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Thyroid Disorders

I have a 52-year-old male with Graves’ disease who we are tracking with thyroid labs. His TSH is consistently 5 and occasional palpitations despite being on LDN, autoimmune Paleo diet, and various supplements over the past few years, including bugleweed, L-carnitine, meriva, etc. We ran the Cyrex Array 2, which was normal, and the Array 10. He’s completely gluten, dairy, and grain-free, so we didn’t do Arrays 3 or 4. Array 10 showed to be positive to egg whites, some nuts, most fruits and vegetables across the board, but negative to white rice and black beans. I spoke with Dr. Alexander at Cyrex about the discrepancy between Array 2 being negative and Array 10 being very positive, and he felt that the negative Array 2 definitely means the patient does not have leaky gut and that Array 10 was still positive due to immune system reaction to the food antigens in the system. Do you have any recommendations either for this patient and/or how to explain the test discrepancies?

Chris Kresser: Interesting question. Going back to the case, you mentioned he has Graves’ disease, but his TSH is 5,...

I’m somewhat confused about testing the HPA axis in terms of thyroid health and how this could confuse things. On page 14 of Datis Kharrazian’s thyroid book, he says, ‘In people with hypothyroidism, urinary excretion of several arena hormones decreases. So someone could appear to have an advanced case of adrenal fatigue when, in fact, they’re simply doing a poor job of clearing the hormones through the kidneys. He’s basically explaining that he prefers salivary testing. You briefly mentioned this in last week’s material how urinary cortisol metabolite measurement might become a means of diagnosing subclinical thyroid dysfunction in both hyperthyroid and hypothyroid. Do you agree with Datis that this is a problem with urine testing, and if so, are there ways around this or extra tests on top of the DUTCH Complete so the thyroid malfunction doesn’t get confused with HPA-D?

Chris Kresser:  No, I don’t think it’s a problem because you’re testing free cortisol and metabolized cortisol in the urine,...

I have a female client, 30 years old, recently diagnosed with subclinical hypothyroidism. Has been taking 25 mcg of thyroxine a day. This brought back her period after a year’s absence, and she has bled twice already in one month. She has had problems with her sex hormones for as long as she can remember, i.e., very severe PMDD, depression, high-low libido, bad lower back cramps, headaches, insomnia, etc., and hormone-induced migraines with aura that leave her paralyzed with pain, trembling, sickness, and give her numbness moving from her lower arm up to each individual finger. Due to her hormonal situation, she didn’t suffer any attacks over the course of the past two years but has now had one again. She is already on a very healthy, balanced, Paleo-type diet. Gets daily gentle movement, long walks, but still struggles with depression and anxiety. It’s sad to see such a young woman not really living her life at all for fear of getting an attack. I’m already trying to work on her stress levels, though this is proving to be a hard task. Any suggestions on how to finally get her hormones balanced?

Chris Kresser:  Well, I’m not sure if you’ve done all of the full case review workup with the gut panels...

This is a case study. A 50-year-old female, weight gain, hair loss, feels cold, follows Paleo and quit her job to work on her health, so that gives you an idea of the intensity of her symptoms. She is on a T4 and T3 combo, but her values on recent testing are really high. This is after reducing her dose by 20 percent. TSH is basically 0, T4 12, free T3 4.6, and reverse T3 is 36. TRP was 3. Ferritin was low a year ago, but don’t know it now. Symptoms are worse after the reduction. She’s taking selenium, iodine, and a zinc supplement for thyroid support. BioHealth salivary adrenal test showed a flattened cortisol curve and overall low cortisol values with low DHEA. She was started on hydrocortisone by another functional medicine practitioner. She was feeling well until her thyroid medications were dropped because her labs were in a hyperthyroid range and she was losing a lot of hair. I treated her for bacterial and yeast overgrowth based on Genova testing, but no breath testing. Practitioner who has her on 5 mg of hydrocortisone is suggesting a Wilson’s protocol of T3 only treatment to knock her reverse T3 back in line. I’m not too familiar with that program. Regarding next steps, (1) Check diet and make sure she’s not too low carb. (2) Recheck inflammation, autoimmune markers, ferritin, iodine, and zinc. (3) Check breath tests for SIBO, and (4) Consider low-dose naltrexone (LDN).

Chris Kresser:  Great study. A lot of stuff to talk about here. So the first thing is that her thyroid...

In the case of low TSH just below the lower end of the normal range and T4 also just below the lower end of the normal range and T3 in range, but low, would you advise taking thyroid medication? No thyroid antibodies are present. Secondly, what could be the reasons for the low TSH?

Chris Kresser:  We’ll cover this in a little more detail when we talk about thyroid and blood chem, but when...

In a patient with high free cortisol and low metabolized cortisol, we were taught this week that thyroid function could play a role. Can you explain how? Maybe I mistaught myself, but I thought adrenal function worsened thyroid dysfunction. Maybe it’s bilateral, but could you specifically explain the mechanism of action for thyroid dysfunction inhibiting the metabolism of free cortisol? Separately, via the DUTCH testing, I’ve superficially learned that liver dysfunction can also negatively impact this conversion. What kind of liver dysfunction? Are we talking about detoxification or something else?

Chris Kresser:   It’s true. High free cortisol and low metabolized cortisol, hypothyroidism is one of the causes of that imbalance,...

For hypothyroid patients, do you check serum iodine and selenium levels? Should we recommend patients to take foods containing these nutrients or even supplement without testing, given the narrow therapeutic range of especially selenium?

Chris Kresser:   Let’s talk about iodine first. I do test for iodine, but I do it based on diet. If...

When treating Hashimoto’s, how essential is it to limit goitrogenic foods? The patient is taking Synthroid at 88 micrograms per day. Her TSH is 3.96. T3 and T4 are in range, but her TPO is 85.

Chris Kresser:  I believe we’re going to talk about this soon in the exposome unit, but when it comes to...

How do you tell exactly if hypothyroidism is autoimmune in nature? What would levels of TPO antibodies need to be? I’m asking because Chris talked about possibly using an AIP diet and how possibly people with Hashimoto’s don’t always respond well to iodine, but often it’s OK if you add selenium. How do you monitor their response to iodine, and how do you check their selenium levels via blood sample for both iodine and selenium? How long after trying to introduce iodine would you test their levels, and what dose would you try adding in the iodine, say, by kelp capsules or adding seaweed in the diet?

Dr. Amy Nett:   I’m glad we get to follow up on this because, Laura, I think you and I were...

A 27-year-old female. She has an elevated TSH. Her TSH was 5.5, and then her total T3 was 1.3. Free T4 was 14 picomoles per liter. Ran DUTCH panel, altered diet to a Paleo template, introduced stress management techniques. Free and metabolized cortisol in the normal ranges. Elevated beta and alpha pregnanediol. Patient metabolizing through the 5-alpha pathway, though no androgenic effects are noticed. Retested TSH six weeks after the above intervention. Now it’s 6.13. Patient now has energy at work and in the morning, no longer feels as though she needs to sleep until noon on weekends, but the doctor is insisting on thyroid treatment. Unsure where to go from here.

Dr. Amy Nett:  It sounds like she had … I think this is subclinical hypothyroidism, without having the reference ranges...
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