My clinic focuses on preventing and reversing diabetes and heart disease, but I've been struck with how prevalent thyroid disease has become in my practice. In particular, hypothyroidism (underactive thyroid) due to an autoimmune condition called Hashimoto's thyroiditis.
Unfortunately in medical training I was not taught about the early presentation of this condition through the more subtle detection of lab abnormalities and the fact that this condition is predominantly caused by lifestyle changes, rather than an irreversible condition that requires you to be on lifelong thyroid hormone therapy.
Hashimoto's thyroiditis is 7-8 times more common in women than men and the peak periods for onset in women are what I call the “3 Ps”…Puberty, Pregnancy and Perimenopause. Other than being female, other risk factors include (but are not limited to) the following:
Family history of thyroid disease
Presence of other autoimmune conditions
History of thyroid injury (thyroid or neck surgery, radiation or radioiodine therapy)
Sudden increase in cholesterol, especially LDL cholesterol
Other lab abnormalities like low sodium (aka “hyponatremia”) and macrocytic anemia
I'm not a thyroid expert, but I take this condition seriously in the context of my efforts to reduce the burden of insulin resistance, since individuals who have suboptimal thyroid function have some combination of fatigue, difficulty losing weight, depression and a whole host of other symptoms which directly or indirectly contributes to their risk of diabetes, heart disease and other chronic health conditions.
By the way, an overactive thyroid is most commonly due to a different autoimmune condition called Grave's disease, but we will focus mostly on Hashimoto's since it is the most common cause of thyroid disease overall.
It's More Than Your Thyroid
Before we dig deep into the inner workings of your thyroid gland and how to potentially heal it, you must understand that if you have this condition you are at risk for many others.
If you just treat your underactive thyroid with a thyroid pill and go on with your usual life, you are doing nothing to calm your immune system's attack on your body.
This is analogous to trying to fix your low back pain by simply getting a massage, getting a steroid injection into your spine, or doing only low back pain stretches. Such treatments may help alleviate some of your back pain, but if you want to cure it, you need to think beyond your low back.
Weight loss, core strengthening and improving hamstring flexibility are a few of the ways to accomplish this, otherwise inevitably you'll deal with future episodes of low back pain, knee pain, plantar fasciitis, etc. If you suffer from low back pain, be sure to read my prior post here.
This post will help you understand the deeper root causes of your thyroid condition, so you not only just heal your thyroid, but also prevent immune system-inflicted damage to other regions of your body (brain, heart, digestive tract, etc.).
Brief Thyroid Science
Your thyroid is a butterfly shaped gland that sits at the front of your neck and helps regulate your metabolism. Think of an overactive thyroid speeding things up, like your heart rate, your bowel function (aka diarrhea), your energy levels and even weight loss, while an underactive thyroid would do the opposite, slowing down your pulse, your bowels (constipation), your energy levels ( fatigue) and causing difficulty losing weight.
In order to understand how the thyroid influences your metabolism, you need to understand the complex interplay of the various thyroid hormones which we'll discuss.
An underactive thyroid can present with any combination of the following symptoms:
Hair: diffuse hair loss (may notice in the shower), hair can become dry/brittle, eyebrow hair loss especially at the outer edges
Eyes: puffy or swollen eyes, eye protrusion, eyelid retraction
Skin: pale color, dry and flaky skin (especially on face), cold extremities (arms and legs) even if warm outside,
Digestive: constipation, irregular bowel habits
Mental: fatigue, depression, anxiety, “brain fog” (trouble with focus, memory, etc.)
Other: menstrual irregularities, infertility, general swelling anywhere in body
By the way, an overactive thyroid may have overlap with some of the symptoms above, but overall you get more hyperactive symptoms due to a revved up metabolism, like unintentional weight loss, anxiety, palpitations, and heat intolerance.
Unfortunately things are not so black and white between having just an underactive or overactive thyroid.
Although Hashimoto's generally causes an underactive thyroid, there can be periods where it alternates with an overactive thyroid as well.
Hashimoto's is basically due to an attack by your immune system on your thyroid cells, which produce your thyroid hormones. Initially this attack may lead to your thyroid cells leaking out an excess of thyroid hormones into your blood, causing the transient overactive thyroid symptoms. However, then the next stage is your wounded thyroid cells, betrayed by the crossfire from your own immune system, can no longer produce sufficient hormones, leading to an underactive thyroid.
The risk of reading through a long list of thyroid symptoms is that anyone can relate to at least a few of these and may jump to the conclusion that they have thyroid disease. Although I said Hashimoto's is the most common cause of an underactive thyroid, the most common cause for many of these symptoms like fatigue and weight gain are more likely some combination of poor diet, insufficient exercise, excess stress and a lack of sleep, which by the way do influence thyroid function too. Taking a thyroid pill is not a replacement for these lifestyle factors.
The listed symptoms can increase your suspicion that you might have Hashimoto's thyroiditis, but then the next step is to determine if your actual thyroid hormones are out of balance. Before we talk about thyroid labs, let's first understand how your thyroid hormones work.
Thyroid Hormone Primer
So now let's discuss the different types of thyroid hormones and how they interact with one another.
1. TSH (Thyroid Stimulating Hormone) is released by the pituitary gland located at the base of your brain (behind your nose), which then travels south to the thyroid gland located in your neck to stimulate the release of the thyroid hormones (T3, T4) which we'll discuss next.
When your thyroid is underactive, like in Hashimoto's disease, your TSH becomes elevated in an effort to trigger greater thyroid hormone release.
So it's an inverse relationship where an underactive thyroid yields a high TSH and an overactive thyroid yields a low TSH.
2. T4 is the precursor form of the active T3 hormone (discussed next). T4 is also referred to as the inactive form of thyroid hormone.
3. T3 is the active form of thyroid hormone that gives you energy. Some practitioners refer to it as the body's gas pedal.
4. RT3 (Reverse T3) is the opposite or “reverse” of T3. If T3 is the gas pedal that revs up your body's energy levels, then RT3 are the brakes. In medical school I learned that an excess level of RT3 is due to a condition called sick euthyroid syndrome, where severely ill, hospitalized patients have high levels of RT3.
What I didn't realize is that individuals, especially women, under the chronic stress of daily life can also have elevated RT3.
Instead of T4 converting into the energizing T3 hormone (the gas pedal), it shifts to production of RT3 (the brake pedal), leaving individuals feeling sluggish, depressed and struggling to lose weight.
There's nothing better than pictures to summarize all this information. The image below nicely summarizes the interaction between the different hormones. You can see how the TSH is released from the pituitary (in your brain) to your thyroid gland (in your neck) and then the thyroid releases the different thyroid hormones.
You can also think of this as a top down corporate hierarchy where the TSH is the CEO who sits in a corner office in the brain and then barks out orders to his management staff in the thyroid gland to deploy the worker hormones (T4, T3, Reverse T3). T3 is the eager beaver high energy worker who gets things done (increase metabolism, burn body fat, etc.).
RT3 is the more conservative worker who doesn't like taking chances and keeps things status quo or even slows down progress. When RT3 is high, you also may lack the energy and drive to get things done (exercise, start that new business, etc.).
Notice from the image how T4 essentially has 2 main fates. It can turn into the active T3 hormone or it can be diverted into RT3 leading to insufficient T3 production. In an ideal world we want T4 to move more in the higher energy T3 direction rather than the sluggish RT3 direction.
Your Thyroid Lab Tests
Unfortunately like most doctors, I also used to focus most of my attention on the TSH test as being the main marker of thyroid health, without paying attention to the other hormone levels. This is a flawed approach because as we discussed above, even if your TSH is in “normal range,” your body may not be converting the T4 precursor hormone into the active T3 hormone which will lead to a sluggish metabolism.
Understanding thyroid lab tests can be difficult, so I'll go over a few basics in my summary below, but please defer to a knowledgeable health practitioner for an accurate interpretation.
In the medical world there has been ongoing debate over what a normal TSH level actually is. Most major health care centers have set their normal range roughly between 0.5 and 5.0 uIU/ml. Recall from above that a high TSH indicates an underactive thyroid gland.
However, expert groups like the American Association of Clinical Endocrinologists (AACE) believe the upper range cutoff should be 3.0 uIU/ml instead of 5.0, while other groups think it should be as low as 2.5 uIU/ml.
Regardless of where you set the cutoff (I favor 2.5 uIU/ml), it's more important to detect trends. Has your TSH gradually crept up over the years, which would indicate an increased risk towards developing Hashimoto's thyroiditis? That doesn't mean we would immediately treat you with thyroid hormone if your TSH is 3.0, but we would consider following your labs more regularly and implementing the lifestyle changes we'll discuss in a moment.
Finally, notice from the previous thyroid anatomy diagram that TSH is not made in the thyroid. It is made one level up in the pituitary gland. A normal TSH doesn't automatically mean your thyroid gland is functioning optimally. In the early stages of Hashimoto's disease your TSH can be within range while the thyroid hormone levels (discussed next) start showing subtle abnormalities.
This is a fundamental reason why so many doctors miss early abnormalities of thyroid function. Because they treat the TSH, made in the pituitary, as a direct mirror of thyroid gland function, which it isn't in so many cases.
Free T3 (aka FT3)
Recall Free T3 (aka FT3) is the active thyroid hormone. Standard lab ranges are 2.3-4.2 pg/mL (varies among labs), but optimal would be approximately 3-4 pg/mL. You are generally looking for the FT3 to be at the mid to upper range of your lab results.
Free T4 (aka FT4)
Recall this is the precursor hormone that is converted into active FT3. T4 does have some metabolic activity, but it's four times less than that of T3. Standard lab ranges are o.59-1.61 ng/dL (varies among labs), while optimal may be more like 1.0-1.5 ng/dL. Like FT3, you are generally looking for the FT4 to be toward the mid to upper range of your lab results.
Reverse T3 (aka rT3) and FT3/rT3 ratio
Recall rT3 are the “brakes” that slow down your metabolic processes. An optimal rT3 level can range between 15-25 ng/dL or less. A better way to assess rT3 is by comparing it to FT3 by using the FT3/rT3 ratio which looks at whether your body is producing more of the active FT3 hormone (the “accelerator”) and less of the rT3 (the “brakes”).
The challenge though is the ratio must be calculated using the right units. This site has a handy calculator, but YOU MUST make sure you choose the right units of measurement or your ratio will be incorrect. Read the instructions on the site very carefully.
You can actually measure some of the key antibodies that attack your thyroid in Hashimoto's disease like anti-TPO (thyroperoxidase) and anti-thyroglobulin antibodies which can return positive even before your standard thyroid labs become abnormal.
I order these tests in many of my patients who have a borderline TSH and if positive this would confirm early stage or at least a high risk of developing Hashimoto's disease. With some of the recommended lifestyle changes we will discuss, antibody levels can potentially be lowered or become undetectable.
Keep in mind that the vast majority of doctors will be unwilling or hesitant to order extensive thyroid lab panels, especially on a recurrent basis. It's not because they don't care or are incompetent. They are following the standard practice guidelines which are TSH-focused, and trying to avoid what they believe is unnecessary and costly additional testing.
However, if you have persistent symptoms and especially significant risk factors (family history of thyroid disease, other autoimmune conditions, history of radioactive iodine exposure, etc.), then it's reasonable to ask for additional testing like FT3, FT4 and the thyroid antibody tests. Even if these are normal, at least you have a baseline for comparison in the future.
If you still need additional expertise, consider seeing an endocrinologist or you may need to consider seeing an integrative or functional medicine doctor who is skilled at interpreting and monitoring thyroid test results.
Is Hypothyroidism (Hashimoto's) Reversible?
In my experience it is reversible but not in all cases. The earlier you can detect this condition or the precursor to this condition following some of the lab principles discussed already, the better the chance of reversing it. Below I've listed just a few of the top strategies for reversing Hashimoto's thyroiditis naturally.
Recall that in the beginning of this post I said Hashimoto's was an autoimmune condition, meaning your own immune system is attacking your thyroid gland. One of the factors that can trigger this attack are certain food proteins like gluten, which is found in wheat, barley and rye.
One study done by Italian researchers showed that after following a gluten-free diet for 1 year, the majority of individuals with a condition called subclinical hypothyroidism normalized their condition. Subclinical hypothyroidism is an early stage of Hashimoto's when your TSH is elevated, but the thyroid hormone levels (FT3, FT4) are normal.
There is not just a connection between celiac disease (more severe form of gluten intolerance that causes damage to the small intestine) and Hashimoto's, but even NCGS (non-celiac gluten sensitivity), which is a milder form of gluten sensitivity, is also linked.
For my patients who have Hashimoto's disease, one of the first recommendations I make is for them to follow a gluten-free diet for at least 3-4 weeks (preferably longer) to see how they feel.
Keep in mind that gluten is hidden in all sorts of foods and to really test whether this helps heal your thyroid, you must completely eliminate it from your diet.
A small bite of toast or using a sauce with gluten, like soy sauce (use tamari instead) is enough to trigger a reaction in those who are sensitive. I have definitely seen improvements in patient's Hashimoto's based on lab results after trials of gluten elimination and many of my colleagues who have tried this have reported the same. The Celiac Disease Foundation has great resources here to help you learn how to follow a gluten free diet.
After gluten, dairy is the next most common food group that can potentially trigger Hashimoto's. In fact, a significant percent of individual's with Hashimoto's disease are also lactose intolerant as shown in this study.
There is lots of controversy regarding whether soy has adverse effects on thyroid function. Soy does belong to a category of foods called goitrogens, which can cause the thyroid gland to enlarge. Soy may also contain specific isoflavones (plant-derived compounds with some estrogenic activity) that interfere with thyroid hormone production, but no definitive studies show that at least moderate consumption of soy causes abnormal thyroid function.
In order to potentially avoid or minimize the need for thyroid medication, it is worth doing a trial of eliminating at least gluten, dairy and soy from your diet.
If you want to be even more rigorous, consider doing a complete elimination diet where you also remove grains, eggs, sugar, caffeine, nuts, seeds and alcohol.
I know that sounds drastic, but it is incredible how often an elimination diet can help heal years of chronic symptoms and health conditions. My RID program includes a comprehensive guide on how to do the elimination diet properly.
There are some specific micronutrients that are essential for proper thyroid hormone production and function such as selenium, iron, copper, vitamin D, B vitamins and zinc. Many of my patients who are eating nutrient deficient diets are often lacking these essential elements. Eat foods that are naturally rich in these minerals such as Brazil nuts, which are an excellent source of selenium (eat around 4 daily), and in some cases supplementation may be necessary.
What about iodine, an essential mineral needed for thyroid hormone production? Either too much or too little iodine can trigger thyroid problems. Industrialized countries typically get plenty of iodine from table salt. The thyroid gland only needs about 50 mcg of iodine daily. Keep in mind that artisanal salts like pink himalayan sea salt have trace amounts of iodine.
We are exposed to multiple toxins on a daily basis through the air we breathe, the food we eat and the water we drink. The thyroid gland itself is not as selective as we'd like. It allows the entry of minerals like iodine and selenium which are needed for normal thyroid hormone production, but unfortunately many harmful chemicals which partially resemble these elements can also get into thyroid cells and cause damage.
BPA (Bisphenol A) in plastic water bottles and food containers, heavy metals (mercury, cadmium, lead, aluminum), industrial chemicals like perchlorate and PCBs, and pesticides from non-organic produce are some of the common toxins that can contribute to thyroid disease.
It may sound overwhelming trying live a toxin-free life, but there are some simple measures you can take to minimize the overall toxic burden and allow your thyroid to significantly improve its function
Replace all plastic water bottles and food containers with glass. Don't compromise. BPA can seriously affect thyroid function along with being linked to diabetes, obesity, heart disease and other health conditions. BPA-free plastics are better but may still contain chemicals that can enter the thyroid and cause harm. Read this article in National Geographic about the potential harms of BPA-free alternatives. Glass is best.
Buy organic produce whenever possible and especially prioritize the Dirty Dozen which are found here (produce with highest pesticide content)
Get a high quality water filter, such as a reverse osmosis filter
Get enough selenium in the diet (mentioned under micronutrients) since this can help protect the thyroid agains some of the toxin damage.
Avoid non-stick cookware which contain a chemical called PFOA (perfluorooctanoic acid ), which can damage the thyroid as shown here.
Eat lots of plants. A variety of different phytonutrients from eating diverse plants can help your body detoxify many of these chemicals. Cruciferous vegetables in particular (broccoli, cauliflower, cabbage, kale, etc.) and bitter vegetables are especially good for detoxifying the liver. For those of you worried about the link between cruciferous vegetables and thyroid disease, you would need to consume abundant amounts of raw crucifers to have issues. Cooked crucifers would not have an impact.
EWG is an incredibly valuable website that highlights practical tips for minimizing many of the above exposures.
As mentioned, chronic stress inhibits conversion of T4 to active T3. I've covered stress in prior blog posts, but managing stress is a critical part of optimizing thyroid function. You can find some of my prior posts on stress here.
Also keep in mind that the negative impact of stress on thyroid function is also one potential mechanism to explain how stress causes fatigue and potentially weight gain due to a slowed metabolism.
Most women are familiar with the effects of low estrogen from menopause such as hot flashes and vaginal dryness. but did you know that having excess levels of unopposed estrogen (too much estrogen without enough progesterone) can have side effects such as impairing thyroid function.
The mechanism for how this happens is that the estrogen causes the liver to produce an abundance of a protein called TBG (thyroid binding globulin), which ties up thyroid hormone and prevents it from entering the cells.
Some ways to minimize estrogen dominance are by losing body fat (excess body fat promotes excess estrogen production), avoiding plastics since BPA mimics estrogen activity, improving liver function and gut health naturally, and avoiding the intake of unopposed estrogen medications and xenoestrogens (estrogen-like compounds found in consumer products like perfumes, lotions, creams, etc.).
This is a good article on estrogen dominance. Consider working with a physician who knows how to diagnose and manage estrogen dominance.
Are Certain Cultures More At Risk
I am seeing quite a bit of Hashimoto's thyroiditis in my Asian and Indian patients since they typically have multiple lifestyle risk exposures, such as the following:
A heavy gluten-based diet coming from abundant wheat
Multiple micronutrient deficiencies, especially in vegetarians (iron, B-vitamins, vitamin D, zinc, selenium, etc.)
Multiple toxin exposures from living in old homes now or in the past (mold, lead paint, etc.), air pollution, pesticide-laden produce, contaminated ground water, use of plastic food containers and non-stick pans (still common practices in Indian and Asian households).
Lead toxicity is especially of concern to children and adults, coming from common sources like turmeric. Read our lead post here.
Why Women Suffer More Often
As mentioned already, women are 7-8 times more likely to develop Hashimoto's than men, especially during the 3 Ps (Puberty, Pregnancy and Perimenopause). We already discussed the role of estrogen dominance.
I also want to highlight that women's bodies have a much lower threshold for switching on a lower metabolic, energy-conservation mode. This is an evolutionary adaptation that allows women to conserve body fat in an effort to preserve fertility during times of physical and/or emotional stress.
A woman who remains habitually worried (even at a low level) or anxious throughout the day because of work, family, finances, etc. sends a signal to her body and hormonal system that she is under low level attack.
The attack only gets worse when women frustrated with their weight gain and fatigue decide to diet harder and exercise harder. A starvation style bootcamp or detox diet might work for a few weeks, but the body then shifts into a slower metabolism by influencing hormonal systems like the thyroid, causing a rapid regain of weight. This is the classic phenomenon of the yo-yo diet and may also explain why the ketogenic diet doesn't work for many women. Read about my top concerns about the keto diet here.
Should You Be Treated for Hashimoto's
This is a decision you need to make with your doctor or health care practitioner. In general, if you've had abnormal labs the first step is to repeat the test for confirmation. I've often found that repeating an abnormal TSH result can return a normal result.
If your test(s) are confirmed to be abnormal, then talk to your doctor about a dedicated lifestyle trial for 2-3 months to address many of the common issues discussed above and then have the test repeated. I've been surprised by how many individuals in my practice have been able to normalize their thyroid function just through lifestyle changes.
However some may have little to no success in which case thyroid hormone replacement becomes necessary. A standard medical approach would be to prescribe T4 therapy, but other alternative and integrative/functional medicine practitioners may recommend some combination of both T3 and T4 therapy.
Talk to your doctor about the best option and if your results are borderline or abnormal, be sure you get your hormone levels checked regularly while you monitor yourself for improvements in your symptoms and overall wellbeing (energy, mood, etc.).
I realize this is a detailed post, but hopefully it helps you understand the complexity of this condition and how our modern lifestyle and environment are contributing. By the way, all of the risk factors we discussed are linked to various other autoimmune conditions and chronic diseases like heart disease, cancer and Alzheimer's disease.
In addition, if you are someone who has had a history of Hashimoto's thyroiditis and have been treated with thyroid hormone to achieve a normal TSH level, don't be complacent. Your thyroid condition was one detectable alarm signal indicating an autoimmune attack on your body.
As I mentioned earlier, there is a strong chance your immune system is reacting against other tissues in your body as well, so be sure you implement a comprehensive diet and lifestyle strategy.
When patients are able to reverse their Hashimoto's, I'm reassured that they have significantly lowered their risk of multiple other conditions by taming an overactive immune system.
Some other resources you may want to check out for your thyroid are listed below.
thyroidpharmacist.com is an excellent and comprehensive website run by pharmacist Izabella Wentz who has also written some great books on the topic.
My RID wellness program targets weight loss, insulin resistance and inflammation, which we discussed is a core part of Hashimoto's
stopthethyroidmadness is a great resource with lots of practical information