stop. Nevertheless, I hope this gives a clue in what to look for as well as the tests that need to be ran in order to truly diagnose a thyroid issue. There are other thyroid disorders that I have not mentioned, I chose the most common ones and the ones we see often.
But if you are going to do anything a diet change should be top priority. We recommend a whole food diet. We just call it the holistic diet, but in reality it is a modified paleo or ancestral diet. You may want to try going gluten-free for a period of time or try one of the other common food sensitivities such as dairy, egg, nightshades, or soy. This is called an elimination diet where you remove the food for a period of time and see how you feel. Then you reintroduce the food to see if the symptoms come back. But nevertheless, the best thing is to seek out a holistic practitioner who will run the proper tests and bend over backwards to help you get better.