Hypothyroidism and Underactive Thyroid
In a nutshell:
Hypothyroidism implies an underactive Thyroid gland
Hyperthyyoidism implies an overactive Thyroid gland
Some Brief Points
In my opinion it is important to measure free thyroid
hormone levels.
If a patient is having problems with their thyroid
therapy then it is important to measure FREE T3 and FREE
T4...sometimes just making sure that there is enough of
the free hormone levels makes a large difference to
well-being.
Adequate amounts of minerals such as iron, selenium and
zinc are important for the transformation of T4 to the
much more potent T3.
Proper adrenal function is essential for treatment of
an underactive thyroid gland to be effective.
Thyroid physiology - a synopsis
The thyroid gland is situated in the neck just behind
the Adam's Apple or thyroid cartilage and this gland sets
the pace for the whole body's metabolism.
The thyroid is a little like an orchestral conductor
giving out the rhythm to the whole orchestra - It affects
the activity of each and every cell in the body.
Too little thyroid hormone means that the body's
processes all slow down too much with resultant
sluggishness, mental fuzziness and weight gain.
Conversely, too much thyroid speeds the metabolic
processes too much resulting in everything running too
fast with resultant weight loss, fast heartbeat, insomnia
and anxiety.
In the adult female hypothyroidism may result in
menstrual irregularities and difficulty conceiving.
Thyroid Hormone
There are two active thyroid hormones T3 and T4 which
are carried 'bound' in the blood to transport (carrier)
proteins.
While attached to the carrier proteins they are
inactive. Think of an analogy involving skiers - they
cannot ski when they are sitting in the chair-lift - only
when they are 'released' from the chairlift can they start
to ski.
It is important to realise that the at any given time
the vast majority of the body's thyroid hormone (over 90
%)is totally inactive biochemically because it is bound to
transport proteins.
Free Thyroid hormones: Free T3 and Free T4 (also known
as Free Thyroxine)
Only when the T3 and T4 are released from their carrier
proteins are they free to do their work. They are then
referred to as Free T3 and Free T4.
Frequently standard laboratory testing only measures
TSH and Total T4 (total includes the portion bound to
carrier protein and the free 'unbound' portion).
Personally I prefer to look at the level of Free T3 and
FreeT4.
T3 is several times more potent than T4 but lasts for
substantially less time (in medical jargonese we say that
T3 'has a shorter half-life'). If metabolism is working
properly much of the T4 is converted to T3 but this is
dependent on many factors including the person's mineral
(especially iron, zinc and selenium) status.
The Thyroid is critical to normal growth and
development of infants and children. For infants and
children the processes of growth and development -
especially the development of the nervous system - are
dependent on normal thyroid function and so all newborns
are screened in the maternity units for this.
Thyroid Stimulating Hormone (TSH) controls the level of
thyroid hormone in the blood.
The manufacture of thyroid hormone by the thyroid gland
is under the control of a part of the brain known as the
anterior pituitary. The more TSH that is in the
bloodstream the higher the level of thyroid hormones.
The amount of TSH released is also controlled by
another centre in the brain called the hypothalamus. The
hypothalamus constantly monitors the level of thyroid
hormones in the bloodstream and then releases substances
which either increase (TSH-RF) or slow (TSH-IF) the
release of TSH.
How reliable are thyroid blood tests?
There is substantial controversy about this issue even
in the medical community. It varies from those individuals
in the medical community who believe that once TSH and T4
level are normal then there is 'no problem' with an
individual's thyroid gland to those (thankfully) few
doctors who if twenty people all complaining of tiredness
lasting over a year or two were lined up in their waiting
room would be very likely to 'diagnose' an under-active
thyroid gland in the vast majority of them and promptly
proceed to dish out replacement thyroid hormone to them.
These are two extreme viewpoints and I think that the
truth probably lies somewhere in between.
My view is that there may be sub-group of patients who
despite having 'normal' T4 and TSH may well have a thyroid
problem.
This being said there is a potential for real harm to
patients if this deviation from normal medical practice is
undertaken in a casual and thoughtless manner. Think
before bending the rules.
Clinical (i.e. from the patient) and Laboratory data must
be integrated for a ‘proper’ diagnosis:
If I am seriously considering a diagnosis of
hypothyroidism in the presence of 'normal' T4 and TSH
(both of which investigations will usually have been
carried out long before the patient arrives at my door)
the first thing I do is to look at free T3 and free T4
levels along with another TSH and usually at thyroid
antibody levels. This means I am measuring how much
thyroid hormone is active in the person’s body rather than
the amount which is merely present. If the free T3 and T4
levels are in the lower one-third of the range and the
basal body temperature is low then I may begin to
seriously entertain the diagnosis.
Be cautious
I do not consider starting someone who is tired on
thyroid replacement an appropriate first line of
treatment. Sometimes a patient will come to me wondering
if their thyroid is underactive. Sometimes it will be.
Other times not. Sometimes they may have all the symptoms
of a low-grade bowel infection. We treat the bowel
infection and the fatigue goes away - without any
treatment of the thyroid at all.
Broda Barnes and Basal Body Temperature
measurement and hypothyroidism.
An endocrinologist in the United States some forty or so
years ago felt that the most reliable and sensitive test
for hypothyroidism was the basal body temperature test.
This involves measuring the axillary (underarm)
temperature first thing in the morning on awakening before
there is any physical activity. An old-fashioned mercury
thermometer should be used and it should be left in place
for ten minutes. I ask patients to take at least ten
readings scattered over the course of a month or so.
Personally I interpret the readings in the light of the
clinical symptoms, total history and blood tests. Good
medicine is about collating all the data and not getting
diagnostically 'carried away' by any particular part of
it. We need clinical balance. I am concerned about the
hazards of over-treatment of people who do NOT need extra
thyroid hormone being given it as much as I have sympathy
for those people who may benefit from thyroid
supplementation but who are denied it without due
consideration.
What is Reverse T3?
Reverse T3 is a form of T3 which has exactly the same
chemical composition as 'normal' T3 but which does not
function to stimulate cells in the way which T3 normally
should do. Unfortunately, as well as not functioning to
stimulate cells as it normally should, reverse T3 still
functions to block receptor sites for 'normal' T3 and also
still functions in negative feedback by duping the
hypothalamus into believing that it is 'real, functioning
T3' and so reduces the TSH released by the pituitary
which, in turn, contrives to reduce the overall amount of
thyroid hormone in the body.
Armour Thyroid, Tertroxin (a form of T3), l-thyroxine
(or eltroxin).
These are all forms of thyroid replacement therapy. 'Thyroxine'
is T4 only. 'Tertroxin' is the UK brand name of a
preparation which contains solely T3. 'Armour thyroid' is
porcine-derived glandular thyroid which contains mostly T4
but a small amount of T3. Some patients do well on
'ordinary, inexpensive thyroxine' while other patients
appear to experience side effects on l-thyroxine which
they do not experience on Armour thyroid. Some people do
better on standard eltroxin with a small amount of added
T3. It's about individual variation in response to
treatment and patient preference. I should point out that
Armour thyroid is somewhat more expensive than normal
thyroid hormone replacement.
There is currently a vogue among a small group of
doctors for routinely giving adrenal hormones along with
thyroid hormones. How sensible is this?
As a general rule it is probably not medically sensible to
to decide too quickly that a patient should have cortisol
replacement. It is important to at least check salivary
cortisol levels if a diagnosis of functional
hypoadrenalism is being seriously entertained.
What is the bottom line about deciding whether thyroid
hormone supplementation in the presence of normal basic
screening blood tests is worth trying?
Before considering thyroid hormone supplementation in the
presence of normal screening blood tests there should be a
consistently low basal body temperature and screening
tests for minerals that affect thyroid function should be
used. If there are symptoms such as irritable bowel
syndrome which may denote a low-grade bowel infection then
this possibility should be dealt with. Under-active
adrenal glands need to be considered. Depending on context
oestrogen and progesterone imbalances may also need to be
considered. Sometimes when other issues such as these are
dealt with the patient's sense of well-being returns
without any need to commit them to long-term thyroid
replacement therapy.
The Adrenal Gland
It is important to make sure that the adrenal glands
are functioning well as the Adrenal Glands are critical to
health and well-being.
If the adrenal glands become completely defunct we die.
If the adrenal glands become so weak that they can
produce hardly any cortisol this condition is described as
Addison's disease.
There is also (in my opinion) a group of patients whose
condition is not severe enough to satisfy the diagnostic
criteria for Addison's disease but who, nevertheless, are
unable to produce adequate amounts of cortisol.
What Symptoms might suggest an Adrenal Gland problem?
Cold hands and feet, constantly low blood pressure,
general weakness, needing to eat very frequently, problems
standing in a queue (do much better if walking than
standing still), poor ability to handle stress, sometimes
low body temperature or recurrent infections.
How may adrenal gland function be tested?
There is a reasonable correlation between the amount of
cortisol in the saliva and the blood cortisol. This test
is useful as an adjunct alongside the standard medical
tests for adrenal function. Salivary cortisol is measured
by the patient using a home kit at 8AM, midday, 4PM and
midnight. Many individuals who have low adrenal function
may be very tired in the morning (as may be a lot of
hypothyroid patients) and take a long time to 'get going'.
Patients with co-existent low thyroid function and low
adrenal function.
Patients who have both low thyroid function and low
adrenal function may feel worse when commenced on thyroid
replacement therapy. I have certainly experienced this
with one or two patients over the years. These patients
may remark something along the lines of "I was started on
thyroxine/armour thyroid and I immediately felt worse and
began to have palpitations and feel weak and so I stopped
the thyroid medication".
There is currently a vogue among a small group of
doctors for routinely giving adrenal hormones along with
thyroid hormones. How sensible is this?
As a general rule it is probably not medically sensible
to decide too quickly that a patient should have cortisol
replacement. It is important to at least check salivary
cortisol levels if a diagnosis of functional
hypoadrenalism is being seriously entertained.
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