Hypothyroidism

by Michael B. Schachter, MD, FACAM

Introduction

One of the most under diagnosed and important conditions in the United States has been called the "unsuspected illness" and accounts for a great number of complaints in children, adolescents, and adults. This condition is an underactive thyroid system.

What kinds of complaints characterize an underactive thyroid system? Low energy and fatigue or tiredness, especially in the morning, is frequent in these patients. Difficulty losing weight, a sensation of coldness--especially of the hands and feet, depression, slowness of thought processes, headaches, swelling of the face or fluid retention in general, dry coarse skin, brittle nails, and chronic constipation are also common. In women, menstrual problems--such as PMS and menstrual irregularities including heavy periods and fertility problems are further signs and symptoms. People with an underactive thyroid may also have stiffness of joints, muscular cramps, shortness of breath on exertion, and chest pain. Be aware that a person with a low functioning thyroid doesn't have to have all of these symptoms; he may have only a few.

Where is the thyroid located in the body and what does it do? The thyroid gland consists of two small lobes connected together. It is located in the front of the neck, just below the voice box. The thyroid gland is responsible for the speed of metabolic processes in the body and therefore affects every organ and organ system. It is the metabolic stimulator, analogous to the accelerator of a car. Normal growth requires normal thyroid functioning. When the thyroid is not functioning properly, organs become infiltrated with metabolic wastes and all functions become sluggish.

When the thyroid gland is working properly, it uses the amino acid tyrosine and the element iodine to make the thyroid hormone called thyroxine or T4. Thyroxine is called T4 because it contains 4 iodine atoms. If a person is deprived of iodine in his diet, he develops an enlarged thyroid gland, called a goiter and symptoms of an underactive thyroid or hypothyroidism. The other important thyroid hormone is triiodothyronine or T3, which has three iodine atoms. T3 is actually the major active thyroid hormone, being much more active than T4. T4 is produced within the thyroid gland and is later converted to the active T3 outside the thyroid gland in peripheral tissues. Under certain conditions, such as stress, the thyroid gland may produce sufficient amounts of T4 to obtain normal thyroid blood tests, but its conversion to T3 may be inhibited, causing a relative insufficiency of active T3. Under this circumstance, the patient will have hypothyroid symptoms in spite of normal thyroid blood tests. As you will see, this fact results in many missed diagnoses of an underactive thyroid system.

Conventional Diagnosis

In the Introduction, I discussed the production of thyroxine (T4) in the thyroid gland and its conversion to T3 outside the thyroid gland in peripheral tissues.

A hormone from the pituitary gland, which is located at the base of the brain, controls the production and release of T4 from the thyroid gland. This pituitary hormone is called thyroid-stimulating hormone or TSH. When the level of T4 in the bloodstream is low, the pituitary increases TSH production and release, which in turn stimulates the thyroid gland to produce and release more T4. The T4 then feeds back to the pituitary, reducing the secretion of TSH in a negative feedback loop. When a person has difficulty making T4 due to iodine deficiency or for some other reason, one would expect to find an elevated TSH. In this case, the pituitary's TSH is trying to get the thyroid gland to produce more T4. If both T4 and TSH are low, this may indicate a pituitary problem with a low TSH secretion resulting in the lower production and secretion of T4.

How is hypothyroidism diagnosed today by conventional medicine? Unfortunately, the diagnosis by conventional physicians, including thyroid specialists called endocrinologists, is made almost exclusively from blood tests. Generally, T4 and TSH are measured in the bloodstream. Additionally, a protein that binds T4 is also measured. From this protein and T4, the free, or unbound, T4 is calculated. If a patient has a normal TSH and a normal free-T4, the conventional physician tells him that he does not have hypothyroidism, no matter how many signs and symptoms of hypothyroidism he has. I believe that this mode of thinking is incorrect and that the thyroid blood tests miss many cases of hypothyroidism that would respond favorably to thyroid hormone treatment.

If most hypothyroid cases cannot be diagnosed by the usual blood tests, how can they be diagnosed? Prior to the extensive use of blood tests, astute clinicians, who obtained careful medical histories, including family histories from the patient, and who performed a complete physical examination were able to diagnose hypothyroid states. Later, basal metabolic rates were measured in patients using special equipment. Then came the blood tests--the protein bound iodine or PBI, T4, TSH and even T3 by special radioactive studies. Instead of using the blood tests as adjuncts to diagnosis, many physicians soon relied upon the tests exclusively. To properly diagnose hypothyroidism, the clinician must go back to a careful medical history, physical examination, and measurement of the basal temperature of the body.

Complete Diagnosis

What in the medical history suggests the likelihood of hypothyroidism? With regard to infancy and childhood, a high birth weight of over 8 lbs. suggests low thyroid. During childhood, early or late teething, late walking or late talking suggests a low functioning thyroid in the child. Also, frequent ear infections, colds, pneumonia, bronchitis, or other infections may be signs. Problems in school including difficulty concentrating, abnormal fatigue--especially having difficulty getting up in the morning and poor athletic ability all suggest a low thyroid. Keep in mind that a person with low thyroid functioning may have only a few of these characteristics. You don't have to find all of them to suspect a low thyroid.

During puberty, we see the same types of problems in school and with fatigue, which is often worse in the morning and gets a little better later in the day. Often, adolescent girls suffer from menstrual irregularity, premenstrual syndrome, and painful periods. Drug and alcohol abuse is common.

Throughout life, disorders associated with hypothyroidism include headaches, migraines, sinus infections, post-nasal drip, visual disturbances, frequent respiratory infections, difficulty swallowing, heart palpitations, indigestion, gas, flatulence, constipation, diarrhea, frequent bladder infections, infertility, reduced libido and sleep disturbances, with the person requiring 12 or more hours of sleep at times. Other conditions include intolerance to cold and/or heat, poor circulation, Raynaud's Syndrome, which involves the hands and feet turning white in response to cold, allergies, asthma, heart problems, benign and malignant tumors, cystic breasts and ovaries, fibroids, dry skin, acne, fluid retention, loss of memory, depression, mood swings, fears, and joint and muscle pain.

With regard to the family history, all of the above disorders can be checked in family members. Particular emphasis should be placed on hypothyroid conditions in parents or siblings. Also, a family history of tuberculosis suggests the possibility of low thyroid.

The physical examination often reveals the hair to be dry, brittle and thinning. The outer third of the eyebrows is often missing. One often finds swelling under the eyes. The tongue is often thick and swollen. The skin may be rough, dry and flaky and show evidence of acne. The skin may also have a yellowish tinge due to high carotene in it. Nails tend to be brittle and break easily. The thyroid gland may be enlarged. The patient is more often overweight, but may also be underweight. Hands and feet are frequently cold to the touch. Reflexes are either slow or absent. The pulse rate is often slow even though the patient is not a well-trained athlete.

The Basal Temperature Test

As I stated in the Complete Diagnosis section, to better diagnose a low thyroid, the physician should carefully evaluate the patient's medical history, family history, physical examination, and the basal body temperature.

Instructions for taking basal body temperatures are relatively easy. Use an old-fashioned, oral glass thermometer. I think it is more accurate than the digital kind. Shake the thermometer down before going to bed, and leave it on the bedside table within easy reach. Immediately upon awakening, and with as little movement as possible, place the thermometer firmly in the armpit next to the skin, and leave it in place for 10 minutes. Record the readings for three consecutive days. Menstruating women should only take the basal temperature test for thyroid function on the 2nd, 3rd or 4th day of menses (preferably beginning on the 2nd day) to get the most accurate readings. Males, pre-puberty girls, and post-menopausal or non-menstruating women may take basal temperatures any day of the month. However, women using oral or topical progesterone should not take progesterone the day before or on the days that the basal temperatures are taken. In summary, to perform the temperature test:

Shake the thermometer down before retiring
Upon awakening, place it in your armpit and leave it there for 10 minutes before getting out of bed.
Record the temperature
Take the average of 3 days of temperatures

Most of the information on the manifestations of hypothyroidism, its diagnosis, including the technique for measuring and interpreting basal temperatures, and the treatment were compiled and described by the late Dr. Broda O. Barnes, M.D. He is the author of the book Hypothyroidism: the Unsuspected Illness. His work is disseminated to physicians and the public by the foundation bearing his name, the Broda O. Barnes, M.D. Research Foundation, which is located in Trumbull, Connecticut.

How does one interpret the results of the basal body axillary temperature test? If the average temperature is below 97.8 Fahrenheit, then the diagnosis of a low functioning thyroid system is likely. An average temperature between 97.8 and 98.2 is considered normal. An average temperature above 98.2 is considered high and might reflect an infection or a hyperthyroid condition.

Once a pattern of hypothyroid symptoms is established and the basal body temperatures are found to be low, the next step is a therapeutic trial of thyroid hormone. Dr. Barnes, his physician followers, and many patients have found that the most effective thyroid medication is Armour Desiccated Thyroid Hormone. This medication, which requires a physician’s prescription, is derived from the thyroid gland of the pig. It most closely resembles the human thyroid gland. It is dried or desiccated and processed into small tablets. This desiccated thyroid contains T3 as well as T4, and other associated factors that may be helpful.

In contrast, most conventional physicians prefer to use the synthetically produced thyroxine or T4. The most common brand name of this medication is Synthroid. The reason some physicians prefer this form is that the variability of dosage from tablet to tablet is virtually non-existent because it is produced synthetically, whereas there may be some slight variability in the dosage of desiccated thyroid because the processing of an animal product is not as precise. Another reason for using synthetic T4 is the general failure of conventional clinical medicine and endocrinology to recognize the importance and clinical relevance of a person having trouble converting T4 to T3. Such a person would benefit from a hormone preparation containing T3.

Interestingly, in recent years, there has been some recognition of the value of T3 in psychiatry, as several studies on depression have shown that response rates to an anti-depressant medication are often improved when T3 is added to the protocol. Furthermore, a recent study in The New England Journal of Medicine (Vol. 340, No. 8, pp.424-29, 469-70, Feb. 11, 1999) comparing the treatment of hypothyroid patients using either T4 or a combination of T3 and T4 showed that the group receiving the combination exhibited better results, particularly with regard to hypothyroid associated mental and emotional symptoms. Nevertheless, most hypothyroid patients receiving conventional treatment usually receive only T4. Occasionally, conventionally treated patients are given T3 or triiodothyronine, frequently in the form of the medication Cytomel. Unfortunately, this form of T3 is short-acting and should be given a few times a day, in contrast to T4. Still, because of its short-acting activity, the patient may experience a roller coaster type of response to the treatment with mood and energy swings during the day. This problem may be circumvented by the use of long-acting T3, which is available from compounding pharmacies, but not commercially in most drug stores. I’ll discuss this further when I explain Wilson’s Syndrome in a subsequent section.

In my experience and the experience of many other physicians using Dr. Barnes' protocol, the synthetic T4 is not as effective as the desiccated thyroid. Therefore in treating most patients with a hypothyroid system, I generally prescribe Armour Desiccated Thyroid or its equivalent.

Treatment

How can we monitor the results of treatment if the conventional blood tests are inadequate to do the job? We do this by asking how the person feels, whether or not the low thyroid signs and symptoms have improved or disappeared, whether or not symptoms of an overactive thyroid gland have developed, and by monitoring the basal body temperature as I described under the section on the Basal Temperature Test.

Generally, the dosage of Armour thyroid is best started at a low dose; with a gradual increase every week or two, until the optimal therapeutic dosage is reached. It may take four to six weeks at the optimal dosage to feel the full therapeutic benefits. In my practice, I generally start the patient on 1/4 grain or 15 milligrams daily. Every week or two, I increase the dosage by 1/4 grain per day until 1 to 2 grains daily are reached. Usually, the optimal dosage is in this range, provided that the patient is doing the other necessary adjunctive things, which I will discuss shortly. Occasionally, the dosage may need to be 2 and 1/2 grains daily or more. Full therapeutic benefits many not be fully realized for months and the basal temperatures may not come up to normal for a year or more. The dosage for infants is usually 1/8 to 1/4 grain daily. For one to six years old, the dosage is usually 1/4 grain. From 7 years to puberty, 1/2 grain is usually used, but it may need to be increased.

There are a few special cases that need to be discussed in the context of this treatment. If a person has recently had a heart attack, treatment should not begin for at least two months following the heart attack. After that, the protocol discussed above can be used.

If a person has evidence of weak adrenal function, as discussed in my article on Stress and Adrenal Insufficiency, the adrenal gland problem must be treated first or simultaneous to the thyroid treatment. The reason for this is that hydrocortisone is necessary for the conversion of T4 to the active T3. If the weak adrenals are not addressed, the patient may actually feel worse and/or develop symptoms of an overactive thyroid gland, such as palpitations, a rapid heart beat, and increased sweating. Clues to low adrenal functioning include a low blood pressure (less than 120/80), allergies, asthma, breathing difficulties, skin problems (such as acne, eczema, psoriasis, lupus, dry flaky skin), joint or muscle pains, as in arthritis, and emotional problems, such as mood swings, weeping, fears and phobias. Using low physiologic doses of hydrocortisone along with Armour thyroid, when the patient shows evidence of both low adrenal and low thyroid functions will help to assure the desired results.

Another consideration when treating low thyroid conditions is the necessity of treating the whole person and dealing with whatever is out of balance. In particular, thyroid hormone is essential for efficient oxidative phosphorylation, the process the body uses to store energy when oxygen is used to burn or oxidize foodstuffs. This process requires several B vitamins (vitamins B1, B2, B3, B5), coenzyme Q10, minerals, such as magnesium, and other substances. If a person is either frankly deficient or does not have optimal amounts of these substances, then a prescribed thyroid hormone will not work optimally and may even cause side effects. Additionally, other hormones may be out of balance and require attention as well. Consequently, it is necessary to try to supply whatever else is needed when treating thyroid conditions.

Wilson’s Syndrome

In the section on Treatment, I discussed the general treatment protocol using Armour Desiccated Thyroid including how to treat patients with low thyroid who have recently suffered a heart attack and those low thyroid patients who are also suffering from low adrenal functioning. Here, I shall elaborate on the important process of converting the relatively inactive T4 to the active T3 thyroid hormone.

As I’ve previously mentioned, frequently low thyroid function is not due to the low production of thyroxine, T4, by the thyroid, but the failure of conversion of T4 to T3 by peripheral tissues. What nutrients are necessary to help with this conversion? In addition to sufficient quantities of the adrenal hormone cortisol, the minerals iron, zinc, copper, and selenium are also necessary for this conversion. Deficiencies of any of these minerals can prevent the conversion of T4 to T3 and should be corrected if present. Sufficient protein and especially the amino acid tyrosine and the element iodine are necessary to make T4 in the thyroid gland.

A young physician, E. Denis Wilson, M.D., has proposed another approach to the problem of conversion failure of T4 to T3. He has found that the body often adapts to various stressful situations by switching to a conservative mode in order to preserve energy. For example, when a famine occurs, an excellent adaptive change that the body can make in order to use less energy (because food calories are scarce) is to stop converting T4 to T3. However, this response appears to occur in response to a wide variety of stressors and sometimes this mode is not reversed, even after the stress is removed. This can lead to all of the signs and symptoms of a low thyroid that I’ve discussed.

Dr. Wilson has suggested the therapeutic use of a special long-acting T3 preparation to reset the conversion of T4 to T3 process. Dosages of T3 are given exactly every 12 hours in increasing amounts with close monitoring of oral temperatures during the day. High doses of T3 may be given in order to normalize the oral temperature to 98.6 F. After the optimal temperature is reached and maintained for approximately three weeks or if the patient develops an intolerance to the particular dosage of long-acting T3, the dosage is tapered down to zero.

When the treatment is successful, the temperature will remain optimal with the loss of hypothyroid symptoms, even after the medication is tapered to zero. In other words, the thyroid system is reset at a higher temperature. This process may take several cycles of going up and down on the T3. This treatment requires a lot of discipline from the patient and often leads to symptoms during the treatment. However, it does seem to be useful in some patients. If the patient is stressed significantly and again enters the low thyroid system mode, the entire process can be repeated again. Usually, the treatment is easier at each subsequent episode.

Nevertheless, for most patients, especially if there are adrenal problems or other medical complications, the use of Armour Desiccated Thyroid on a continuous basis is probably easier and preferable.

Duration of Treatment

Recent studies indicate that patients who have been treated with excessive doses of thyroid hormone over long periods of time may be at increased risk for developing osteoporosis. This may be due not only to too much thyroid hormone, but also to an imbalance between the anabolic and catabolic endocrine hormones. The catabolic hormones are those that help to break down dead tissues and rid the body of metabolic waste. These would include thyroid hormone and hydrocortisone. The anabolic hormones are those that help to rebuild the body and would include DHEA, estrogen, progesterone, and testosterone. A physician who is trying to balance a person's thyroid system must also look at all of the other hormones and also all aspects of the person's lifestyle, including diet, nutritional supplements, exercise patterns, and stress coping mechanisms.

How long should patients take thyroid hormone? When using the desiccated thyroid protocol, patients often remain on the thyroid for life. However, there may be times when the patient can be weaned off the thyroid as all other functions improve, as long as the patient is carefully monitored for the development of low thyroid signs and symptoms as well as low basal temperatures. When a person's basal temperatures are low, many of the enzymes of the body function in a suboptimal way, which leads to all of the problems I’ve discussed.

On the other hand, well-treated hypothyroid patients should enjoy a vibrant life with lowered risks of all of the degenerative diseases including arthritis, cancer and heart disease. I personally have seen a number of patients whose arthritis pains have completely cleared when treated with proper doses of thyroid. With regard to cancer, the well-known alternative cancer treatment developed by Max Gerson, involves the use of Armour Desiccated Thyroid in virtually all of his cancer patients. High serum cholesterol and the development of atherosclerosis are well known effects of hypothyroidism. Therefore, all patients with coronary artery disease and other atherosclerotic conditions should be checked carefully for evidence of a low functioning thyroid condition and treated cautiously and appropriately if a low thyroid condition is found. Psychiatrists have found that the addition of thyroid hormone to treatment of patients suffering from refractory depression is often helpful, even when the blood tests are normal, as previously explained.

The proper appreciation of low thyroid conditions and their subsequent treatment should aid greatly in reducing the morbidity and premature mortality of virtually all degenerative diseases.

References

Barnes, Broda, M.D. and Galton, Lawrence, Hypothyroidism: The Unsuspected Illness
New York: Harper Collins Publishers, Inc., 1976.

Wilson, E. Denis, M.D. Wilson’s Syndrome: The Miracle of Feeling Well (2nd Ed.) Orlando: Cornerstone Publishing Co., 1991.