Without targeted labwork, hypothyroidism detection can be eclipsed by states of hormone imbalance, such as perimenopause, menopause and use of birth control medication. This is because some symptoms of hypothyroidism have significant overlap with menopausal symptoms, including:
Women taking birth control medication or estrogen replacement therapy also benefit from periodic thyroid screenings, since estrogen replacement can increase sex hormone binding globulin (SHBG) and thyroid binding globulin (TBG), which thereby decreases free thyroxine (free T4). In some women, this can impact free T4 sufficiently enough to induce hypothyroidism, and is readily treated with fine-tuning one's hormone prescriptions.
Lab testing and a physical exam in combination with a clinical consultation are extremely helpful in determining whether hypothyroidism is present.
Primary hypothyroidism is a relatively common thyroid condition which can be effectively treated with levothyroxine (LT4) monotherapy in the majority of cases. All major endocrine societies agree that levothyroxine (LT4) should be the first line treatment for hypothyroidism. This position is based on the therapeutic efficacy and a consistent positive response to LT4 monotherapy in the majority of patients with hypothyroidism, as well as due to the established safety record of LT4 monotherapy. More recently, a number of endocrine societies have recognized that a small number of hypothyroidism patients continue to experience persistent and distressing symptoms of hypothyroidism despite adequate treatment with LT4. In such patients, the addition of T3 may be considered with caution. The routine prescribing of T3 is currently not recommended by any national or international endocrine or endocrine-related societies or organizations. Clinical practice guidelines approach the issue with a conservative approach and provide clear direction regarding patient selection criteria and prescribing recommendations for LT3.
Liothyronine sodium (LT3) is a synthetic pharmaceutical-grade T3 product which is available in a number of dosages. LT3 has been used as a monotherapy as well as in conjunction with LT4. Desiccated thyroid formulas containing both T4 and T3 are also available and sometimes prescribed as a substitute for LT4 monotherapy or in place of synthetic LT4/LT3 combination therapy. The utilization of LT3 monotherapy, synthetic combinations of LT4/LT3, as well as desiccated thyroid extracts (DTE) is an area of both continued investigation and debate. At present, all major endocrine societies agree that LT4 should be the first line treatment for hypothyroidism. Whether T3 is considered is based on multiple health factors. In cases where T3 is used, patients are monitored more frequently and cautiously.
Our clinic follows endocrine guidelines for thyroid lab testing and interpretation, including fasting status, avoiding the B vitamin biotin due to assay interference issues, and the use of high-performance liquid chromatography tandem mass spectrometry (LC/MS/MS) lab testing methods in order to improve specificity and accuracy of thyroid hormone lab results.
Many "normal" thyroid panels run in a hospital, by primary care providers and even by endocrinologists are still being run using an older methods of thyroid testing called immunoassays. Immunoassays are notable for being less accurate and less specific for thyroid hormone results.
Thyroid imaging may be recommended in cases where lab abnormalities or physical examination merit further screening. In some cases, such as uncovering abnormalities on thyroid imaging and in those who are determined to be at risk of a thyroid storm, a referral to an endocrinologist who specializes in thyroid disease for further assessment and integrative management and collaboration is appropriate.
Koulouri, O., Moran, C., Halsall, D., Chatterjee, K., Gurnell, M. ‘Pitfalls in the measurement and interpretation of thyroid function tests’ (2013) Best Practice & Research: Clinical Endocrinology & Metabolism, 27(6), pp. 745-762.
Midgley JEM, Toft AD, Larisch R, Dietrich JW, Hoermann R. Time for a reassessment of the treatment of hypothyroidism. BMC Endocr Disord. 2019 Apr 18;19(1):37.
Soldin, O. P., & Soldin, S. J. (2011). Thyroid hormone testing by tandem mass spectrometry. Clinical biochemistry, 44(1), 89–94.
Autoimmune thyroiditis, more commonly referred to as Hashimoto's thyroiditis, is an autoimmune condition which causes thyroid destruction, and thereby hypothyroidism, over time. This condition impacts women five times more often than men. Autoimmune antibodies are used to diagnose autoimmune thyroiditis in someone who has hypothyroidism. Unlike menopause, it can affect women at nearly any age.
Conventional treatment is based on a monotherapy of levothyroxine. Labs are monitored once a year via TSH, free T4 and total T3, in addition to a comprehensive metabolic panel. Thyroid antibodies are not re-run, and nutrient co-factors impacting thyroid synthesis and immune function are generally not considered. For many women, conventional treatment is sufficient for their concerns, and they do not have to go through additional labs or treatments.
Functional medicine has emerged as a resource for those women with Hashimoto's thyroiditis where levothyroxine as a monotherapy is not sufficient to address their ongoing concerns of "brain fog", mental exhaustion, cold intolerance, constipation, debilitating physical fatigue, depression and weight gain, as well as the emotional fallout that accompanies this new version of reality.
When their thyroid labs come back as "normal" while life is now simultaneously experienced as anything except normal, symptomatic women with Hashimoto's may ask their doctor for further help. At this critical point, the conventional medical model may tell these women to exercise more, to go on a diet or to consider taking anti-depressants or stimulant medications. These prescriptions are often not sufficiently effective in addressing the symptoms of "brain fog", mental exhaustion, cold intolerance, constipation, debilitating physical fatigue, depression &/or weight gain. Each medication presents its own inherent risks, and does not address the root cause of the symptom.
The mounting disconnect between one's body and mind is a microcosm that seems to metaphorically manifest into the
macrocosm of a reductionistic medical experience. The disease-based medical experience, rather than the personalized medical experience, further compounds this disconnect...
Lab tests generally do not reflect the extent of suffering that symptomatic women with Hashimoto's are experiencing, and so it is common for these women to either discount the validity of their symptoms, or default into feeling like they have somehow failed themselves, their duties and even their doctor. If they have no one to turn to, some women may stop advocating for a better version of their health. Yet their symptoms of worsening metabolism, mid-section weight gain, declining brain function and mood disorders signify that chronic disease risks are mounting, and prove that their symptoms not being addressed in their entirety.
Many of these women are not content to merely assuage their health concerns with an antidepressant, for they can literally feel themselves becoming less functional and energetic while the effects of their symptoms pervade. Out of necessity, they seek out a medical paradigm where the constellation of their symptoms guides an inclusive investigation.
By the time this type of woman meets with Dr. Parker for an initial consultation, it is understandable why she may be experiencing fear, anger and frustration, and why she isis seeking an adjunctive medical approach to better understand her options for care.
Common obstacles to overcome when treating quality-of-life complaints of Hashimoto’s thyroiditis may include addressing:
An integrative approach which addresses underlying issues related to autoimmunity can be life-changing in women who are searching for other options to reclaim what Hashimoto's has stolen from them, and what conventional care is unable to detect or treat.
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