Hashimoto’s is the most common cause of hypothyroidism worldwide and research has shown that it also has many similarities to PCOS or Polycystic Ovarian Syndrome.
What’s really interesting about these 2 interacting health challenges is what they reveal about how interconnected everything in the body is.
In this post we explore these connections and how, once again, Hashimoto’s is so much more than a thyroid problem.
In order to be diagnosed with PCOS you must have 2 of the 3 following criteria.
(These are what is known as the Rotterdam criteria)
1) No period (Anovulation) or Irregular Periods
2) High levels of testosterone (Hyper-androgenism)
Clinical hyper-androgenism: adult acne, hirsutism (a male pattern of body or facial hair), or hair loss (androgenic alopecia)
3) Polycystic (multiple cysts) appearing ovaries on ultrasound, containing multiple small follicles
Many women with PCOS are overweight, find it difficult to lose weight, and suffer with fatigue, depression and anxiety and either have excess hair or hair loss.
Many women who suffer from Hashimoto’s are also overweight, find it difficult to lose weight, suffer from fatigue, depression and/or anxiety and they struggle with hair loss.
Is it a coincidence? Well, in a word, no.
There is a clear connection between Hashimoto’s thyroiditis and PCOS.
A 2013 meta-analysis found that in a total of 6 studies involving 1605 women, there was a significant increase in the prevalence of Hashimoto’s, increased serum TSH, increased anti TPO antibodies, and anti TG antibodies in women with PCOS when compared to control groups.
A 2012 study found that women with PCOS had a 65% increase in thyroid peroxidase antibodies, and a 26.6% increase in the incidence of goiter, when compared to other subjects in the same age group.
Both Hashimoto’s and PCOS can also lead to infertility and another recent study showed that women suffering with PCOS-related infertility who also had high anti-TPO levels were significantly more likely to not respond to treatment.
There are a number of common causes that make both PCOS and Hashimoto’s worse and they reveal some important clues into treatment strategies.
Here are some common factors:
1. Blood sugar imbalances
2. Low progesterone
3. High Estrogen
5. Inflammation: The Root of All Evil
I have written extensively about how sugar imbalances can be major triggers for Hashimoto’s and if you don’t take this seriously you won’t get better. It’s just that simple.
If you missed my previous blog post on this check it out here.
50-70% of women suffering from PCOS have blood sugar issues.
And one of the most common is insulin resistance.
This is basically caused by too much sugar in your blood. Or your classic high carbohydrate diet.
Insulin is a hormone that tells muscle and fatty tissue to take up glucose (sugar) from the bloodstream and to store it as fat or energy.
When the body tissues are “resistant” to insulin, the pancreas simply pumps out more to try and keep the blood sugar levels controlled.
And a woman with PCOS will often have much higher insulin levels in their blood than normal for this reason.
With PCOS, even though other tissues in the body are resistant to insulin, the ovaries and pituitary gland remain very sensitive to it.
The pituitary is a master endocrine gland and it must read and make decisions on many important organs including the adrenals, the thyroid, ovaries and lots more.
It is very sensitive to many different hormones and has been shown to absorb these hormones differently than many other cells in the body.
This is one of the reasons why TSH testing can be so inaccurate – it comes from the pituitary.
A recent research study looked at the role of the pituitary-ovary, adrenal, and thyroid axes in PCOS.
The researchers found through testing TRH (Thyroid Releasing Hormone) that PCOS groups had higher TSH and prolactin and lower free T4.
And adrenal stress may contribute to both high testosterone and insulin resistance, in part because of the impact of this pituitary axis .
High insulin levels also cause the pituitary gland to make too much luteinizing hormone (LH), and too much LH causes the overproduction of testosterone, which causes problems with ovulation.
In addition, insulin surges cause an enzyme (17, 20 lyase) to increase activity and this promotes the development of cysts and more production of testosterone.
What is also interesting is that estrogen is transformed into testosterone in fat cells by an enzyme called aromatase.
This is very common in overweight women who are insulin resistant and who are hypothyroid.
Drugs that lower insulin levels like metformin have been shown to be beneficial in the treatment of PCOS in some women because of this connection.
They lower insulin and aromatase levels which helps lower testosterone levels and, thus, cyst formation.
As part of a vicious cycle, the high testosterone in PCOS sparks even more insulin resistance.
And research has shown that this is not a one way street.
Low thyroid function (higher TSH) actually makes insulin resistance worse in women with PCOS.
Boil this all down to one thing?
Too much sugar is like adding gasoline to the flame of both PCOS and Hashimoto’s.
(If you get nothing else from this post, burn that into your brain.)
Also, it is interesting to note that one of the most common factors of hair loss in women with Hashimoto’s is blood sugar imbalances and insulin resistance.
Low progesterone is another thing that is very common in both PCOS and Hashimoto’s.
It is difficult to know which came first, but there are some common factors.
Usually in their mid-thirties, women’s progesterone levels begin to fall more quickly than their estrogen levels, creating what is known as “estrogen dominance”.
If left uncorrected, this imbalance of progesterone and estrogen can get worse over time and all kinds of issues can appear, including: premenstrual headaches (often migraine-like) fluid retention, fibrocystic breast disease, uterine fibroids, heavy, painful menstrual periods, endometriosis and functional hypothyroidism.
Estrogen dominance also causes the liver to produce high levels of a protein called “thyroid binding globulin”, which, you guessed it, binds to thyroid hormone.
When this happens the amount of thyroid hormone that can be used by the cells of the body goes down.
What does this lead to? Low thyroid function and all of the negative side effects that come along with it.
A 2009 study looked at a group of 337 women with PCOS. All of the women were assessed for the key markers of PCOS, including hirsutism, acne, and menstrual irregularity.
What the researchers found was that women with the highest TSH levels tended to have the most severe insulin resistance. Interestingly, this was not related to weight: hypothyroidism caused insulin resistance in women in all weight categories.
The study concluded that a TSH above 2 miU/L was associated with insulin resistance in PCOS.
It seems that for women with PCOS, an optimal TSH range may be below 2-2.5 mIU/L.
While the research on this topic is generally focused on TSH, it is also makes sense that an optimal range also exists for free T3 and free T4 in PCOS.
In my practice, I have found that values at the top part of the range may provide benefit for some women with PCOS.
And, once again, this is not a one way street.
Low thyroid function leads to low progesterone and high estrogen.
This can lead to weight gain and insulin resistance which can lead to estrogen getting transformed into testosterone and too much LH which can all lead to PCOS.
And correcting hypothyroidism can improve and sometimes resolve PCOS.
Do you see how this is all connected into a massive vicious cycle?
Dear reader, if you know me and my work, you know where I’m going with this.
The root of all evil is inflammation.
Both Hashimoto’s and PCOS are driven by inflammation.
Nodules and thyroid inflammation and cysts on the ovaries are both caused by inflammation.
We’ve seen how sugar and inflammation go together like gamblers and con men.
Well, inflammation, Hashimoto’s and PCOS go together like gamblers, pick pockets and con men.
Recent research has shown that there are common inflammatory markers in both PCOS and Hashimoto’s.
(Read this post to learn more about what is happening with the immune system and Hashimoto’s.)
C-reactive protein levels are 96% higher in PCOS patients than in healthy controls. It has also been found to be significantly elevated in patients with subacute thyroiditis.
Interleukin 18 (IL-18) is high with obesity and insulin resistance. IL-18 is a major culprit in the initiation and progression of Hashimoto’s, especially those with severe symptoms that don’t respond to levothyroxine treatment.
Polymorphisms (genetics variations) of the IL-1a, IL-1b and IL-6 genes have also been associated with PCOS.
IL-6 is also elevated with insulin resistance, PCOS and Hashimoto’s and is thought to be a major factor in the initiation and progression of both disorders.
PCOS and Hashimoto’s have many common factors and symptoms and when you boil it all down have very similar origins.
They are made worse by blood sugar imbalances, especially insulin resistance and by inflammation.
So the best way to treat them is?
Conventional treatment for PCOS is to prescribe oral contraceptives to shrink cysts and falsely normalize menstrual patterns.
But many times, this is not a good long term solution because it does not address the underlying causes of the problem.
If the underlying causes are thyroid related, then proper thyroid management will often resolve the cysts.
In addition, the following strategies should be implemented:
Balance blood sugar, improve insulin receptor sensitivity and reduce systemic inflammation.
This is the holy trinity.
Hashimoto’s is an progressive autoimmune disease and, over time, it becomes way more than a thyroid problem.
As this post clearly demonstrates, many different systems of the body get involved and affect each other.
When these start to malfunction, they can cause a web of problems that result in a downward spiral that causes you to get worse and worse.
It is possible to turn this downward spiral on it’s head.
But you need an understanding of what is going on, you need an approach that can help you deal with everything and fix it and you need support in making all these changes.
That’s why I created my program, the 5 Elements of Thyroid Health. It is 3 pronged approach that:
1. First, teaches you what is happening in your body,
2. Then we work with you to create an action plan to fix those problems, and
3. Finally, we also work on creating a lifestyle that will sustain and support those changes to give you the best chances for success.
(The European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) cosponsored the Rotterdam polycystic ovary syndrome (PCOS) consensus workshop to come up with the Rotterdam Criteria in 2004).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683210/ – Thyroid disorders in PCOS
http://www.ncbi.nlm.nih.gov/pubmed/24260593 – 2013 meta-analysis
http://www.ncbi.nlm.nih.gov/pubmed/21866332 – 2012 study
http://www.ncbi.nlm.nih.gov/pubmed/20638057 – poor response to treatment
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002408/ – Origins of PCOS
http://www.ncbi.nlm.nih.gov/pubmed/12477517 – Metformin treatment in PCOS
http://www.ncbi.nlm.nih.gov/pubmed/19654109 – High TSH leads to more insulin resistance
http://www.ncbi.nlm.nih.gov/pubmed/22553983 – PCOS and Chronic Inflammation
http://www.jofamericanscience.org/journals/am-sci/am0706/175_6025am0706_1156_1162.pdf – IL-6 and IL-15 elevated in hashimoto’s