Natural Wellness Center

Hypothyroidism and Underactive Thyroid

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Hypothyroidism and Underactive Thyroid

In a nutshell:
Hypothyroidism implies an underactive Thyroid gland
Hyperthyyoidism implies an overactive Thyroid gland

Some Brief Points

In my opinion it is important to measure free thyroid hormone levels.

If a patient is having problems with their thyroid therapy then it is important to measure FREE T3 and FREE T4...sometimes just making sure that there is enough of the free hormone levels makes a large difference to well-being.

Adequate amounts of minerals such as iron, selenium and zinc are important for the transformation of T4 to the much more potent T3.

Proper adrenal function is essential for treatment of an underactive thyroid gland to be effective.

Thyroid physiology - a synopsis

The thyroid gland is situated in the neck just behind the Adam's Apple or thyroid cartilage and this gland sets the pace for the whole body's metabolism.

The thyroid is a little like an orchestral conductor giving out the rhythm to the whole orchestra - It affects the activity of each and every cell in the body.

Too little thyroid hormone means that the body's processes all slow down too much with resultant sluggishness, mental fuzziness and weight gain. Conversely, too much thyroid speeds the metabolic processes too much resulting in everything running too fast with resultant weight loss, fast heartbeat, insomnia and anxiety.

In the adult female hypothyroidism may result in menstrual irregularities and difficulty conceiving.

Thyroid Hormone

There are two active thyroid hormones T3 and T4 which are carried 'bound' in the blood to transport (carrier) proteins.

While attached to the carrier proteins they are inactive. Think of an analogy involving skiers - they cannot ski when they are sitting in the chair-lift - only when they are 'released' from the chairlift can they start to ski.

It is important to realise that the at any given time the vast majority of the body's thyroid hormone (over 90 %)is totally inactive biochemically because it is bound to transport proteins.

Free Thyroid hormones: Free T3 and Free T4 (also known as Free Thyroxine)
Only when the T3 and T4 are released from their carrier proteins are they free to do their work. They are then referred to as Free T3 and Free T4.

Frequently standard laboratory testing only measures TSH and Total T4 (total includes the portion bound to carrier protein and the free 'unbound' portion). Personally I prefer to look at the level of Free T3 and FreeT4.

T3 is several times more potent than T4 but lasts for substantially less time (in medical jargonese we say that T3 'has a shorter half-life'). If metabolism is working properly much of the T4 is converted to T3 but this is dependent on many factors including the person's mineral (especially iron, zinc and selenium) status.

The Thyroid is critical to normal growth and development of infants and children. For infants and children the processes of growth and development - especially the development of the nervous system - are dependent on normal thyroid function and so all newborns are screened in the maternity units for this.

Thyroid Stimulating Hormone (TSH) controls the level of thyroid hormone in the blood.

The manufacture of thyroid hormone by the thyroid gland is under the control of a part of the brain known as the anterior pituitary. The more TSH that is in the bloodstream the higher the level of thyroid hormones.

The amount of TSH released is also controlled by another centre in the brain called the hypothalamus. The hypothalamus constantly monitors the level of thyroid hormones in the bloodstream and then releases substances which either increase (TSH-RF) or slow (TSH-IF) the release of TSH.

How reliable are thyroid blood tests?

There is substantial controversy about this issue even in the medical community. It varies from those individuals in the medical community who believe that once TSH and T4 level are normal then there is 'no problem' with an individual's thyroid gland to those (thankfully) few doctors who if twenty people all complaining of tiredness lasting over a year or two were lined up in their waiting room would be very likely to 'diagnose' an under-active thyroid gland in the vast majority of them and promptly proceed to dish out replacement thyroid hormone to them. These are two extreme viewpoints and I think that the truth probably lies somewhere in between.

My view is that there may be sub-group of patients who despite having 'normal' T4 and TSH may well have a thyroid problem.

This being said there is a potential for real harm to patients if this deviation from normal medical practice is undertaken in a casual and thoughtless manner. Think before bending the rules.

Clinical (i.e. from the patient) and Laboratory data must be integrated for a ‘proper’ diagnosis:

If I am seriously considering a diagnosis of hypothyroidism in the presence of 'normal' T4 and TSH (both of which investigations will usually have been carried out long before the patient arrives at my door) the first thing I do is to look at free T3 and free T4 levels along with another TSH and usually at thyroid antibody levels. This means I am measuring how much thyroid hormone is active in the person’s body rather than the amount which is merely present. If the free T3 and T4 levels are in the lower one-third of the range and the basal body temperature is low then I may begin to seriously entertain the diagnosis.

Be cautious

I do not consider starting someone who is tired on thyroid replacement an appropriate first line of treatment. Sometimes a patient will come to me wondering if their thyroid is underactive. Sometimes it will be. Other times not. Sometimes they may have all the symptoms of a low-grade bowel infection. We treat the bowel infection and the fatigue goes away - without any treatment of the thyroid at all.

Broda Barnes and Basal Body Temperature measurement and hypothyroidism.
An endocrinologist in the United States some forty or so years ago felt that the most reliable and sensitive test for hypothyroidism was the basal body temperature test. This involves measuring the axillary (underarm) temperature first thing in the morning on awakening before there is any physical activity. An old-fashioned mercury thermometer should be used and it should be left in place for ten minutes. I ask patients to take at least ten readings scattered over the course of a month or so. Personally I interpret the readings in the light of the clinical symptoms, total history and blood tests. Good medicine is about collating all the data and not getting diagnostically 'carried away' by any particular part of it. We need clinical balance. I am concerned about the hazards of over-treatment of people who do NOT need extra thyroid hormone being given it as much as I have sympathy for those people who may benefit from thyroid supplementation but who are denied it without due consideration.

What is Reverse T3?

Reverse T3 is a form of T3 which has exactly the same chemical composition as 'normal' T3 but which does not function to stimulate cells in the way which T3 normally should do. Unfortunately, as well as not functioning to stimulate cells as it normally should, reverse T3 still functions to block receptor sites for 'normal' T3 and also still functions in negative feedback by duping the hypothalamus into believing that it is 'real, functioning T3' and so reduces the TSH released by the pituitary which, in turn, contrives to reduce the overall amount of thyroid hormone in the body.

Armour Thyroid, Tertroxin (a form of T3), l-thyroxine (or eltroxin).
These are all forms of thyroid replacement therapy. 'Thyroxine' is T4 only. 'Tertroxin' is the UK brand name of a preparation which contains solely T3. 'Armour thyroid' is porcine-derived glandular thyroid which contains mostly T4 but a small amount of T3. Some patients do well on 'ordinary, inexpensive thyroxine' while other patients appear to experience side effects on l-thyroxine which they do not experience on Armour thyroid. Some people do better on standard eltroxin with a small amount of added T3. It's about individual variation in response to treatment and patient preference. I should point out that Armour thyroid is somewhat more expensive than normal thyroid hormone replacement.

There is currently a vogue among a small group of doctors for routinely giving adrenal hormones along with thyroid hormones. How sensible is this?
As a general rule it is probably not medically sensible to to decide too quickly that a patient should have cortisol replacement. It is important to at least check salivary cortisol levels if a diagnosis of functional hypoadrenalism is being seriously entertained.

What is the bottom line about deciding whether thyroid hormone supplementation in the presence of normal basic screening blood tests is worth trying?
Before considering thyroid hormone supplementation in the presence of normal screening blood tests there should be a consistently low basal body temperature and screening tests for minerals that affect thyroid function should be used. If there are symptoms such as irritable bowel syndrome which may denote a low-grade bowel infection then this possibility should be dealt with. Under-active adrenal glands need to be considered. Depending on context oestrogen and progesterone imbalances may also need to be considered. Sometimes when other issues such as these are dealt with the patient's sense of well-being returns without any need to commit them to long-term thyroid replacement therapy.

The Adrenal Gland

It is important to make sure that the adrenal glands are functioning well as the Adrenal Glands are critical to health and well-being.

If the adrenal glands become completely defunct we die.

If the adrenal glands become so weak that they can produce hardly any cortisol this condition is described as Addison's disease.

There is also (in my opinion) a group of patients whose condition is not severe enough to satisfy the diagnostic criteria for Addison's disease but who, nevertheless, are unable to produce adequate amounts of cortisol.

What Symptoms might suggest an Adrenal Gland problem?

Cold hands and feet, constantly low blood pressure, general weakness, needing to eat very frequently, problems standing in a queue (do much better if walking than standing still), poor ability to handle stress, sometimes low body temperature or recurrent infections.

How may adrenal gland function be tested?

There is a reasonable correlation between the amount of cortisol in the saliva and the blood cortisol. This test is useful as an adjunct alongside the standard medical tests for adrenal function. Salivary cortisol is measured by the patient using a home kit at 8AM, midday, 4PM and midnight. Many individuals who have low adrenal function may be very tired in the morning (as may be a lot of hypothyroid patients) and take a long time to 'get going'.

Patients with co-existent low thyroid function and low adrenal function.

Patients who have both low thyroid function and low adrenal function may feel worse when commenced on thyroid replacement therapy. I have certainly experienced this with one or two patients over the years. These patients may remark something along the lines of "I was started on thyroxine/armour thyroid and I immediately felt worse and began to have palpitations and feel weak and so I stopped the thyroid medication".

There is currently a vogue among a small group of doctors for routinely giving adrenal hormones along with thyroid hormones. How sensible is this?

As a general rule it is probably not medically sensible to decide too quickly that a patient should have cortisol replacement. It is important to at least check salivary cortisol levels if a diagnosis of functional hypoadrenalism is being seriously entertained.



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