Hey people,
I had a question recently from someone asking what foods can hamper thyroid hormone absorption. This is an important question, so I thought I’d take this opportunity to answer it.
The first thing to understand about thyroid hormone is that it behaves a little differently than many of it’s hormone cousins and binds quite easily to stuff.
Let me break it down for you:
The ability of a hormone to bind to a receptor inside or outside a cell depends on the chemical makeup of that hormone and how compatible it is to the cell’s fatty outer membrane.
Some hormones can go easily into cells to find receptors. For example, fat based steroid hormones like estrogen, progestins, etc. belong to this category. They prefer fatty surroundings (fat or lipid soluble) and they don’t like water.
As a result they can pass easily through the cell membrane, but they need proteins to help them through the watery bloodstream (these are the binding globulins that you may have heard of).
Receptors for these steroid hormones are found in several different places: the cells outer membrane, the cytoplasm and/or the nucleus inside the cell.
Other hormones stay outside the cell and attach to receptors found in the outer membrane. Insulin, growth hormone and other protein based peptide hormones prefer water (water soluble) and don’t like fat (fat insoluble).
The cell’s fatty membrane makes it difficult for these messengers to enter the cell. This keeps these peptide hormones outside the cell where they only bind with receptors found there.
Thyroid hormones, which are derived from amino acids, behave more like steroids than its peptide cousins and can actually bind to receptors both inside and outside the cell.
Which means they are very adaptable and flexible and it can also mean that they are able to bind to other things as well, like food, chemicals and minerals.
Many commonly used medications or supplements like iron, calcium, estrogen, proton pump inhibitors, and statins can cause affect thyroid hormone absorption or binding to plasma proteins.
Sometimes, if the doctor is paying attention, this may require making changes in dosage of levothyroxine. If you have been prescribed any of these drugs with your thyroid medication, you need to be aware of this.
Alcohol can disrupt thyroid function in a number of different ways. There are some indications that it may lower peripheral T4 and T3 levels.
In addition, it has a toxic effect on thyroid cells and ethanol is actually used to treat thyroid nodules in some cases. It can also, potentially, reduce the risk of certain types of thyroid cancer.
On the flip side, alcohol is very hard on the digestive tract and can also lead to destruction of the gut lining and make leaky gut worse.
I generally recommend avoiding alcohol, especially if you are trying to heal the gut.
Coffee also impacts the absorption of levothyroxine; this is why thyroid patients need to take their hormone replacement pill at least an hour before drinking coffee.
Caffeine found in coffee can also increase blood sugar levels . This is especially bad for people with hypoglycemia (or low sugar levels) because it can lead to complications.
For example, blood sugar fluctuations can cause cortisol spikes, which not only exhaust the adrenals, but also can wreak havoc on the immune system. Obviously, this is not a good thing for those of us with adrenal fatigue, and/or Hashimoto’s.
I recommend avoiding coffee if you have adrenal issues or hypoglycemia.
Black and green tea also has caffeine (though in lesser amounts than coffee), and it contains tannins which can hamper iron absorption and many teas also contain fluoride which blocks iodine absorption and may hamper thyroid function.
Green and Black tea are also Th2 stimulants. Drinking it in moderation may be ok for some and not good for others. If you drink a lot of tea, you may want to eliminate it for a period of time to see if it has an impact on your symptoms.
High doses of green tea have also been found to cause a significant decrease in serum T3 and T4 and increase in TSH levels has been reported along with decreased TPO and deiodinase activity in response to dietary green tea extract in rats.
There is ample evidence that gluten can lead to poor absorption of thyroid hormone. This is true for a couple of reasons; it can lead to destruction of the intestinal lining (which can hamper absorption), and it can cause systemic inflammation (which can clog receptors) This can lead to hypothyroidism and/or poor results from medication.
If you follow this page, you know I recommend eliminating gluten 100%. (For an in depth look at this read this post.)
Lactose has also been found to hamper thyroid hormone absorption. And casein, a protein found in milk is similar in protein structure to gluten and can also cause gluten like problems.
I also recommend eliminating dairy 100%. (Grass fed butter is one possible exception) (For an in depth look at this read this post.)
Soy is rich in phytoestrogens and affect levels of thyroid binding globulin (creating more of it). It can also hamper thyroid hormone absorption. Soy can also be goitrogenic in large quantities.
Soy protein and isoflavones doesn’t seem to harm people with sufficient levels of iodine, but it still may interfere with absorption of thyroid medication.
I generally recommend avoiding soy with the occasional exception of miso and fermented soy products like tempeh.
As mentioned above, the adrenals release cortisol to compensate for low blood sugar levels.
Cortisol directly inhibits the enzyme (5’-deiodinase) which converts inactive T4 into active T3. This can lead to low T3 levels.
In addition, elevated cortisol will cause thyroid hormone receptor insensitivity meaning that even if T3 levels are high enough, they may not be able to bind normally to receptor sites. And when this happens it doesn’t get into the cells.
Cortisol will also increase the production of reverse T3 (rT3) which is inactive. (It’s kind of like the anti-hormone.)
rT3 can cause an increase in the production of substances known as thyronamines that can cause hypothyroid symptoms (like, low basal body temperature,fatigue, depression, etc.) along with insulin resistance symptoms of increased blood sugar.
Cortisol can also lower the levels of protein that binds to thyroid hormone so it can circulate in a stable structure.
And finally, elevated cortisol will slow TSH production by messing with hypothalamic-pituitary feedback leading to lower TSH production.
Sugar should be treated as the addictive drug that it is. Use with extreme caution.
Processed foods tend to be high in both sodium, sugar and saturated fat. High sodium levels have been linked to autoimmunity and to thyroid disease. Sodium is important for getting iodide into thyroid cells.
Excess amounts of sodium can lead to higher amounts of iodine in the thyroid which can lead to a more aggressive autoimmune attack.
We have already discussed problems caused by low sugar. High blood sugar levels can lead to insulin resistance. This can also cause a reduced conversion of T4 to T3 hormones.
Eat real whole food. Processed food has little or no nutritional benefit. Don’t eat it.
Diets high in polyunsaturated fat caused significant thyroid dysfunction in rats. High triglycerides, decreased total T4 and free T4 levels and elevated TSH were all noted.
Naturally Found in found in legumes, plants, amiodarone, lithium, as well as cabbage, cauliflower, broccoli, turnip, forms of root cassava. These may reduce T4 absorption if iodine and/or selenium levels are low.
Generally, I think these foods have so many health benefits that they should be eaten. Goitrin is an active goitrogen present in plants of Rutabaga, turnip and Brassicae seeds.
Steam or blanch the vegetables as cooking destroys the enzyme responsible for activation of progoitrin to goitrin thus negating its anti-thyroid effects.
So, eat these vegetables, but don’t eat wheel barrels’ full. Normal moderate amounts are fine, in my opinion.
This common gluten free ingredient contains C-glycosylflavones which may inhibit TPO activity. Be cautious with millet. In moderate amounts it is probably ok.
Pesticides can lead to decreased half life of T4.
BPA (bisphenol-A) has been found to be an endocrine disruptor and may have direct action on thyroid receptors.
Percolates found in rocket fuel, thiocyanates and nitrates interfere with iodine uptake. A study in California on pregnant women found a strong association between urinary percolate levels and decreased total and free T4 and increased TSH.
Heavy metals like cadmium and lead are also known to affect thyroid function. In a study on pregnant women, those from lead exposed town had lower mean free thyroxine (FT4), higher mean TPO antibodies along with higher lead concentration suggesting stimulation of auto-immunity by prolonged lead exposure.
As you can see, there are many things that can bind to thyroid hormone both natural and chemical. All must be considered when deciding on dosage and when trying to improve thyroid hormone function in the body.
https://www.ncbi.nlm.nih.gov/pubmed/25040647 Drugs and thyroid hormone interactions
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743356/ Alcohol and the thyroid axis
https://www.ncbi.nlm.nih.gov/pubmed/9846599 Affects of caffeine on glucose levels
http://www.thyroid.org/patient-thyroid-information/ct-for-patients/vol-5-issue-6/vol-5-issue-6-p-3-4/ Gluten, celiac and thyroid hormone absorption.
https://www.ncbi.nlm.nih.gov/pubmed/16571087 Soy and Thyroid hormone absorption
https://www.ncbi.nlm.nih.gov/pubmed/15642784 Sodium and thyroid hormone
https://www.ncbi.nlm.nih.gov/pubmed/20561943 Green tea and thyroid function
in rats
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220075/ Fat and rats
https://www.ncbi.nlm.nih.gov/pubmed/26485730 California Percolate study
https://www.ncbi.nlm.nih.gov/pubmed/24866691 Lead exposure and thyroid function
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740614/#b52 Possible Toxicants Involved in thyroid dysfunction
As many of you know, all I do is treat Hashimoto’s and over the last 4 years I have worked and spoken with over 2,000 people with Hashimoto’s.
Most of these conversations have happened during my consultations. In these, people share with me their struggles and I offer advice that helps them right away.
By far, the most common theme of these conversations is that they have normal lab results (this usually means TSH and T4 – to learn more about what are better tests to order read this post) and yet they have all the common hypothyroid symptoms.
In other words, they are fatigued, they have brain fog and memory issues, their hair is falling out, the may have depression, constipation, difficulty sleeping and muscle weakness or joint pain and more.
While researchers sometimes claim that this is rare, clinical experience and empirical data prove otherwise. I put this question to my Facebook support group on 2 occasions and over 300 people responded that they have some or all of the symptoms above and “normal” lab test results.
This situation isn’t rare, it’s very common.
And the vast majority of these people are taking some type of thyroid replacement hormone. The prescriptions vary from Synthroid to Armour to Levothyroxine and sometimes there’s some Cytomel thrown in or they’re taking Naturethroid or Tyrosint.
But often, regardless of the prescription or the dosage, they still have all the hypothyroid symptoms. And some people are over-medicated so they have hyper symptoms, as well. Like, palpitations, insomnia, tachycardia, anxiety, etc.
And after a while you have to ask: What is going on here?
It’s the same story over and over again. The medications are different, the constellation of symptoms are different, but the basic pattern is the same.
People are getting plenty of thyroid hormone, but it’s not getting into their cells and having the effect it is supposed to.
If it were, they’d have no hypothyroid symptoms. But virtually everyone does have hypothyroid symptoms.
In this post we examine why thyroid hormone conversion doesn’t happen the way it’s supposed to and what to do about it.
Let’s Review the Physiology
First of all, let’s look at basic physiology. In the body, normally, the thyroid is signaled by the pituitary with TSH (Thyroid Stimulating Hormone). The purpose of this is to goose the thyroid into producing more thyroid hormone.
This occurs because of signals from the body that it needs more. If it’s cold or you need your heart rate to increase, or your metabolism to rev up or you needs to get things moving for sex, etc.
When this happens the thyroid releases T4 (about 97%) and a little bit of T3 (do the math – yup, 3%).
And this is the basic premise of thyroid replacement hormones like Synthroid. It’s synthetic T4. The theory is that you just give it to the patient and tell them to call you in 6 months. An everything should be hunky dory.
And the reason it doesn’t work is that thyroid hormone must be converted from T4 into T3 in order for the body to utilize it. This conversion happens differently in different parts of the body.
The problem with TSH only testing to determine thyroid hormone levels in the entire body is that the pituitary, which releases TSH, converts thyroid hormone differently than the rest of the body.
This is why you often see normal TSH with lots of hypothyroid symptoms.
Many doctors, somehow, are ignorant of this fact and instead of truly understanding what is happening physiologically, blame the patient for having symptoms when their lab tests say that they should be fine.
There is an enzyme that is largely responsible for thyroid hormone conversion. It is called 5′ deodinase. And it actually comes in 3 forms: deodinase type I (D1), deodinase type II (D2)and deodinase type III (D3).
D1 converts inactive T4 to active T3 throughout the body. In the pituitary, D2 controls this conversion. These two forms behave very differently and are affected by different things.
D1 is suppressed and down-regulated (which means it decreases T4 to T3 conversion and increases reverse T3 levels) in response to stress (both physiologic and emotional), depression, dieting, weight gain and leptin resistance, insulin resistance, obesity and diabetes, inflammation from autoimmune disease or systemic illness, chronic fatigue syndrome and fibromyalgia, chronic pain, and exposure to toxins and plastics.
What did we just describe? Your average Hashimoto’s patient living in the modern world! Most people with Hashimoto’s have the majority of conditions mentioned above.
In addition, D1 activity is also lower in females, making women more prone to tissue or functional hypothyroidism.
Sound familiar? Normal lab results but hypothyroidism at the cellular level.
And when you have these conditions, there are reduced tissue levels of active thyroid hormone in all tissues except the pituitary because D2 does not behave like this, at all.
D2 is 1,000 times more efficient at converting T4 to T3 than D1 in the rest of the body. And it isn’t suppressed and down regulated by any of the things we mentioned.
So TSH is within normal range because the pituitary is getting plenty of thyroid hormone, but the rest of the body is hurtin’ for certain.
D3 converts T4 into reverse T3. There is none of it in the pituitary. D3 also competes with D1. T4 can go either way. It can be converted to T3 which the body can use or into reverse T3 which is not active.
And reverse T3 blocks the effect of T3. It blocks T3 from binding to receptors and when this happens it doesn’t work. So your metabolism slows, and D1 is suppressed so it can’t do it’s job and convert T3 to T4. And D3 blocks T3 and T4 from getting absorbed into cells.
So the result is you have low T3 levels in the cells of your body and you get all the hypothyroid symptoms.
Like most things related to Hashimoto’s the solution is not simple and it requires a multi-prong approach.
As I have said and written many times, Hashimoto’s is way more than a thyroid problem and way more than a thyroid and autoimmune problem. It is a multi-system disorder that can only be healed using a multi-system approach.
Nowhere is this more evident than in trying to fix poor thyroid hormone conversion.
There are 5 important areas that need to be assessed and addressed if you want better conversion of T4 to T3.
Let’s break it down:
1. Liver Detoxification and Other Metabolic Pathways
2. Increasing T3 and Lowering Reverse T3 Levels
3. The Gut and Thyroid Hormone Conversion
4. Adrenal Stress Can Cause Lower T3 and Higher Reverse T3
5. Systemic Inflammation Lowers T3
And as a bonus we’ll look at key nutrients that support better thyroid hormone conversion.
In the liver D1 is involved in converting T4 into T3 and selenium is an important part of this process. Reverse T3 is also broken down there.
So having enough selenium is essential. (It is recommend to take from 200 to 400 mcg. (micrograms) per day. Make sure you do not take selenium supplements that contain dairy or gluten based fillers.)
Other important factors that can prevent T4 to T3 conversion include stress (both emotional and physiological), poor nutrition, chronic illness and exposure to heavy metals like cadmium, mercury and lead.
Another important factor is lipid peroxidation and antioxidants in the liver. One of the most important in helping the body deal with the damage caused by these heavy metals and to nourish antioxidant enzyme systems is glutathione.
The best form to take orally is S-Acetyl-L-Glutathione. It can also be taken in liposomal cream form or in an IV.
In addition, there are 2 metabolic pathways in the liver that can have an impact on thyroid hormones. One such pathway is the glucoronidation pathway. This pathway is supported by B vitamins, magnesium, and glysine.
The second is sulfation. Sulfation involves binding things partially broken down in the liver with sulfur containing compounds. It is one of the major detoxification pathways for neurotransmitters, toxins, and hormones (like thyroid hormones).
Vitamin B6 and magnesium are important for sulfur amino acid metabolism, as are foods containing sulfur such as: eggs, meat, poultry, nuts and legumes. (Eggs, nuts and legumes might be a problem if you are on the Autoimmune diet.)
Lowering reverse T3 levels and increasing T3 levels is not a simple thing. There are so many variables and other factors that may hinder this process that it’s hard to offer general things that will help.
To really do this properly, one must be tested, evaluated and treated according to what results, symptoms and patterns present themselves.
That being said, let’s look at some general things that may help.
Glucoronidation, mentioned above, has been shown to degrade reverse T3.
The addition of T3 to your thyroid replacement hormone regimen may also be helpful. There are those in the thyroid community that strongly advocate T3 only treatment. Some suggest doing with natural cortisol rhythms, some with time released T3 and others with slow and deliberate increases in T3 therapy.
This may or may not work and what they fail to say is that T3 can also be toxic to the liver in high doses. Again, proper assessment and treatment is required to determine if this course of action is a good idea for you.
Elevations in cortisol, catecholamines, and some cytokines (IL-6, TNF-a, and IFN-a), and low serum albumin levels have also been associated with low T3 syndrome.
Gut bacteria is important for converting T4 into T3.
About 20 percent of T4 is converted to T3 in the GI tract, in the forms of T3 sulfate (T3S) and triidothyroacetic acid (T3AC). The conversion of T3S and T3AC into active T3 requires an enzyme called intestinal sulfatase.
Intestinal sulfatase comes from healthy gut bacteria. (Sulfur is an important nutrient for this, as well).
When you have an imbalance between good and bad bacteria in the gut, this may significantly reduce the conversion of T3S and T3AC to T3. This is one reason why people with poor gut function may have thyroid symptoms but normal lab results.
Inflammation in the gut also reduces T3 by raising cortisol. Cortisol decreases active T3 levels while increasing levels of inactive T3.
Studies have also shown that cell walls of intestinal bacteria, called lipopolysaccharides (LPS), negatively effect thyroid metabolism in several important ways.
LPS:
• reduce thyroid hormone levels;
• dull thyroid hormone receptor sites;
• increase amounts of reverse T3;
• decrease TSH; and
• promote autoimmune thyroid disease (AITD).
With stress, cortisol levels often go up. The increased cortisol levels contribute to this disconnect in the body between the TSH and peripheral tissue T3 levels.
Stress reduces T3 levels in the tissues and increases reverse T3 and this results in tissue hypothyroidism and potential weight gain, fatigue, and depression.
This vicious cycle of weight gain, fatigue, and depression that is associated with stress may be prevented with supplementation with timed-released T3 according to some studies.
The reduced immunity from chronic stress has also been thought to be due to excess cortisol production; but the associated reduction in tissue thyroid levels are shown to play a larger role in the decreased immunity seen with stress.
As with stress, treatment with prednisone or other glucocorticoid will suppress D1 and stimulate D3, reducing T4 to T3 conversion and increasing T4 to reverse T3, causing a relative tissue hypothyroidism that is not detected by TSH testing.
This low cellular thyroid level certainly contributes to the weight gain and other associated side-effects with such treatment. Thus, in stressed patients or those treated with corticosteroids, there are reduced tissue T3 levels that are not reflected by the TSH level, making the TSH an inappropriate marker for tissue levels of T3.
So making sure that you have proper levels of DHEA and cortisol is very important.
As is changing the things in your life that cause you stress. With Hashimoto’s we have emptied our stress savings accounts. We have so much physiologic stress that added emotional stress is incredibly destructive. And one area, in particular, is in the impact of stress on tissue levels of T3.
Hashimoto’s is, at it’s root, a disease of inflammation. And research has found that the inflammatory immune cells (cytokines) and proteins like IL-1, Il-6, C-reactive protein (CRP), and TNF-alpha will significantly decrease D1 activity and reduce tissue T3 levels. Any person with an inflammatory condition – Hashimoto’s – will have a decreased T4 to T3 conversion in the body and a relative tissue hypothyroidism.
These immune proteins will, however, increase the activity of D2 and suppress the TSH despite reduced peripheral T3 levels; again, making a normal TSH an unreliable indicator of normal tissue thyroid levels.
There is also a direct inverse correlation between CRP and reduced tissue T3, so individuals with elevated CRP (greater than 3 mg/l) or other inflammatory cytokines may have a significant reduction in cellular T3 levels.
The suppression of T3 levels inside the cells is linked with the degree of elevation of CRP, despite serum thyroid tests being “normal”.
So, if any inflammation is present, the body will have lower T3 levels in the cells and this can impact function; but the pituitary will have increased levels of T3, resulting in a lowering of the TSH so that, once again test results appear normal. (Have I made this point enough times?)
This really emphasizes the importance of anti-inflammatory strategies to improve T3 levels in the tissues. Anti-inflammatories like Turmeric, ginger, resveratrol, glutathione, and Vitamin D are all helpful.
Sometimes these are needed in rather high dosages.
Eliminating foods that cause inflammation is also absolutely critical: gluten, dairy, soy, sugar, alcohol, processed foods, pesticides and chemical additives should all be strictly eliminated.
The Autoimmune Paleo approach is an excellent diet for reducing systemic inflammation and increasing tissue T3 levels.
Commiphora muku guggulu (Myrrh resin) Guggul produces a resinous sap known as gum guggul. The extract of this gum, called gugulipid, guggulipid or guglipid, has been used in Ayurvedic medicine, a for nearly 3,000 years in India. The active ingredient in the extract is the steroid guggulsterone. This has been shown to stimulate healthy synthesis of T3.
Selenium is a major cofactor for the enzyme 5′ deiodinase which is responsible for converting T4 into T3 as well as degrading reverse T3.
Low zinc status has been shown to compromise T3 production. Zinc can improve thyroid hormone production and play a role in reducing antibodies.
Lipid peroxidation and antioxidant enzyme systems have been shown to play a profound role peripheral thyroid hormone conversion. Glutathione is extremely effective in supporting peroxidation.
Lastly, it is essential to work with someone who understands the complexity of this situation and who can evaluate what is going on properly and who can determine which course of action and combination of things may be best for you.
http://nahypothyroidism.org/deiodinases/
http://www.aaqm.org/Downloads/doc-qmuAUG08.pdf
http://www.chiro.org/nutrition/FULL/Peripheral_Metabolism_of_Thyroid.html
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This pill may not be the answer.
Some of the most common questions I receive via phone, email, Facebook, and yelled across the street concern thyroid replacement hormone.
The question usually goes something like, “Hey, what’s the best thyroid hormone?”
And like most things with Hashimoto’s, this is a super difficult, complicated question disguised as a simple one.
All I can do is mumble, “It depends”
In addition, the problem is that, in reality, many, many people don’t feel better after taking thyroid replacement hormone.
Or they feel better for a while, then they feel worse again.
And a lot of Hashimoto’s patients get fixated on this drug.
Some have to change to natural desiccated. Some are told they have to get on a synthetic. Others have to add T3 or only be on T3. Or they have to raise the dosage, then lower it, then change to something else.
And doctors also share this fixation because thyroid hormone is really important physiologically and for most, thyroid replacement hormone is the only tool in their tool box. And many refuse to budge from the myth that synthetic T4 is the only safe option.
So we wind up with dueling and intractable obsessions resulting in people being pissed off at their doctors, doctors refusing to prescribe anything except Synthroid or the generic equivalent and, unfortunately for the patient, little or no improvement in their hypothyroid symptoms.
There has got to be a better way.
In this post, we will look past this obsession and help break down and demystify thyroid replacement hormone.
The first question, and one that is controversial, is do you really need to be on thyroid replacement hormone?
This is an important question and, of course, the answer is….(wait for it)…it depends.
On what?
Really, it depends on how much thyroid function you have left.
Hashimoto’s is an autoimmune disease in which your immune system slowly destroys your thyroid.
If enough of your thyroid gets destroyed and it stops producing sufficient amounts of thyroid hormone, you can not be without replacement hormone. End of conversation.
On the other hand, if you do have enough thyroid function (and a lot of people do), then the problem may lie elsewhere.
Often the problem is an out of control immune system impacting thyroid function or problems with breakdowns in thyroid pathways that are causing the hypothyroidism.
It’s not the lack of thyroid replacement hormone.
If you focus on properly managing the autoimmune disease part of the equation and on properly evaluating and improving the pathways that make thyroid hormone work, then you may not need extra thyroid hormone at all.
(To complicate matters, once you start taking replacement hormone it impacts the amount of thyroid hormone your body is producing.
So if you have been on it for many years, chances are you may have compromised the thyroid’s ability to produce it alone.)
Even when thyroid hormone replacement is used, it is still very important to manage the autoimmune condition.
This will make the medication work better, slow the destruction of the thyroid gland, and prevent the progression of the autoimmune condition into attacks on other parts of the body like the brain, which comes in really handy, at times.
This is where we should really be fixated. Slowing or stopping the progression of the autoimmune part of this disease should be our obsession. (Ok, I admit it, it’s mine.)
Let’s Look At The Options
That being said, let’s take a look at what the options are and how you can make the best decision for you and your unique set of circumstances.
First there are 2 important factors to consider:
* Bio-identical versus Synthetic
* T3
Bio-identical Versus Synthetic
Bio-identical, as the name suggests, is more like what your body actually produces. The most popular of these are Armour or Nature-throid. The advantage to these is that we can actually test their levels in your system using laboratory testing other than TSH.
The disadvantage is that some people with Hashimoto’s will feel worse on these because their immune system can attack T3 and T4 because they actually have antibodies against them.
Unfortunately, we do not yet have laboratory tests available to test these antibodies.
The advantage of synthetic drugs like Synthroid and levothyroxine is that they are synthetic and the immune system will not attack them.
The disadvantage is that TSH is the only test to measure levels of these drugs and there are many reasons why TSH is an unreliable marker of thyroid hormone levels.
The criticism by doctors leveled against bio-identical hormones is that the dosage varies from batch to batch. A frequently perpetuated myth (from the marketers of Synthroid) is that the dosages and ratio of T4:T3 in Armour aren’t consistent.
That’s just not true, studies have shown otherwise. Armour contains a consistent dose of 38 mcg T4 and 9 mcg T3 in a ratio of 4.22:1. As does Nature-throid.
T3 to the Rescue
Many patient advocates and thyroid support groups sing the praises of T3. And for some, there is no question, T3 is the answer. For others, it’s a nightmare.
T3 is the active form of thyroid hormone, this is what has the greatest impact on our bodies. This is what gives you energy, gets the bowels moving, makes you feel happier and helps you think more clearly. For some this is what helps their hair grow better and their skin get that blood flow back into it.
These people may have trouble converting T4 to T3 because their cells develop thyroid hormone resistance.
On the other side of this are the people who get hyperthyroid with the addition of T3. Think anxiety, insomnia, palpitations, weirdness, a strong desire to vacation at the funny farm.
This is also the case with people who are not managing the autoimmune part of this disease. The attacks against the thyroid causes more thyroid hormone to be released into the bloodstream.
For these people, synthetic T4 might be the better choice along with a concerted focus on managing the causes of these inflammatory incidents (like eliminating gluten, dairy, soy, stress and environmental toxins).
2 Common Things Make You Feel Worse
There are also 2 important factors that can make you feel much worse on thyroid replacement hormone:
Fillers and Adrenal Issues.
Fillers: These are extra things added to the drugs by the manufacturers. Many popular thyroid medications contain common allergens such as cornstarch, lactose and, in some cases, even gluten.
Most Hashimoto’s patients have issues with gluten, and many of them also react to corn and dairy (which contains lactose).
Synthroid has both cornstarch and lactose as a filler. Cytomel, which is a popular synthetic T3 hormone, has modified food starch – which contains gluten – as a filler.
Even the natural porcine products like Armour use fillers. In 2008, the manufacturers of Armour reformulated the product, reducing the amount of dextrose & increasing the amount of methylcellulose in the filler.
This was great for some patients who were sensitive to dextrose and a disaster for others who were sensitive to the methylcellulose.
Nature-throid is considered the most hypo-allergenic of the bio-identicals.
The best choice may be to ask your doctor to have a compounding pharmacy fill the prescription using fillers you aren’t sensitive to. This can be more expensive and unfortunately, some insurance companies refuse to cover it.
Adrenal Issues: If you take Synthroid or even a bio-identical and feel so horrible on the drug that you just can’t continue taking it, one thing to check right away is your adrenals.
The warning label of Synthroid states explicity “Patients with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation of treatment with levothyroxine sodium.”
This can cause an acute adrenal crisis in the most extreme cases.
But even in less extreme cases, like those people who have adrenal fatigue and/or exhaustion, taking this drug can result in the patient feeling really lousy.
The adrenals should always be evaluated whenever a patient is prescribed thyroid replacement hormone. (Ideally, this should happen before it is prescribed. Good luck with that.)
Let’s take a look at some other common clinical situations and look at why these things happen.
Normal TSH, But Still Feel Like Crap
This is by far the most common scenario for people with Hashimoto’s. Chronic inflammation can prevent thyroid hormone from getting absorbed in to the cells of the body. This the root of autoimmune disease, but can also come from other things (like infections, surgery, obesity, overtraining, poor diet, etc.).
This can:
*Inhibit thyroid receptors on cells from responding to thyroid hormone.
*Prevent T4 from converting to T3.
*Interfere with the communication between the pituitary and the thyroid (and the adrenals).
Felt Better With Bio-Identical
Some people truly do feel better with bio-identicals. It’s not true of everyone but the addition of T3 can sometimes be the answer because these people:
*May need T3 due to problems with the thyroid hormone receptors on cells
* Were unable to convert T4 to T3 when using T4-only medication
*Had sensitivities to dyes or fillers in synthetic compounds that are not in bio-identical compounds
*Have receptor sites on cells that simply respond better to bio-identical than synthetic hormones
Did Better With T3 Only
As we have seen, some people improve with the addition of T3, while others do their best with T3 only. And these can be synthetic or bio-identical.
This can happen for a couple of reasons:
* Their receptor sites are resistant to thyroid hormone because of high cortisol, high homocysteine, inflammation, low progesterone, vitamin A deficiency and more.
* Difficulty in converting T4 to T3
Didn’t Feel Better With T3 or Bio-identical Hormones
In both cases, more T3 is introduced. These people often don’t have too little T3, they have an active and uncontrolled autoimmune process causing the release of thyroid hormone.
These are also the people who often vacillate from hyper to hypo. They have an immune flare up, more hormone is released and then they crash, it calms done and they are hypo again.
In some cases, these people can have excess adrenal hormones caused by too much nicotine, caffeine, stress or exercising too much.
Feel Better on Synthetic Hormones
Some people actually feel better on synthetic hormones. These can be people who are converting well, have an overactive metabolism and just don’t need more T3.
These are people who also really benefit from an approach that will calm the autoimmune attacks that cause their thyroid to be revved up in the first place.
In every single case described above addressing the underlying autoimmune process first will result in a better clinical outcome (you will feel better) because by reducing the inflammation which is the root of this problem you can:
Improve thyroid receptor site sensitivity
Prevent further destruction of the thyroid
Slow the progression of the autoimmune disease so it doesn’t spread to other parts of the body.
Once again, there are so many variables with Hashimoto’s. The best approach involves a full thyroid work-up and exam, followed by trial and error of different types of replacement medications.
Such a work-up includes more than just TSH, it also has a more complete thyroid panel (including antibodies), other important blood markers (glucose, lipids, CBC with diff, electrolytes, iron, etc.) and additional inflammatory markers like homocysteine, vitamin D, CRP, ferritin, etc.
A history must be taken with attention paid to the patient’s past responses to replacement hormones. With Hashimoto’s patients what a patient feels is clinically relevant and diagnostically important.
Unfortunately, this rarely happens in the conventional model, where the standard of care is to test only for TSH and, if you’re lucky T4.
If TSH is elevated, the patient will get whatever hormone that particular doctor or practitioner is fond of prescribing and that’s the end of it.
Then they are told, “Come back in 6 months to a year and get your TSH tested again. Buh bye.”
And all too often, as many of you know, this approach is doomed to failure. But there is a better way and we are practicing it here at Hashimoto’s Healing.
We offer a complete work up and we focus…, ok, I’ll say it…rather obsessively on reducing the inflammation at the root of this disease and at doing other things to calm, slow and prevent the advancement of autoimmunity to other parts of your body.
This is not just a thyroid problem and there is a lot at stake here. If we’re going to be obsessive, let’s obsess about the things that are at the root of the problem.
I set aside time every week to talk to people with Hashimoto’s about what’s going on with them. In the last year, I have had over 500 of these conversations.
I offer a free 30 minute Hashimoto’s Healing Discovery Session.
In it you can share where you are and where you want to be, I can give you some advice that will help right away and we can discuss how else I may be able to get you feeling better.
If you want to talk with someone who gets it, someone who has been there and who has devoted his life to help people with Hashimoto’s, then I suggest you schedule a time to chat with me.
You might just learn something. Here’s the link to schedule.
http://www.ncbi.nlm.nih.gov/pubmed/23072197 T3 to T4 ratios
http://www.womensinternational.com/pdf/thyroid_hormone_therapy_options.pdf T3 to T4 ratios
http://www.medscape.com/viewarticle/722086_1 Full on medical discussion
http://www.ncbi.nlm.nih.gov/pubmed/15767619 Interesting study on the difference additional T3 therapy makes
http://chriskresser.com/3-steps-to-choosing-the-right-thyroid-hormone
http://thyroidbook.com/blog/which-thyroid-hormone-is-right-for-you/
http://www.rxlist.com/synthroid-drug.htm
http://www.rxlist.com/armour-thyroid-drug.htm
http://www.rxlist.com/cytomel-drug.htm
http://www.nature-throid.com/what_is_nature_throid.php
http://tpauk.com/main/?page_id=1054 Argument against marketing propaganda
The Thyroid, A Fundamental and Clinical Text, Braverman and Utiger, 9th Edition, 2005
Why Do I Still Have Thyroid Symptoms When My Lab Tests Are Normal? Dr. Datis Kharrzian, Elephant Printing 2010
Today’s health tip is about thyroid hormone resistance. This is a common cause of feeling like crap because when this happens in your body, the cells aren’t absorbing and utilizing thyroid hormone.
So you might be taking thyroid hormone and your lab work might all look great, but you still feel like they just scraped you off the tires of a Greyhound bus.
It’s as if thyroid hormone is knocking on the cell’s door and the cells are saying,
“I hear you knocking but you cain’t come in.”
“Please let me in? Please, please, please, please?” says thyroid hormone.
“I’d like to, really I would, but no.” answers the cells.
What is their problem?
Well, there are lots of possible reasons for this. Let’s focus on 1 today:
Inflammation suppresses the hypothalamic-Pituitary-Thyroid axis, by reducing the body’s available stores of TSH , T4, and T3.
The pituitary/hypothalamus also regulates many other hormones, including sex hormones; therefore, taking thyroid hormone medication may help some symptoms of hypothyroidism, but will not help all symptoms (since the hormone supplementation does not do anything if the cause is the pituitary or hypothalamus).
Inflammation can also reduce the number and sensitivity of thyroid hormone receptors throughout the body. All thyroid hormone (in the form of T3) has to be able to get into the body’s cells in order to have an effect;
if there are not enough cells, or they are not sensitive enough, it doesn’t matter how many thyroid meds you take.
Inflammation also decreases conversion of T4 to T3. Ninety percent of the thyroid hormone produced by the body is in the form of T4, but much of that has to be converted into T3 to be used.
Which is why T4 thyroid medications are not a great idea–you may end up taking more and more, and you’ll definitely get _effects_ from them, but not necessarily the benefits that your body would receive if it were able to convert T4 into T3 and utilize it to begin with.
Basically: Hashimoto’s is an inflammatory condition, and you must address inflammation in order to heal.
This begs the question: How do we address inflammation?
By any means necessary, if you have Hashimoto’s this should be your job, hobby, passion and obsession 24/7, 365.
Here are some things you can do:
1. Optimize vitamin D levels in the blood via supplementation with D3. Inflammation inhibits the body’s ability to convert Vit. D from the sun, and of course in people with Hashimoto’s, inflammation is everywhere.
2. Get to know and love glutathione, since this helps prevent oxidative damage. Autoimmunity and stress depletes the body’s stores of glutathione. (This can be challenging and there’s more to this than simple supplementation…more on this to come.)
3. Fatty acid balance is also very important. Omega-six fats promote inflammation, and omega-3 fats are anti-inflammatory. The best way to get omega-3s is to eat a lb. of fatty fish (salmon, makerel, sardines, halibut, herring) per week.
Of course, you have to weight this with all the chemical toxins in fish. Smaller fish like sardines, generally have less.
At the risk of sounding like a broken record, let me repeat. Reducing inflammation is key for overall healing. And STRESS AND LEAKY GUT are also the all stars of the Professional Inflammation League (The P.I.L.).
People who find the most success in healing their healing their Hashimoto’s are the ones who deal with both of these things.
Leaky gut is to inflammation what money is to politicians. It’s a license to ill, people.
And a lot of people don’t really take the impact that stress has on their health seriously. For people with autoimmune disease, research has shown that over 80% experienced a very stressful event prior to its onset.
http://www.ncbi.nlm.nih.gov/pubmed/18190880
Hashimoto’s is one of the most common autoimmune diseases in the US. It is routinely undiagnosed or under-diagnosed and when it is treated, the gold standard of treatment is to give patients Synthroid or Levothyroxine (Synthetic T4).
To monitor whether or not this is working most doctors periodically test TSH.
This approach often does not work and, more importantly, millions of women and men with Hashimoto’s who are being treated this way do not feel any better, or feel better for a period of time, then end up feeling really lousy.
They wind up feeling all the symptoms of hypothyroidism like being tired all the time, they can’t lose weight, they have lots of joint and muscle pain, they suffer from brain fog, anxiety and depression, their hair falls out, they feel cold, they have no sex drive and their lives become miserable.
And many of them have blood test results that look normal.
In this post I will examine why TSH is not a good measure of whether or not thyroid hormone is absorbed by the cells of the body and discuss some better alternatives to testing, supplementation and monitoring of whether or not a given approach is working.
How Does Thyroid Hormone Work in The Body?
Before we look at how most people are treated, it’s important to understand how thyroid hormone works in the body.
TSH is thyroid stimulating hormone. This is released by the pituitary gland to stimulate the thyroid so that more thyroid peroxidase (an enzyme) is made. This enzyme combines with iodine to make thyroid hormone, T4 and T3. About 97% is T4 and 3% is T3.
The body can’t really use T4, so it has to convert this into T3 which is the form that the cells of the body can use to do stuff. 60% of T4 is converted by cells in the liver, another 20% by cells in the gut and the remaining 20 or so % is converted by cells in the peripheral tissues of the body (muscles, fat, etc.)
Why Is Synthroid (Levothyroxine) Sold As The Answer?
Because most of the hormone that is made in the thyroid is T4, the logic is that for those with Hashimoto’s (an autoimmune disease that slowly destroys the thyroid) and hypothyroidism (low thyroid activity) giving a synthetic form of T4 such as Synthroid or Levothyroxine will replace what the body is not doing for itself.
Then, theoretically, the rest of the process will happen as it should – the liver will do it’s thing, the gut will do it’s thing, and the rest of the peripheral tissues will do what they are supposed to do.
Oh, if it were only as simple as that!
Many Things Hinder the Conversion of T4 to T3
There are many, many factors that can cause problems all along the way in getting this synthetic hormone into a form that the body can use and, getting the tissues of the body to effectively absorb it.
And for millions of people, this process just does not work. This is because there are so many things that disrupt thyroid hormone’s ability get into cells, these include: dieting, anxiety, stress, insulin resistance, obesity, diabetes, depression and bipolar disorder, high cholesterol and triglycerides, chronic fatigue syndrome, fibromyalgia, neurodegenerative diseases (Alzheimer’s, Parkinson’s and multiple sclerosis), migraines, cardiomyopathy, and aging.
(Here’s a really interesting graph that shows how this works.)
Testing TSH, T3 and T4 Doesn’t Measure Thyroid Hormone In The Cells
What most doctors learn in medical school is that testing TSH and total T3 and total T4 will tell you how the thyroid is functioning or how well thyroid hormone replacement is working.
This is just not true. This false idea is based on assumptions about how thyroid hormone gets into the cells of the body. In the old, out dated theory, it is thought that thyroid hormone simples diffuses or is absorbed like soda from a straw into the hungry mouths of eager cells.
More recent research has shown that its not diffusion at all, but rather active transport that requires energy from the cells to get the hormone in. What this means is that anything that compromises energy production in the cells (mitochondria make energy in the cell – so things that mess with the mitochondria) will cause less thyroid hormones to get into cells.
These include all of the list of conditions mentioned above and stress is one of the most profound blockers of this process.
In addition, the different thyroid hormones require different amounts of energy to get into the cells. For example, T4 takes more energy to get into cells than T3. (This is why many people do better on T3 only supplementation or combinations of hormones that combine T3 and T4.)
So if you have any or some combination of these conditions: dieting, anxiety, stress, insulin resistance, obesity, diabetes, depression and bipolar disorder, high cholesterol and triglycerides, chronic fatigue syndrome, fibromyalgia, neurodegenerative diseases (Alzheimer’s, Parkinson’s and multiple sclerosis), migraines, cardiomyopathy, and/or aging, and you are taking T4 only, you are going to have a very hard time getting that into the cells of your body.
Almost Everybody Has This Problem
That pretty much covers most of the population on thyroid replacement hormones.
This is important because T4 has to get into cells to be converted. What’s also interesting is that measuring serum T4 (T4 in the blood) won’t tell you anything about how much of it is getting into the cells. Instead, you have to measure Reverse T3 and free T3 levels and measure their ratio. (More on this in a moment).
This is also why some people have normal numbers but still have lots of hypothyroid symptoms (fatigue, hair loss, joint pain, brain fog, constipation, depression, low libido, etc.) even though their lab results are normal.
They have low T4 levels in their cells and more in their serum. So everything looks hunky dory, but they feel terrible. TSH testing will not pick up this problem because TSH is produced in the pituitary and this gland absorbs thyroid hormone very differently than the rest of the body.
The Pituitary Not the Thyroid Determines TSH Levels
The pituitary is much more sensitive to thyroid hormones and transports thyroid hormone differently than all other cells in the body.
In the pituitary, thyroid hormone does not depend on energy to get into the cells. The transporters for T4 and T3 in the pituitary are also not inhibited by numerous environmental toxins and substances produced by the body during physiologic stress and dieting, things that inhibit thyroid transport into other cells in the body, including bilirubin and fatty acids.
In other words, all of the stuff that prevents the cells in the rest of the body, do not affect the absorption of T3 and T4 in the pituitary. So TSH does not reflect the hypothyroid state in the rest of the body and is really only a good measure of thyroid hormone IN THE PITUITARY.
Thyroid hormone is absorbed into the cells of the liver differently than it is by the cells of the pituitary. This is really important to understand and most doctors and endocrinologists do not know this. Since 60% of T4 is converted in the liver, this makes a huge difference.
Why Dieting Can Make Thyroid Hormone Less Available
Many overweight people with Hashimoto’s try to lose weight and are just not able to. This has lead to a huge industry of weight loss drugs, products and procedures.
But what many people do not understand is that the reason that weight loss may be so difficult for these people is that the very process of trying to lose weight may be preventing them from being able to absorb thyroid hormone into their cells.
This creates a vicious cycle of dieting, yo-yo weight loss and gain and miserable results. And all those things actually create a state of a slower, more sluggish metabolism that all but dooms them to failure.
If thyroid hormone is not being absorbed by the cells, then you have a state of cellular hypothyroidism and your body slows down and does not lose weight. And this state of poor cellular absorption of thyroid hormone is not seen in laboratory results unless free T3 and Reverse T3 levels are done.
A very interesting study published in the American Journal of Physiology-Endocrinology and Metabolism, Van der Heyden et al studied the effect of dieting on the transport of T4 and T3 into the cell.
It was found that dieting obese individuals had a 50% reduction of T4 into the cell and a 25% reduction of T3 into the cell due to less energy in their cells, showing that in such patients standard thyroid blood tests are not good indicators of thyroid hormone levels inside the cells.
This also demonstrates why it is very difficult for obese patients to lose weight; as calories are decreased, metabolism drops.
This will, however, not be detected by standard TSH, T4 and T3 testing. In addition, there are increased levels of free fatty acids in the blood with chronic dieting, which further suppresses T4 absorption into the cells and this causes more cellular hypothyroidism.
How You Feel Is More Important Than What Your Lab Tests Say
Another interesting study published in the Journal of Clinical Endocrinology and Metabolism, by Zulewski et al clearly shows that TSH is not a useful measure of proper thyroid replacement because there was no connection between TSH and tissue thyroid levels.
Levels of T3 and T4 were better, and T3 was the best indicator. However, a thorough assessment of how patients felt determined by how many signs and symptoms of hypothyroidism they had (i.e. weight gain, fatigue, hair loss, depression, low libido, brain fog, etc.) was shown to be the most accurate method to determine proper thyroid hormone replacement dosage.
How you feel is a lot more important than what your TSH test results say.
This Is Why You Are So Tired All The Time
What all of this means is that people with Hashimoto’s and hypothyroidism who are on T4 only thyroid replacement hormone feel tired all the time, are losing their hair, can’t lose weight, etc. and just generally feel like crap because this hormone is not getting into the cells of their body.
When thyroid hormone doesn’t get into the body’s cells, it can’t do its job.
There Is Another Way
It doesn’t have to be this way. You can change this by, first, testing appropriately to see how well your cells are absorbing thyroid hormone and then by making changes in your diet, lifestyle and medications (if necessary) to make sure that you are converting and absorbing enough thyroid hormone for it to work in your body.
The proper way to test whether of not your cells are absorbing thyroid hormone is to order free T3 (fT3) and/or T3 and reverse T3 (rT3). And then to measure their ratio: the proper ratio of free T3 to reverse T3 is greater than 20. The proper ratio of T3 to reverse T3 is greater than 10.
If your numbers demonstrate that you have high reverse T3 and a low ratio, then you are not absorbing thyroid hormone into the cells of your body.
The next step is to improve the function of the areas that convert thyroid hormone and to clean up your diet and alter your lifestyle to support proper absorption of thyroid hormone.
Since 60% of T4 is converted into T3 in the liver is vitally important to make sure that you improve liver function and make sure that your liver is working properly. A good liver detox and changes in diet can accomplish this.
The next step is to clean up your gut and make sure that you don’t have intestinal problems or inflammation of the intestines that can slow or prevent proper absorption and conversion of thyroid hormone.
Next, you need to supplement and gradually heal the body so that the many conditions that can slow or stop absorption of thyroid hormone are reversed and make sure the cells of your body have enough energy to get thyroid hormone into your cells.
Lastly, you may need to start taking T3 or try a thyroid hormone that contains both T4 and T3. This will insure that enough T3 is getting into the cells of your body.
30 Minute Confidential Telephone Consultation
I am offering a 30 minute telephone consultation if you would like to learn more and discover whether or not you have issues that may be preventing your cells from absorbing thyroid hormone.
Click on this link to schedule the consultation.
Its Not Easy, But The Results Can Be Dramatic
This is not a simple process and you need to work with someone who understands how to guide you through this process.
That’s why I have created a simple 60 day program that can dramatically improve the way the cells of your body absorb thyroid hormone:
This program includes:
* Free T3 (fT3) and reverse T3 (rT3) testing
* A 30 day liver detox program
* A 30 day gut healing program that incorporates the Hashimoto’s Diet Plan
* Supplementation and guidance to improve cellular energy production.
* Follow Up testing
Click on this link to schedule a confidential 30 minute consultation.
References:
http://nahypothyroidism.org/thyroid-hormone-transport/
http://nahypothyroidism.org/files/thyroid_transport_graph_3.pdf
http://www.stopthethyroidmadness.com/rt3-ratio/
Zulewski H, Muller B, Exer P, et al. Estimation of tissue hypothyrodisim by a new clinical score: Evaluation of patients with various grades of hypothyroidism and controls. J Clin Endocrinol Metab 1997;82(3):771-776.
Kharrazian, Datis, DC, Why Do I Still Have Thyroid Symptoms When My Lab Tests Are Normal? 2010, Elephant Printing