Hyper or Hypo? Balancing the Thyroid
I continue in my daily efforts to educate and treat patients who are having thyroid difficulties. A few case histories illustrate the range of concerns that come to my practice each day, and the efforts we make together to achieve balance and health.
“Valerie,” a 51-year-old retired teacher, came to see me and frankly said she hoped it would be worth the two-hour drive. Prior to the past two years, she had always been healthy and energetic. Now she had a variety of symptoms including muscle aches in her back and arms, headaches, ringing in her ears, as well as fatigue, burning sensations in her stomach, insomnia due to body jerking as she was falling asleep, pounding in her ears, sinus congestion, inability to focus or concentrate, and a feeling of overall apathy. Life was certainly not fun for this woman.
She had been taking thyroid medication (Unithroid and then Synthroid, both T4 preparations) without relief of her fatigue or other symptoms. Actually, on thyroid medication she had symptoms of both hypothyroidism and hyperthyroidism! Symptoms of low thyroid include weakness, fatigue, hair loss, feeling cold, constipation, weight gain, and puffy face, hands and feet. People with hyperthyroidism are often jittery, nervous, weak, and often experience heart palpitations, rapid heart rate, and shakiness.
This patient’s tests showed her to be low in thyroid, but whenever her doctor increased her dosage of thyroid she would immediately have symptoms of severe hyperthyroidism! She never felt well. I questioned her closely and found that she did not tolerate medications well in general. Blood tests revealed that Valerie had high levels of antibodies to her own thyroid: she had a very active case of Hashimoto’s or Autoimmune Thyroiditis. This posed two potential problems when dealing with her hypothyroidism: she could be periodically sending out some of her own thyroid hormone when the Autoimmune Thyroiditis was active; or she might have problems with eliminating T4 from her body through the liver.
It became clear in her case that she could not eliminate the T4, so when giving her thyroid replacement initially she was given more T3, which is easier to eliminate than T4. After a number of months of treatment, where all of her problems were addressed and improved, she stabilized on a standard, more balanced combination of T4 and T3. The important issue was to address the underlying problems that caused the Autoimmune Thryoiditis (an autoimmune disease) in the first place and strive for the health of the whole system. A year later, all of her symptoms are resolved and she has decided she feels so well she is going back to work!
Sally came in for her first appointment looking upset and distressed. She had seen a number of doctors for her problems, and had done a lot of research on her own. She is an attractive, slim blond, about 30 years old, a PhD college professor who jogs 2-5 miles three times a week. Sally had severe pain with her menstrual periods due to endometriosis, she sometimes missed periods, was diagnosed with Irritable Bowel Syndrome, and had many signs of hypothyroidism, such as hair loss, dry skin, fatigue, abnormal periods, moodiness, and feeling cold all the time.
Blood tests revealed her pituitary gland was under-functioning. The pituitary, in the brain, sends signals to the thyroid and ovaries (and other organs), and in Sally’s case, it was not sending the right messages to these glands. Thus, we monitored her thyroid hormone replacement by free blood levels of thyroid hormone rather than the TSH, which is the pituitary hormone.
The pituitary also affects the ovaries, and thus affected Sally’s ability to ovulate and produce progesterone. Having regular periods was also a problem. Later, after she responded to treatment and was feeling very well, she decided to get pregnant. She went to two fertility specialists in state who offered her a number of treatments to get pregnant but could not tell her the nature of the problem
She went to a fertility “guru” in another state, who told her that her pituitary was hypo-functioning. She called me and said, “You told me that on my second visit!” She is now the proud mother of a beautiful baby girl.
Karen came into my office sad and frustrated. She stated, “I have been sick for 12 years, I have seen over 15 doctors and if you do not help me I am giving up on doctors!”
Among the many approaches and treatment prescribed for her chronic fatigue and fibromyalgia, her thyroid was checked. In her case, the pituitary and thyroid were both functioning properly but the T4 (the main hormone produced by the thyroid) was not changing into the more active form, T3, in her tissues. In her case a very low dose of long-acting T3 was prescribed. As her health improved her dosage was reduced until she no longer needs any thyroid hormone. This poor conversion of T4 to T3 is a common problem in patients with fatigue, stress, diabetes, or carbohydrate intolerance, or in any chronic debilitating disease.
And so is this diagnostic work “art” or “science?” It is both. The “art” part of what I do comes in listening carefully, and at length, to the patient so that I can use all available tools to assess the physical, mental, and emotional issues that may underlie the patient’s distress. Though the clues may be subtle, they need to be pursued. The “science” part of this diagnostic work is the critical, complementary component of what I do.
Often our scientific pursuit of reliable information is as subtle as the clue we’re checking out. And science helps us understand how to fine-tune the system so it is working at its optimal level, for as long as possible. That’s a good goal for all of us!