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HEALTH CONCERN? BioHealth Health Concerns

Hypothyroidism - The Underdiagnosed Dilemma

Contributing Author: Tranchitella, Tracy N.D.

TracyTracy Tranchitella, N.D. is a Doctor of Naturopathic Medicine who specializes in providing nutritional and homeopathic consultations, lifestyle counseling, botanical medicine and women's health assessments and detoxification programs. She graduated in 1998 from the Southwest College of Naturopathic Medicine (SCNM) in Tempe, Arizona. Currently, she lives and practices in Temecula, California. Dr. Tranchitella is licensed in the State of California and a member of the American Association of Naturopathic Physicians (AANP) and the California Association of Naturopathic Physicians (CANP).

» Website: Sunrise Medical


A recent study indicated that nearly 13 million Americans may have an undiagnosed low thyroid function. This is in addition to the approximately 20 million individuals who are receiving thyroid replacement treatment for hypothyroidism. Why the large discrepancy in diagnosis? One reason may be inadequate testing for thyroid hormone levels and the sole reliance by medical practitioners on these lab tests despite individuals’ specific health complaints.

This article will help explain the shortcomings of traditional medicine’s view toward thyroid function and low thyroid diagnosis, while exploring the vast array of nutritional and biochemical influences on thyroid function. However, before we can begin, an explanation of normal thyroid physiology is warranted.

Thyroid Physiology

The thyroid is a small, “butterfly-winged” shaped gland at the base of the neck. It forms a core link of (hormone) glands in the body, with a specific function to help regulate cellular metabolism and energy production.

The thyroid receives information from the pituitary gland in the form of TSH (thyrotropin stimulating hormone). This pituitary hormone under direct control from the hypothalamus directs the thyroid to produce thyroid hormone from iodine, protein, and amino acid tyrosine. The thyroid gland makes thyroxine (T4), which is relatively inert, and tri-iodothyronine (T3), the biologically active hormone, in an approximate 90/10 ratio, respectively. This preserves a steady pool of T4 for eventual conversion to T3 in the bloodstream, which is needed for cellular energy activation. The conversion of inactive T4 to active T3 is crucial in the progression of thyroid physiology.

Once T4 to T3 conversion takes place, cellular membranes are activated to assist transfer of thyroid hormone into the interior of our cells. Once inside, the thyroid hormone activates various enzyme pathways to increase energy production and metabolism, protein synthesis and breakdown of fat and carbohydrates, increased tissue oxygenation, mineral exchange within cells, and insulin production. In fact, thyroid hormone activates over 100 enzymes to produce a multitude of bodily functions. This is the main reason that altered thyroid production and/or function has/have such a broad range of negative effects on people’s behavior, moods and emotions, energy level, and physical well-being. In fact, the brain, heart, lungs, intestines, sex glands, muscles, and adrenal glands owe much of their function to normal thyroid physiology.

Finally, through blood level sensoring, the hypothalamus and pituitary help regulate thyroid hormone production by either increasing or decreasing signal input to the thyroid gland based on the overall needs of the body. In the case of low thyroid, the hypothalamus will stimulate the pituitary to secrete TSH, which in turn stimulates the thyroid gland to produce and release the thyroid hormones T4 and T3.

“Reverse” T3 phenomenon

As a normal byproduct of T4 to T3 conversion, a chemical called reverse T3 is produced. This hormone, an inactive form of T3, has no appreciable biological effects on cellular metabolism. Instead, the body should reabsorb it without causing untold problems. Unfortunately, in excessive amounts, this inactive hormone can have a negative feedback effect on the pituitary and hypothalamus, leading to reduced production of thyroid hormone. This is important in the context of low thyroid because many abnormal physical stressors can lead to this abnormal production, or reverse T3. Increased cortisol, heavy metal and chemical pollutants, nutrient deficiencies such as selenium, and certain drugs such as steroids and asthma inhalers are all contributors.

Signs and Symptoms of Hypothyroid

The symptoms of low thyroid are extensive and touch on many aspects of our physical, mental, and emotional well-being. It is important to realize that thyroid hormones regulate energy production. Therefore, hormone production and balance, immune function, digestion, biochemical regulation, and thought and mood production may all be affected:

  • Depression and Anxiety
  • Insomnia and Restlessness
  • Fatigue and Weakness
  • Heart Problems
  • Decreased Libido and Sex Hormone Issues
  • Weight Problems
  • Blood Sugar Imbalances
  • Cold Sensitivity, Dry Skin and Brittle Nails
  • Infertility and Miscarriages
  • Retarded Growth in Children
  • Cholesterol Problems
  • Immune Dysfunction
  • Osteoporosis

Thyroid Testing – The Area of ‘Repeated’ Misdiagnosis

Before the advent of laboratory testing, most doctors used clinical judgment based on the patient’s history of complaints and physical examination indicators to diagnosis hypothyroidism. Unfortunately, this skill has been all but lost unless an individual presents with end-stage signs and symptoms of ‘classic’ hypothyroidism. Even in this situation, many people go undiagnosed. One reason for this is the long-held belief that certain laboratory markers are absolutely specific for the evaluation of thyroid function. The main culprit is the TSH (thyrotropin stimulating hormone).

TSH – The normal reference range for TSH is 0.35 to 5.50. Strict adherence to this broad range is used as sole evidence for the existence of normal thyroid function by many health care practitioners despite an individual’s physical signs and symptoms. Therefore, a TSH above 5.50 would indicate low thyroid function. This rigid interpretation leads to many undiagnosed cases of thyroid function!

A recent report in the Journal of the American Academy of Endocrinology revealed that the range for TSH may be too broad. That is, numbers approaching the upper range of normal, i.e., 4.25 to 5.0 may in fact indicate developing hypothyroidism. This is a major shift in the field of traditional endocrinology, which for years has steered away from non-diagnostic absolutes, specifically with relationship to thyroid disease. Our experience is that TSH numbers above 2.0 (sometimes 1.5) indicate a potentially underactive thyroid function.

Total T4 and T3 – Often, a doctor will obtain a total thyroid (T4 and/or T3) level in addition to a TSH. These tests reveal the total amount of T4 and T3 thyroid hormone in your blood. What is confusing about this measurement is that it does not indicate the actual amount of active thyroid needed at the cellular level. These active components are called Free T3 and Free T4.

After T4 (and some T3) is produced in the thyroid gland, it is excreted into the bloodstream attached to a protein molecule. This protein molecule acts as a transport module for the thyroid as it courses through our bodies. Once in the liver and kidneys, T4 can convert to T3. Much of this conversion unlocks the thyroid hormone from the protein carrier and ‘frees’ it into the bloodstream. This unbound hormone is then free to perform its necessary metabolic activity. Total thyroid hormone measurements are important, but unfortunately are often misleading in the diagnosis of hypothyroidism. This is evidenced by a common scenario in which the total T4 and/or T3 is normal, but the free fraction is low.

T3 Uptake and Free Thyroxine Index (FTI) – These are common tests still performed by many laboratories. Our experience is that they are outdated and unreliable gauges of thyroid function and therefore should be abandoned.

Free T4 and Free T3

These two measurements, along with a highly sensitive TSH, are necessary to adequately evaluate thyroid hormone production. Anything less is inadequate. Because of the high reliability of FT4 and FT3, many alternative-minded clinicians are performing them. However, it is still important to look at these numbers in the context of the patient’s history. Many other factors, such as elevated cortisol levels, increased melatonin levels, and environmental factors, can have an impact on thyroid function.

The normal range for FT4 is .70–1.53 and FT3 is 2.3–4.2. Our experience is that most people should maintain levels in the upper two-thirds of normal. A variety of thyroid medications, diet, and/or nutritional supplementation can help achieve these levels.

Thyroid Treatment – The ‘Synthroid’ Dilemma

For many years, pharmaceutical companies have cornered the market in relation to thyroid treatment. The most successful campaign has been that of Knoll Pharmaceuticals, the producers of Synthroid. This particular medication has been the mainstay in the treatment of hypothyroidism, and patients present very few other options to their patients. People are told that they have to be on Synthroid for life, and that this is the best treatment for them. Albeit, Synthroid is an easy medication to regulate in its dosage and frequency, but for many people it is not ultimately effective.

One problem with Synthroid and other similar drugs is that they are synthetic derivatives of T4 only. Usually, T3 is not given to hypothyroid people because of fear of potential side effects such as osteoporosis, irritability, hormone irregularities, etc. The major error in prescribing T4-only medications is that the active component of T3 is forgotten. Most doctors assume that the body will make the necessary conversion of T4 to T3 with resulting correction of the hypothyroid state. This is a big mistake!

T4 to T3 – Factors Controlling Conversion

The conversion of T4 to T3 is a crucial step in the thyroid function process. If this step is deficient or altered in any way, the individual will suffer symptoms of low thyroid. Many factors are involved in this important step in thyroid physiology, and are completely overlooked by the narrowed-minded prescription of T4-only drugs. Eighty percent of T3 is produced outside the thyroid gland. Therefore, what clinically appears to be low thyroid function could actually be occurring for reasons that have nothing to do with the thyroid gland. The primary player in this process is the enzyme T4-5 deiodinase. This enzyme cleaves off one iodine molecule from T4 to make T3. Many factors have an effect on this enzyme, including:

  • Certain pharmaceutical drugs such as propylthiouracil, amiodarone, and propanolol all decrease the activity of T4-5 deiodinnase.
  • Starvation, diabetes, uremia, and other chronic debilitating conditions and diseases.
  • Nutrient deficiencies, most notably selenium. Also, zinc, glutathione, cobalt, vitamin D and riboflavin deficiencies have been implicated.
  • High carbohydrate diets.
  • Stress and the increased cortisol response.
  • A restricted calorie diet.

Other Factors of Thyroid Inhibition

Besides the effects on T4 to T3, there are many other factors that inhibit thyroid function:

  • Chemical exposure from PCBs, PVCs, DNPs, red dye #3, cigarette smoke, and the halogenated organic compounds chlorine and fluoride.
  • Heavy metal exposure such as mercury from fish, water, vaccines, and dental filling contamination.
  • Certain flavonoids in foods, such brussel sprouts, rutabaga, turnips, kohlrabi, cabbage, radishes, cauliflower, kale, and soy products. Millet has the highest content of antithyroid flavonoids.
  • Exposure to radiation.
  • Neck trauma and whiplash.
  • More pharmaceutical drugs such as lithium, dilatin, tegretol, dopamine, and excess iodine.

Treatment Options – The Natural and Nutritional Approach

There are many options for the treatment of thyroid problems. Not everyone needs to take the synthetic hormones such as Synthroid and Levoxyl. Instead, replacement with the natural hormone compound armour thyroid can be advantageous.

Armour thyroid, a compound of porcine thyroid, utilizes both T4 and T3. It is not limited to just replacing the T4 component of thyroid hormone like Synthroid, but helps augment the entire thyroid function. At times, an individual may develop sensitivities to the porcine compounds, or have a thyroid condition that is too unstable to benefit entirely from amour thyroid. In these cases, use of synthetic T4 and T3 may be warranted. However, other nutritional interventions may be employed to assist in proper thyroid function:

  • L-Tyrosine – This amino acid is a precursor to thyroid hormone, and dosage is 500 mg twice daily on empty stomach. Avoid use with milk. B6 and vitamin C can help absorption.
  • Iodine – Take in the form of kelp at 2,000 to 3,000 mg daily. Caution: Some people with autoimmune thyroid disease can develop aggravations from taking iodine.
  • B-Complex Vitamins including B2 and B12 – Approximately 100 mg three times daily is good. Brewer’s yeast is an excellent source of natural B-complex vitamins.
  • Essential Fatty Acids such as Fish Oil – These are essential for thyroid function. One tablespoon per day of each is recommended.
  • Increase consumption of molasses, egg yolks, fish, parsley, apricots, dates, and prunes.
  • Avoid processed and refined foods, including white flour and sugar.
  • Avoid alcohol, soda, and diet drinks.
  • Increase consumption of fresh, organic produce with a wide variety of fruits, vegetables, vegetable juices, and meats if desired.

Herbal Uses:

  • Black Cohosh Root – Glandular tonic
  • Triphala – Ayurvedic herbal glandular tonic
  • Saw Palmetto – Tonic
  • Siberian Ginseng – Tonic for adrenal and glandular system
  • Astragalus – Immune support
  • Fo-ti Root (Ho Shou Wu) – Similar to Siberian ginseng, but slower and broader action.

Basal Body Temperatures (BBT) – Factors Beyond the Thyroid

In the early 1980s, Broda Barnes, M.D., wrote a book titled Hypothyroidism: The Unsuspected Illness. Dr. Barnes attempted to make the public more aware of the use of axillary (armpit) basal body temperature as a sign and symptom of hypothyroidism. Many alternative and complimentary health care practitioners still use this method today. The premise is simple: if your average axillary basal body temperature is below 97.6, then you are suffering low thyroid function. The temperature readings need to be averaged over a five-day period, first thing in the morning before arising. Although the basal body temperature reading is a good way to assess low functioning metabolism, it does not indicate a primary thyroid problem. Other factors can have an impact on body temperature, leading to false diagnosis of hypothyroidism.

Cortisol, Melatonin, Neurotensin, and the BBT Riddle

Cortisol is an adrenal gland hormone with many important functions within our bodies. Apart form its role in glucose (blood sugar) control, anti-inflammatory properties, and immune system function, it has an impact on thyroid function, energy production, and body temperature set point. One of the major functions of cortisol is during a stressful event. When our bodies are confronted with stress, the adrenal glands are stimulated to secrete cortisol, which is necessary to meet the demands for increased use of fuel and energy by our muscles and brain cells. In a normal situation, cortisol levels should drop after the stressful event to prevent overstimulation of our energy production systems.

Unfortunately, this is rarely the case in our modern culture, as people are pushed beyond their normal coping mechanisms to deal with stress. For many people, elevated cortisol levels become the norm, leading to a multitude of problems including depressed immune function, sugar control issues, low thyroid function, and ultimately overtime adrenal fatigue and chronic illness.

Elevated cortisol leads to an inhibition of TSH. This reduces the signal to the thyroid gland and decreases production of the thyroid hormone. It also disrupts the production of Free T3 and increases reverse T3, leading to reduced thyroid function at the cellular level. In relationship to body temperature, cortisol is a key factor in setting the core temperature set point. With chronically elevated cortisol levels, especially in the morning, the basal body temperature will be low.

Melatonin – This hormone produced from the pineal gland within our brains is intimately involved in sleep and nervous system recovery. Along with cortisol, it is involved in the core body temperature set point. Melatonin tends to reduce this set point by 50–60%. When melatonin is at its peak, the core body temperature can drop by one degree. This is especially problematic if too much melatonin is being produced in the morning, when basal body temperatures are being taken.

Neurotensin – This chemical is not widely known. It is thought to be a neurotransmitter in the brain that is released when people are under stress. One of its functions is to suppress the thyroid at the cellular level. In experimental animals, an injection of neurotensin can mimic hypothyroidism.

It is important to realize that measuring basal body temperatures is a good way to assess problems with the metabolic state of the body, including thyroid function, but can give a false analysis of primary low thyroid function, leading to unnecessary thyroid treatment.

Key Points – What You Can Do If You Suspect Hypothyroidism

  • Obtain a thyroid panel that includes a high-sensitive TSH, Free T4, and Free T3.
  • If your TSH number is above 1.5 then low thyroid may be an issue. The higher your TSH numbers past 5.5, the greater the chance your thyroid is underfunctioning.
  • Make sure your Free T4 and Free T3 numbers are in the upper two-thirds of the normal range. Always obtain copies of your laboratory results for analysis. If you suffer from a chronic debilitating illness such as heart failure or other cardiovascular ailments where elevated thyroid levels may be contraindicated, then lower levels may be necessary.
  • If you are currently on synthetic T4 (Synthroid or Levoxyl), consider switching to a combination formula (armour thyroid) to better supply T4 and T3.
  • Increase consumption of thyroid-enhancing nutrients (see above).
  • Obtain an Adrenal Stress Profile to assess cortisol levels.
  • Avoid or reduce consumption of goitrogenic foods (see above list).
  • Reduce stress in your life by getting adequate rest, sleep, exercise, and avoiding stimulants such as cigarettes, caffeine, and diet pills.

If attempting to change your medication, or if you suffer from a chronic debilitating illness, always work in conjunction with a friendly, supportive, and open-minded physician to better handle your health care needs.