The Diagnosis and Treatment of Hypothyroidism
© Michael Schachter M.D., F.A.C.A.M.
Hypothyroidism, or an underactive thyroid system, is one of the most underdiagnosed and important conditions in the United States. It has been called the "unsuspected illness" and accounts for a great number of complaints in children, adolescents and adults.
What kinds of complaints characterize an underactive thyroid system? Low energy and fatigue or tiredness, especially in the morning are 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, chronic constipation, menstrual problems-such as PMS and menstrual irregularities including heavy periods, fertility problems, stiffness of joints, muscular cramps, shortness of breath on exertion and chest pain are some of the symptoms that can be seen in people with underactive thyroid systems. 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.
Function of the Thyroid Gland
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 iodine to make the thyroid hormone called thyroxine or T4. Thyroxine is called T4 because it contains four 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.
The production and release of T4 from the thyroid gland is controlled by a hormone from the pituitary gland, which is located at the base of the brain. This 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 trouble making T4 due to iodine deficiency or for some other reason, one would expect to find an elevated TSH. 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 low production and secretion of T4.
Diagnosis of Hypothyroidism
So, 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 T4 is calculated. If a patient has a normal TSH and a normal free T4, he is told by the conventional physician that he does not have hypothyroidism, no matter how many symptoms or signs of hypothyroidism he has. This is the fatal error because these tests only pick up the most severe cases of hypothyroidism and miss virtually all of the milder cases 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, hypothyroid states were diagnosed by astute clinicians, who obtained careful medical histories, including family histories from the patient, and who performed a complete physical examination. Later basal metabolic rates were measured 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, they were soon relied upon exclusively. To properly diagnose hypothyroidism, the clinician must go back to the careful medical history, physical examination and measurement of the basal temperature of the body. I'll discuss important aspects of the medical history and physical examination relevant to the diagnosis of hypothyroidism.
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; 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 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 are 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.
Measuring Basal Body Temperature
Instructions for taking basal body temperatures are relatively easy. Use an oral glass thermometer. 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 must only take the basal temperature test for thyroid function on the 1st, 2nd, 3rd or 4th day of menses(preferably beginning on the 2nd day). Males, pre-pubertal girls, and post-menopausal or non-menstruating women may take basal temperatures any day of the month. Women taking progesterone should not take it the day before and the days that the basal temperatures are taken.
Most of the information on the manifestations of hypothyroidism, its diagnosis, including the technique for measuring and interpreting basal temperatures, and the treatment to be discussed was compiled and described by the late Dr. Broda O. Barnes. 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, 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.
Treatment of Hypothyroidism
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 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. In contrast, most conventional physicians prefer to use the synthetically produced thyroxine or T4. 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.
How can we monitor the results of treatment if the blood tests are inadequate to the job? We do this by how the person feels, whether or not the thyroid symptoms and signs have improved or disappeared, whether or not symptoms of an overactive thyroid gland have developed, and by monitoring the basal body temperature.
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 adjunctive necessary things, which I will discuss in a moment. Occasionally, the dosage may need to be 2 and a half 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 and from 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.
Special Cases: Recent Heart Attacks and Weak Adrenal Function
There are a few special cases that needs 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, 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 adrenal is 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 function, will help to assure the desired results.
Problems in Converting T4 to the T3 Hormone
The conversion of the relatively inactive T4 to the active T3 thyroid hormone is an important process. As mentioned previously, frequently low thyroid function is not due to the low production of thyroxine, T4, by the thyroid, but due to 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 cortisol, iron, zinc, copper and selenium are necessary for this conversion. Deficiencies of any of these minerals can prevent the conversion T4 to T3 and should be corrected if present. Sufficient protein and especially the amino acid, tyrosine, and iodine are necessary to make T4 in the thyroid gland.
Another approach to the problem of conversion failure of T4 to T3 has been proposed by a young physician, Dennis Wilson. 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 unavailable, is to stop converting T4 to T3. However, this response appears to occur 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 symptoms and signs of a low thyroid that I have been discussing.
He has suggested the 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 and 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.
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, 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, estrogens, progesterone and the male hormone, 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. The nutrients that are especially important to a proper functioning thyroid system are iodine and the amino acid tyrosine to make thyroid hormone in the thyroid gland and the minerals iron, selenium, zinc and copper to convert the inactive T4 to the active T3.
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 symptoms and signs and 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 we have 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 patients suffering from refractory depression often is helpful, even when the blood tests are normal.
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.
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