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ARTICLE 1:  Treatment of Thyroid

Treatment of Thyroid

Robert Carlson, MD

Andlos Institute

I found the management of Thyroid Disease or insufficiency to be very rewarding and the results are beneficial to the long-term health of the patient. I have always been interested in surgical endocrinology, spending some time at Harvard with Dr Blake Cady and having a tremendous experience in my general surgery residency at Shands Hospital under Dr. William Pfaff.  I believe the challenge of managing thyroid issues depends on listening to the patient. Yes, listening to the patient. Unfortunately, often patients describe classic symptoms of low thyroid function, and their physician checks some labs, deeming the labs normal, and thus the patients “classic” symptoms are disregarded.

Symptoms:

  •  Progressive Weight Gain,
  •  Fatigue, especially in the later part of the afternoon,
  •  Thinning of hair, dry skin and swelling.
  • If not in the grips of menopause, will often be cold, or at least colder than everyone around you. Are you wearing a sweatshirt to go grocery shopping in the heat of the summer?
  • In ladies, continued weight gain, or failure to lose weight despite exercising and eating properly. This is a thyroid problem! Recently I spoke with a patient who had all the symptoms I have listed above, and her doctor checked the labs, having the office receptionist call to tell her everything was “normal”. In fact he even implied that she was eating more than she was telling him. But she wasn’t, and all he needed to do was to check the appropriate labs, talk to his patient, and he would have realized that she was in a severely low thyroid state. She lost over 20 pounds in the first month after starting armour thyroid replacement therapy, no longer takes naps in the afternoon, and her hair stopped falling out. There is hope.

It is not uncommon for thyroid problems to surface around menopause, so that often ladies don’t complain of the classic cold intolerance or feeling more often cold than hot, because they are struggling with hot flashes.

Thyroid imbalance will affect every organ in your body.  The thyroid is critical in maintaining energy through close regulation of metabolism and temperature control.  Ongoing growth and repair of tissues with protein synthesis is a critical function of a normal operating thyroid. When thyroid function is not at its optimum then abnormalities begin to surface, some initially subtle, but becoming progressively worse.

The thyroid controls and regulates a number of other important systems like digestion, with low thyroid levels causing constipation, and indigestion. The side effects of low thyroid levels have significant ramifications on the function of the heart, with increased atrial fibrillation, worsening heart function with acceleration of congestive heart failure, and an increased mortality associated with a heart attacks. In addition, low thyroid hormone levels cause cholesterol metabolism abnormalities with elevation of the LDL or bad cholesterol, and diminishing HDL levels or good cholesterol.

Patients with low thyroid levels will demonstrate abnormalities in skin, hair and fingernail growth, all related to the importance of thyroid on protein metabolism. It is for this reason that patients also experience swelling in their faces as well as their arms and legs. The list for symptoms associated with thyroid function is long, however some of the symptoms include, Depression, the inability to concentrate on a task and decreased memory.  Fatigue, weight loss, anxiety with panic attacks has also been attributed to low thyroid levels. External manifestations may include weight gain, brittle nails, rough or dry skin, swollen legs, feet, hands and face.  Hair growth is often sparse and hair loss is accelerated.  One of the classic signs of poor thyroid function is the thinning of the lateral eyebrows. This means the hair on the outside region of the eyebrows either becomes thin or may even disappear. There is a very close relationship with thyroid hormones, estrogen, cortisol and growth hormone, thus symptoms are often compounded by abnormalities of other hormonal systems.

I believe one of the most important components of lab testing for the thyroid is the free T3 level. This level is unfortunately not often tested, but it should be.  T3 or triiodothyronine is the most active of all the thyroid hormones. It is the worker bee that interacts with all the important functions in your body that the thyroid controls. Other lab values examined include the TSH, which is the hormone that the pituitary uses to communicate with the thyroid. The TSH makes the thyroid produce T4, or thyroxine. This is relatively inactive and needs to be transported through the liver to be activated into T3, so that it can perform its job in the blood stream. Let’s examine your thyroid function results. Again, lab values are only a part of the picture. Patients may have normal lab results in acceptable ranges or even optimal ranges, but still demonstrate symptoms of low thyroid function. I adjust doses on medications based on how the patients feel, versus lab tests. In addition, optimizing the T3 level or active form of thyroid hormone into the upper 75thpercentile will provide the patient the maximum benefit of thyroid supplementation, without increasing risks. A number of physicians look at TSH levels as indicators of thyroid function, but in optimizing the thyroid these levels are often lower than normal, and the T3, and patient’s symptoms should be the values utilized to adjust the thyroid replacement therapy.

If your TSH level is between 1 and 2. The TSH is the hormone that the pituitary uses to communicate with the thyroid. The TSH makes the thyroid produce T4, or thyroxine, and will regulate the levels minute to minute. Your TSH level represents a true normal range for normal thyroid function. Despite a normal level of TSH, a patient still may demonstrate symptoms of hypothyroidism, and this is often better defined by looking at the free T3 levels.

The normal or reference lab ranges listed on most lab results forms are grossly inaccurate, and list a TSH of almost 5.5 as normal. Patients with TSH’s this high are often with exception profoundly hypothyroid. An Endocrinological society refers to a level of 2.8, but other endocrinologists have used the value of 2 as a cut-off for determining a normal TSH. Especially with symptoms, a TSH of greater than 2 should suggest a degree of hypothyroidism. The communication between the pituitary, which is located behind the bridge of your nose, and inside of your brain, and the thyroid gland is through the hormone TSH or Thyroid Stimulating Hormone. TSH is made in the pituitary gland, secreted in the blood and travels to the thyroid to affect thyroid function. When the TSH is below 2, the communication between your pituitary and your thyroid is like a soft spoken conversation. “How are you doing today?”, “What are you having for dinner?”, “What are you doing this weekend?”.  When your levels of TSH are between 2 and 3, the conversation becomes a little different with the pituitary asking the thyroid questions like:  “What’s going on down there?”, or “You’re not working as hard as you used to, so what’s the matter?” Now when the level goes over 3 the pituitary starts yelling at the thyroid to work harder. When the TSH exceeds 4, the pituitary is now violently yelling at the thyroid, trying to get it to make more thyroid hormone. Going over 5, the pituitary is using expletive delete’s every other word, screaming at the top of its proverbial lungs, trying to get the thyroid to start working.

If your TSH level is elevated, or greater than 2. The TSH is the hormone that the pituitary uses to communicate with the thyroid. The TSH makes the thyroid produce T4, or thyroxine, and will regulate the levels minute to minute. The normal or reference lab ranges listed on most lab result forms are grossly inaccurate, and list a TSH of almost 5.5 as normal. Patients with TSH’s levels this high are often without exception profoundly hypothyroid. One of the Endocrinological societies refers to a level over 2.8 as being abnormally high, but other endocrinologists have used the value of 2 as a cut-off for determining a normal TSH. Especially with symptoms, a TSH of greater than 2 should suggest a degree of hypothyroidism. The communication between the pituitary, which is located behind the bridge of your nose, and inside of your brain, and the thyroid gland is through the hormone TSH or Thyroid Stimulating Hormone. TSH is made in the pituitary gland, secreted in the blood and travels to the thyroid to affect thyroid function. When the TSH is below 2, the communication between your pituitary and your thyroid is like a soft spoken conversation. “How are you doing today?”, “What are you having for dinner?”, “What are you doing this weekend?”.  When your levels of TSH are between 2 and 3, the conversation becomes a little different with the pituitary asking the thyroid questions like:  “What’s going on down there?”, or “You’re not working as hard as you used to, so what’s the matter?” Now when the level goes over 3 the pituitary starts yelling at the thyroid to work harder. When the TSH exceeds 4, the pituitary is now violently yelling at the thyroid, trying to get it to make more thyroid hormone. Going over 5, the pituitary is using expletive delete’s every other word, screaming at the top of its proverbial lungs, trying to get the thyroid to start working.

If your TSH level is less than 1. This may represent a normal range, or it could represent a decreased function of your pituitary, and its inability to respond to the need for higher thyroid levels. Or maybe that it doesn’t care what your thyroid is doing. This is also a possibility.  The TSH makes the thyroid produce T4, or thyroxine, and will regulate the levels minute to minute. Your TSH level represents a true normal range for normal thyroid function. Despite a normal level of TSH, a patient still may demonstrate symptoms of hypothyroidism or under active thyroid, and this is often better defined by looking at the free T3 levels. If the TSH levels fall below .3 then another consideration is to evaluate for hyperthyroidism or overactive thyroid. However, with thyroid treatment, low levels of TSH are acceptable, as long as the T3 levels are in the normal range. Optimization of thyroid function is achieved by optimizing T3 levels.

The normal or reference lab ranges listed on most lab results forms are grossly inaccurate, and list a TSH of almost 5.5 as normal. Patients with TSH’s this high are often without exception profoundly hypothyroid. An Endocrinological society refers to a level of 2.8, but other endocrinologists have used the TSH value of 2 as a cut-off for determining a normal TSH. Especially with symptoms, a TSH of greater than 2 should suggest a degree of hypothyroidism, or under active thyroid gland. The communication between the pituitary, which is located behind the bridge of your nose, inside of your brain, and the thyroid gland in your neck is through the hormone TSH or Thyroid Stimulating Hormone. TSH is made in the pituitary gland, secreted in the blood and travels to the thyroid to affect thyroid function. When the TSH is below 2, the communication between your pituitary and your thyroid is like a soft spoken conversation. “How are you doing today?”, “What are you having for dinner?”, “What are you doing this weekend?”.  When your levels of TSH are between 2 and 3, the conversation becomes a little different with the pituitary asking the thyroid questions like:  “What’s going on down there?”, or “You’re not working as hard as you used to, so what’s the matter?” Now when the level goes over 3 the pituitary starts yelling at the thyroid to work harder. When the TSH exceeds 4, the pituitary is now violently yelling at the thyroid, trying to get it to make more thyroid hormone. Going over 5, the pituitary is using expletive delete’s every other word, screaming at the top of its proverbial lungs, trying to get the thyroid to start working.

If your T4 level is in the upper 75th percentile of the normal referenced levels.  This is in the ideal level and supports optimization of your thyroid hormone levels.  T4, or thyroxine, is produced in the thyroid gland in response to stimulation from the pituitary gland.  T4 is a relatively inactive form of thyroid hormone, less than 1/5 the activity of T3.  I like to think of T4 like a group of workers standing around, waiting to be told what to do. If they aren’t working than the job isn’t getting done. You know the feeling of driving by a crew of workers, who are repairing a road, and nobody seems to be working. Well guess what, the road repairs will never be completed. The T4 is then activated in the liver into T3.  The T3 is the active form of thyroid, five times more powerful and active than T4. It is the workhorse of the thyroid hormonal system. That is why it is so critical to measure the T3 levels.

If your T4 level is between the 40th and the 75th percentile.This is not in the ideal level and optimization of your thyroid hormone levels may improve symptoms of underactive thyroid.  T4, or thyroxine, is produced in the thyroid gland in response to stimulation from the pituitary gland.  T4 is a relatively inactive form of thyroid hormone, less than 1/5 the activity of T3.  I like to think of T4 like a group of workers standing around, waiting to be told what to do. If they aren’t working than the job isn’t getting done. You know the feeling of driving by a crew of workers, who are repairing a road, and nobody seems to be working. Well guess what, the road repairs will never be completed. The T4 is then activated in the liver into T3.  The T3 is the active form of thyroid, five times more powerful and active than T4. It is the workhorse of the thyroid hormonal system. That is why it is so critical to measure the T3 levels.

I like to use the analogy of graduating from high school. It is normal to graduate from high school. At the graduation ceremony, everyone is wearing their cap and gown, and receiving a diploma. With the exception of the valedictorian, you have no idea where the students graduated in there class. They are all normal. Now there is quite a difference between the student that graduated in the upper 20thpercentile, and will be undoubtedly attending college with all the hopes of a bright future, and the student who graduated in the lower 20thpercentile, probably not working too hard through high school, and now faced with limited options for future plans of enrichment. Are you happy being between the 40thand the 75thpercentile of your class? If you are not having symptoms of low thyroid function than often treatment with a thyroid supplement is held. However if you are in this range, and suffering from symptoms of low thyroid function, than I believe patients will benefit from optimization of their thyroid levels.  I often prefer Armour Thyroid, as it has T4, and T3, in it, as well as the beneficial weight loss characteristics of T1 and T2. Armour Thyroid also possesses enzymes, calcitonin, selenium, and iodine that help process the thyroid hormones, and aid in conversion into the active T3 form of thyroid hormone.

If your T4 level is less than the 40th percentile. This is not in the ideal level and optimization of your thyroid hormone levels will undoubtedly improve symptoms of an underactive thyroid.  T4, or thyroxine, is produced in the thyroid gland in response to stimulation from the pituitary gland.  T4 is a relatively inactive form of thyroid hormone, less than 1/5 the activity of T3.  I like to think of T4 like a group of workers standing around, waiting to be told what to do. If they aren’t working than the job isn’t getting done. You know the feeling of driving by a crew of workers, who are repairing a road, and nobody seems to be working. Well guess what, the road repairs will never be completed. The T4 is then activated in the liver into T3.  The T3 is the active form of thyroid, five times more powerful and active than T4. It is the workhorse of the thyroid hormonal system. That is why it is so critical to measure the T3 levels.

I like to use the analogy of graduating from high school. It is normal to graduate from high school. At the graduation ceremony, everyone is wearing their cap and gown, and receiving a diploma. With the exception of the valedictorian, you have no idea where the students graduated in there class. They are all normal. Now there is quite a difference between the student that graduated in the upper 20thpercentile, and will be undoubtedly attending college with all the hopes of a bright future, and the student who graduated in the lower 20thpercentile, probably not working too hard through high school, and now faced with limited options for future plans of enrichment. Are you happy being in the lower 40thpercentile of your class? Most patients are experiencing symptoms of low thyroid function and I believe patients will benefit from optimization of their thyroid levels.  I often prefer Armour Thyroid, as it has T4, and T3, in it, as well as the beneficial weight loss characteristics of T1 and T2. Armour Thyroid also possesses enzymes, calcitonin, selenium, and iodine that help process the thyroid hormones, and aid in conversion into the active T3 form of thyroid hormone.

If your T3 level is in the upper 75th percentile. This is in the ideal level and supports optimization of your thyroid hormone levels.

If your T3 level is between the 40th and the 75th percentile. This is not in the ideal level and optimization of your thyroid hormone levels may improve symptoms of an underactive thyroid. T4 or the inactive form of thyroid hormone is produced in the thyroid and must be converted into the active thyroid hormone, T3 or triiodothyronine. Stress and elevated cortisol levels can significantly affect the conversion of T4 into T3. Numerous medications alter that conversion as well including beta-blockers (lopressor, toprol, and tenormin), Cordarone, Dilantin, and Lithium. Nutrient deficiencies including Zinc, iodine, the B-vitamins and iron also block the production of T3 from T4.

Thyroid function is associated with numerous age-related disease including cardiovascular disease, degenerative neurological diseases (Alzheimer’s/Dementia/Memory disorders), gastrointestinal abnormalities, weight gain, and fibromyalgias.

If a patient presents to the hospital with a heart attack and has a low T3 level, then they will do worse, having more complications. Also a 5x increase risk of heart disease with low free T3 levels. Low T3 levels are a more dangerous risk factor than cholesterol levels. When the T3 level is low, there is a 23% lower blood flow to the brain. In addition, depression is 8 times more prevalent with low T3 levels.  Low T4 levels are not correlated well with symptoms like those with low T3 levels. Needless to say T3 levels are very important to follow and measure. I judge a patients response to therapy by clinically how well they are doing, and the T3 levels.

If your T3 level is lower than the 40th percentile.This is not in the ideal level and optimization of your thyroid hormone levels will improve symptoms of an underactive thyroid. T4, or the inactive form of thyroid hormone is produced in the thyroid and must be converted into the active thyroid hormone, T3 or triiodothyronine. Stress and elevated cortisol levels can significantly affect the conversion of T4 into T3. Numerous medications alter that conversion as well including beta-blockers (lopressor, toprol, and tenormin), Cordarone, Dilantin, and Lithium. Nutrient deficiencies including Zinc, iodine, the B-vitamins and iron also block the production of T3 from T4.

Thyroid function is associated with numerous age-related disease including cardiovascular disease, degenerative neurological diseases (Alzheimer’s/Dementia/Memory disorders), gastrointestinal abnormalities, weight gain, and fibromyalgias.

If a patient presents to the hospital with a heart attack and has a low T3 level, then they will do worse, having more complications. Also a 5x increase risk of heart disease with low free T3 levels. Low T3 levels are a more dangerous risk factor than cholesterol levels. When the T3 level is low, there is a 23% lower blood flow to the brain. In addition, depression is 8 times more prevalent with low T3 levels.  Low T4 levels are not correlated well with symptoms like low T3 levels are associated. Needless to say T3 levels are very important to follow and measure. I judge a patients response to therapy by clinically how well they are doing, and the T3 levels.

If your thyroid antibodies are positive. This is associated with an autoimmune disease called Hashimoto’s. Initially this starts out as hyperthyroidism as your own body attacks your own thyroid with antibodies. This reaction results in very high thyroid levels because of over stimulation. Eventually the thyroid gland begins to get “burned out”  because of the worsening thyroid function. Someone who was initially hyperthyroid after the antibodies attacked their thyroid, now become hypothyroid, They will require thyroid supplementation for the remainder of their live. The process of Hashimoto’s thyroiditis is mediated by antibodies, that when they  are too high, they can  bind to thyroid receptors, thus stopping thyroid hormone from binding to these receptors, and activating the thyroid gland. A patient may have entirely normal thyroid hormone levels, but still be hypothyroid or underactive thyroid because the thyroid hormone can’t stimulate the receptors. Aging also produces a decreased number of thyroid hormone receptors, so if antibodies block other receptors one may have normal hormone levels, but be severely hypothyroid. Studies have identified that up to 30 % of the women over the age of 50 will have thyroid antibodies. In these patients, symptomatic relieve will NOT occur unless higher doses of thyroid hormone, specifically T3 and T4 are used.

If your thyroid antibodies are negative. You do not have evidence of antibodies to your thyroid but if they were too high they could bind to thyroid receptors, thus stopping thyroid hormone from binding to these receptors, and activating the thyroid gland. A patient may have entirely normal thyroid hormone levels, but still be hypothyroid, or underactive thyroid because the thyroid hormone can’t stimulate the receptors. Aging may also produce a decreased number of thyroid hormone receptors, so one may have normal hormone levels, but have symptoms of low thyroid function.

Your reverse T3 levels are elevated. This is not ideal. Reverse T3 may be produced instead with the conversion of T4 into T3. Unlike T3, which is very active, the reverse T3 is inactive, and not beneficial to thyroid hormonal activity. Stress, Diabetes, elevated free radical exposure, aging, and fasting cause an increased production of reverse T3.

Your reverse T3 levels are normal. This is ideal, and represents an optimal condition. Reverse T3 may be produced instead with the conversion of T4 into T3. Unlike T3, which is very active, the reverse T3 is inactive, and not beneficial to thyroid hormonal activity. Stress, Diabetes, elevated free radical exposure, aging, and fasting cause an increased production of reverse T3.

 reprinted with permission from Andlos Institute, Robert Carlson, MD

Related Symptoms

Related Terms

  • Thyroid Stimulating Hormones (TSH)
  • T3
  • T4

Related Treatment Options