DO YOU KNOW IF YOU HAVE HASHIMOTO’S THYROIDITIS?

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THYROID OVERVIEW

The thyroid gland is a butterfly shaped gland situated at the base of the neck. It is a part of a large network of glands comprising the endocrine system. The thyroid gland produces hormones that regulate metabolism, growth and development. Thyroid diseases occur when the gland produces either too little hormone (hypothyroidism) or too much hormone (hyperthyroidism).

The most common thyroid diseases are:

  • Hashimoto’s Thyroiditis
  • Grave’s Disease
  • Goiter
  • Thyroid Nodules

Hashimoto’s Thyroiditis (HT) and Graves’ Disease (GD) are Autoimmune Thyroid Disorders (AITD). Autoimmune conditions develop when your own immune system considers your own tissue as harmful foreign invaders that need to be destroyed.

HASHIMOTO’S THYROIDITIS

This is also known as chronic lymphatic thyroiditis and is the commonest cause of hypothyroidism worldwide. Some of you may have it but not know it because, you have not been tested for Thyroid Antibodies. A regular thyroid test done by most practitioners does not include an Anti TPO or Antithyroglobulin Antibody (Anti TG) test. The main reason being that in conventional medicine there is nothing much that can be done to reduce the antibodies apart from prescribing Levothyroxine (Synthroid/Eltroxin/Thyronorm). However, this is where the Functional and Metabolic Medicine approach differs. We know that when we address gut health, nutrient depletions, your HPA Axis dysfunction (Dysregulated Stress response), reduce toxic exposure, maintain adequate Vitamin D3 and help you make lifestyle changes, antibodies to many autoimmune conditions either reduce or disappear. Am I suggesting that you should stop your thyroid medications? Definitely not! However, the amount of medication that you need may be less. Some of you will still need lifelong thyroid medication if your immune system has destroyed most of your normal tissue or you have been diagnosed late.

Symptoms of hypothyroidism:

  • Fatigue
  • Weight gain
  • Depression
  • Anemia
  • Cold feet & palms
  • High cholesterol
  • Lack of motivation
  • Slow movements
  • Hoarse voice
  • Loss of libido
  • Ringing of the ears
  • Hair loss
  • Palpitations
  • Breathlessness
  • Intolerance to heat or cold
  • Carpal Tunnel syndrome
  • Loss of outer third of eyebrow
  • Memory loss
  • Poor concentration
  • Loss of drive
  • Mood swings
  • Irregular menstruation
  • Infertility
  • Constipation
  • Goiter (enlarged thyroid)

THYROID HORMONE SYNTHESIS

The two most important hormones produced by the thyroid gland are tetraiodothyronine (thyroxine or T4) and triiodothyronine (T3).

HYPOTHALAMIC-PITUITARY-THYROID (HPT) AXIS 

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As shown in the picture, the thyroid gland is influenced by two other hormones.

  • Thyroid Releasing Hormone (TRH) from the hypothalamus in the brain and
  • Thyroid Stimulating Hormone (TSH) from the pituitary gland, located at the base of the brain.

The hypothalamus, pituitary and thyroid glands along with the hormones they produce are together called the Hypothalamic-Pituitary-Thyroid (HPT) Axis. The thyroid gland produces T4 and some T3. The more active form of the hormone is T3. The conversion of T4 to T3 happens mostly in liver, kidneys and brain. Most of the thyroid hormones are bound to thyroid binding globulin (TBG). It is the unbound form of the hormones, the Free T3 and Free T4 that are important for thyroid hormone actions. This is why measuring only TSH, Total T3 & Total T4 do not provide an accurate picture of thyroid function.

If thyroid hormone levels are low in the blood, the hypothalamus and pituitary detect this.TRH released from the hypothalamus stimulates the pituitary to produce TSH, which in turn acts on the thyroid gland to produce thyroid hormones.TSH levels can go up if adequate thyroid hormones are not produced as a result of autoimmune destruction of thyroid tissue or because of nutritional deficiencies, like iodine deficiency.

There are few enzymes called deiodinases which are important for activation and inactivation of T4. One of them called the DIO2 (Type2 Deiodinase), which is present in the brain, is very important for thyroid hormone actions. This is relevant in thyroid hormone replacement (Ref Chapter 7).

FUNCTIONS OF THYROID HORMONES:

It is likely that every cell in the body is a target for thyroid hormones. The most important functions are:

Lipid Metabolism: Thyroid hormones are important for lipid metabolism. This is the reason for raised cholesterol and triglyceride levels when your thyroid function is deficient. Thyroid hormones are also important for carbohydrate metabolism.

Brain Development in the fetus is dependent on the mother’s thyroid function. This is the reason for checking thyroid function before contemplating a pregnancy. Normal thyroid hormone levels are also important for normal development of children.

Reproduction: Thyroid dysfunction can lead to infertility in some people.

Cardiovascular System: Thyroid hormones increase heart rate, contractility and cardiac output.

Central Nervous System: Thyroid hormones are intimately associated with mental state. In fact, about 20 % of people with depression may have undiagnosed hypothyroidism.

FACTORS AFFECTING THYROID FUNCTION

  • Iodine
  • Iron
  • Zinc
  • Selenium Vitamins A, B complex, C, D& E
  • Tyrosine
  • Stress
  • Inflammation
  • Drugs like lithium, amiodarone.
  • Heavy metal toxicities
  • Pesticides
  • Exposure to Endocrine Disruptors like Bisphenol-A
  • Infections
  • Trauma

THYROID FUNCTION TESTS:

Below is a list of thyroid function tests. All the tests may not be necessary for all of you. However, this is a decision to be made by you in consultation with a knowledgeable doctor.

  • TSH
  • Free & Total T3
  • Free & Total T4
  • Anti TPO & Anti Thyroglobulin Antibody (For Hashimoto’s Thyroiditis)
  • Anti-TSH receptor Antibody (For Graves’ Disease)
  • Thyroglobulin
  • Thyroid Binding Globulin
  • rT3
  • Tests for nutrient depletions like Iron,vitamin D3, Selenium,Zinc, Iodine etc.
  • Tests for heavy metal toxicities

TRH is usually not tested for because the TSH test is sufficiently sensitive.

TREATMENT : Please check my previous post:http://www.betterforlife.in/blog/2016/05/thyroid-hormone-replacement-only-t4-or-a-combination-of-t3-and-t4/

ACTION STEPS:

  1. Get the right tests done. If you have not been tested for thyroid antibodies, you DO NOT KNOW whether you have Hashimoto’s Thyroiditis (Autoimmune Thyroid Disease)
  2. Do not stop or reduce your thyroid medications without discussion with a knowledgeable doctor.
  3. Maintain adequate Vitamin D3 levels
  4. Check for nutrient depletion.
  5. Maintain good gut health.
  6. Look for anemia.
  7. Reduce your toxic burden
  8. Address your dysregulated stress response.

 

 

 

 

 

THYROID HORMONE REPLACEMENT-ONLY T4 OR A COMBINATION OF T3 AND T4?

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Hypothyroidism is a condition where your thyroid gland produces insufficient amounts of thyroid hormone. The most common cause of hypothyroidism is an autoimmune condition called Hashimoto’s Thyroiditis, where your body’s own immune system attempts to destroy your thyroid tissue.

WHAT IS THE BEST TREATMENT FOR HYPOTHYROIDISM?

  • Is it Levothyroxine T4 (Synthetic T4, Synthroid, Thyronorm, Eltroxin)?
  • Is it a combination of T4 and T3 (Levothyroxine and Cytomel)?
  • Is it compounded bioidentical combined T4 and T3?
  • Or is it thyroid glandular extracts?

The truth is there is no one right answer! It depends on what works for you!

LEVOTHYROXINE (T4) MONOTHERAPY

Using Levothyroxine to replace thyroid hormone in hypothyroidism is the standard of care all over the world. This is the view endorsed by major thyroid and endocrine associations worldwide. However, many people on synthetic T4 alone have not felt their best despite progressively increasing their T4 dosage. This can happen because of several reasons, some of them being low iron storage, poor gut health causing improper absorption of T4 or wrong time of taking T4 in relation to meals. For optimal T4 absorption, you should not take any food or supplements one hour before and one hour after taking T4. In such people who still experience fatigue, weight gain and “brain fog” and their test reports are in the” normal” range, while on T4 only, what should the doctor do? Should you consider a combination of T4 and T3? I get a lot of my patients at this point, when their regular doctor has decided that they need an anti-depressant in addition to T4 or even worse, they are told it is “all in their head” (ironically this may not be far from the truth when we consider the Type 2 Deiodinase(DIO2) enzyme in the brain! More on this later).

COMBINATION THERAPY WITH T4 AND T3 (T4/T3)

Triiodothyronine (T3) is the more active form of thyroid hormone. Your thyroid gland produces T4 and a small quality of T3. Most of the T3 in the blood comes from conversion of T4 in tissues like liver, kidneys and brain. This conversion happens through the action of certain enzymes called Deiodinases. Several studies in the past few years have suggested that in some patients, treatment with combined T4/T3 instead of monotherapy with T4 may show better results, particularly in terms of psychological well-being. Why is this so? One of the possible explanations could be a genetic variation in the DIO2 (Type 2 Deiodinase) gene, which affects the conversion of T4 to T3 in the brain. This DIO2 gene variation does not affect blood levels of thyroid hormones. So your blood levels of thyroid hormones may remain in the normal range, but you don’t feel well. However, this genetic test is not routinely available yet, other than in research settings. So what should you do? A trial of combined T4/T3 is definitely a worthwhile option.

What combinations of T4/T3 are available?

1) Synthetic T4 and Cytomel (T3)

2) Compounded combined T4/T3

Which should you choose? Depends on many variables. But as always, adequate knowledge in their use is extremely important.

WHAT ABOUT THYROID GLANDULAR EXTRACTS?

Thyroid glandular extracts are prepared from thyroid glands of pigs. Armour Thyroid and Naturethyroid are the common ones. It is a combination of T4 and T3 and on US Pharmacopeia, which means that it has standardized dosage of T4 and T3. Use of thyroid glandular extracts sometimes becomes an emotional issue, with one camp being all in favor of it and another completely against it.

One crossover study of 70 patients by Hoang et al in The Journal of Clinical Endocrinology & Metabolism (2013) found that people on Armour Thyroid felt better and about 48% of them preferred Armour over T4 mono therapy. There were no adverse effects on thyroid glandular extracts. However, one major question that this study did not answer was whether there was any change in thyroid antibody levels when on porcine glandular extracts. The study did not measure thyroid antibodies in the patients. Many of us in Functional Medicine do not recommend porcine glandular extracts in patients with positive thyroid antibodies because of the risk of increased autoimmunity from an animal protein.

Sometimes we forget how far we have come in Medicine. George R Murray’s account “The life-history of the first case of myxedema treated by thyroid extract” in BMJ 1920 reads like a beautiful story.Dr. Murray mentions that Dr. Michell Clarke in 1892 had failed to find success in using thyroid glandular extracts because his butcher had been providing him with thymus instead of thyroid glands to make glandular extracts! At least we don’t have to depend on our butcher!

 

For Readers in India: 

As far as I know Cytomel (T3) is not available in India. Compounded combined T4/T3 is not easily available either. More importantly, thyroid hormone is not easy to compound so quality control in the compounding pharmacy is very important. Moreover, compounded hormones are more expensive than the synthetic T4 (Thyronorm, Eltroxin). Thyroid glandular extracts are made from pig thyroid glands and not available in India.

You may be interested in Autoimmunity

REFERENCES:

Murray, George R. “The life-history of the first case of myxedema treated by thyroid extract.” British medical journal 1.3089 (1920): 359.

Panicker, Vijay, et al. “Common variation in the DIO2 gene predicts baseline psychological well-being and response to combination thyroxine plus triiodothyronine therapy in hypothyroid patients.” The Journal of Clinical Endocrinology & Metabolism 94.5 (2009): 1623-1629.

Hoang, Thanh D., et al. “Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study.” The Journal of Clinical Endocrinology & Metabolism 98.5 (2013): 1982-1990.

Pepper, Gary M., and Paul Y. Casanova-Romero. “Conversion to Armour thyroid from levothyroxine improved patient satisfaction in the treatment of hypothyroidism.” Journal of Endocrinology, Diabetes & Obesity 2 (2014): 1055-1060.

Wiersinga, Wilmar M. “Paradigm shifts in thyroid hormone replacement therapies for hypothyroidism.” Nature Reviews Endocrinology 10.3 (2014): 164-174.

Schmidt, Ulla, et al. “Peripheral markers of thyroid function: the effect of T4 monotherapy vs T4/T3 combination therapy in hypothyroid subjects in a randomized crossover study.” Endocrine Connections 2.1 (2013): 55-60.

AUTOIMMUNITY: A FUNCTIONAL & METABOLIC MEDICINE PERSPECTIVE

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Worldwide there is an unprecedented rise in autoimmune conditions. Did you know that you may have autoimmune antibodies in your blood many years before you develop the disease? Studies have shown that Thyroid Antibodies or Antibodies for Lupus or Rheumatoid Arthritis, Type 1 Diabetes (and many more) may be present in your blood 4 to 15 years before you develop the disease! 

There are about 80 different autoimmune conditions and they are all potentially serious chronic diseases. All of them involve an underlying problem with your immune system. You need your immune system to work well because it protects you from outside invaders. Your immune system tries to protect you by identifying, killing and eliminating invaders that may harm you. Sometimes problems with your immune system can cause it to mistake your own healthy tissue as harmful and attempt to repeatedly attack and destroy them. This is when you develop an autoimmune condition. “Autoimmunity “means immunity against the self.

Your body is combating something-an infection or toxin or allergen or dysregulated stress response and somehow that immune response gets misdirected to your thyroid tissue, nerve layer, skin, kidneys or even the whole body. Your immune system is very highly developed. Therefore, why should it get confused between friend and foe? One possible explanation is molecular mimicry, where your own tissue seems similar to an invader, either structurally or immunologically. Another explanation is “bystander activation”, where your own tissue is destroyed as collateral damage because your immune system is dealing with an infection or inflammation. The underlying dysfunction common to all autoimmune conditions is chronic inflammation.

Different autoimmune conditions affect different organs or organ systems. For example in Hashimoto’s your immune system makes antibodies against your thyroid tissue, in Multiple Sclerosis (MS) your immune system attacks myelin which is a fatty layer that wraps around your nerve fibers ,in Rheumatoid Arthritis (RA) it is the lining of your joints that are attacked. Some conditions like Systemic Lupus Erythematosus (SLE) or lupus, the skin, joints, kidneys or brain may be affected. Depending on which autoimmune condition you have, you will meet different specialists. For example, if you have MS you will meet a Neurologist, RA or SLE a Rheumatologist, Psoriasis a Dermatologist and so on. But as Dr.Yehuda Shoenfeld,Professor of Medicine at Tel Aviv University in Israel, says there should be a separate specialty of Autoimmunology.

Conventional treatment of autoimmune conditions may sometimes make you feel worse. Many of these drugs have serious side effects. However, when used judiciously these drugs can be life changing. But these potentially toxic drugs when used alone, are not a long-term solution. These drugs can temporarily take care of the inflammation while we treat the actual causes of the disease.

WHAT IS DIFFERENT ABOUT THE FUNCTIONAL AND METABOLIC MEDICINE APPROACH?

We know that the following factors influence autoimmune disease:

  • Genes
  • Immune System
  • Environmental Triggers like gluten (Celiac Disease), bacteria, viruses.
  • Intestinal Permeability.
  • Gut Dysbiosis
  • Chronic Inflammation
  • Metal Toxicities like Mercury, Lead, Arsenic.
  • Environmental Pollutants like Persistent Organic Pollutants (POP), Bisphenol-A.
  • Stress (HPA axis Dysfunction)
  • Food Sensitivities
  • Hormonal Imbalance.
  • Vitamin D Deficiency
  • Low Antioxidant Reserve
  • Insufficient Sleep

In the next few posts I will talk about these topics. Meanwhile,

HERE ARE A FEW THINGS THAT YOU CAN DO:

  • Reduce your toxic exposure. Stop using plastic food & water containers. Check your cosmetics & household cleaning products for possible harmful substances. A good place to check is the Environmental Working Group’s website (ewg.org)
  • Eat plenty of fresh vegetables and some fruit.
  • Eat plenty of dark leafy greens.
  • Stop sugar. Sugar causes inflammation.
  • Stop eating processed food.
  • Manage Stress
  • Sleep!