Think your symptoms point to an under- or over-active thyroid? Have you been told your thyroid is fine? What if you're already taking thyroid medication, but still not feeling well? In this series, will explore common questions I hear from patients.
I love helping patients who are suffering from thyroid disorders finally feel like themselves again. Most of my patients with thyroid disorders, including hypothyroidism and autoimmune thyroiditis (Hashimoto's or Graves'), come to me for a second opinion. They've already been diagnosed and are taking the prescribed medication, yet they are still struggling with a multitude of persistent symptoms. Often, they're told their follow up labs look fine, but they still don't feel well and they know something's not quite right. For other patients, they may have similarly been told that their screening labs were normal and therefore their symptoms are not due to an underlying thyroid disorder. So when they come to me, tired of feeling tired, we dig deeper.
In this series, I'll discuss my approach to diagnosis, treatment, and management of hypo- and hyperthyroidism, including those due to autoimmune conditions.
First, a bit of anatomy and physiology review. The thyroid is a butterfly-shaped gland located in front of your trachea (windpipe) in your lower neck. It has two lobes that are divided by an isthmus (a piece of tissue that connects the two lobes). The thyroid is considered an endocrine gland, meaning it produces hormones. These hormones affect every cell, tissue, and organ in the body and regulate the body's metabolism. That's why the symptoms of thyroid disorders can be felt systemically, or body-wide. The thyroid gland makes three hormones, but we're going to focus on these two:
Thyroxine, known as T4 = inactive thyroid hormone
Triiodothyronine, known as T3 = active thyroid hormone
Another hormone, called thyroid stimulating hormone (TSH), is not made by the thyroid gland. TSH is actually made by the pineal gland, within the brain. TSH is a regulatory hormone. If your thyroid makes too much T4, TSH levels drop to signal the thyroid to decrease production of T4. Conversely, if the thyroid isn't making enough T4 and metabolism slows down, TSH increases to communicate to your thyroid gland to increase production. In hypothyroidism, TSH is classically elevated and T4 is low. In hyperthyroidism, we see the opposite: suppressed TSH and high T4. However, for many patients this communication and feedback between TSH and T4 doesn't happen and standard labs can miss the diagnosis. We'll come back to this important point in Part 2 of this series.
TSH is not a complete picture of thyroid function. Furthermore, the reference range used to determine a "normal" level is not universally agreed upon.  If you're experiencing symptoms associated with under- or over-active thyroid, make sure that FT3 and FT4 are checked along with TSH, minimally.
The American Thyroid Association estimates that more than 12% of the US population will develop a thyroid condition during their lifetime. Unfortunately, 60% of these individuals are unaware of it due to being misdiagnosed or not seeking medical care.  Thyroid conditions are more common in women; compared to men, women are five to eight times more likely to develop a thyroid problem during their life.  After pregnancy and during menopause, women are particularly susceptible to misdiagnosis when their symptoms are more likely to be discounted or attributed to other changes.  Part of the reason for misdiagnosis is because the symptoms are not unique to thyroid conditions. Many other conditions can cause fatigue, for example. Here are some classic symptoms associated with hypo- and hyperthyroidism:
Symptoms of hypothyroidism:
difficulty losing weight / unexplained weight gain
heavier and longer menstrual cycles
Symptoms of hyperthyroidism:
rapid or irregular heartbeat (tachycardia, palpitations)
unexplained weight loss
anxiety or irritability
diarrhea or loose stool
trembling of the hands
shorter, lighter menstrual periods
For an accurate diagnosis, a thorough history from the patient must be paired with a physical examination and comprehensive lab evaluation.
When working with patients, every case is unique. Generally, if patients have an existing diagnosis, I'll take a careful history and review records from their former PCP and/or endocrinologist. I'll perform a physical examination and order additional labs and imaging as needed based on what work has already been completed and how long ago. If patients have symptoms suggestive of a thyroid condition, but have never been diagnosed with one, I will perform a thorough physical exam after gathering their history, and order comprehensive blood work.
I listen to my patients. If they tell me their labs were "normal" in the past, but they still don't feel well, I'll help them figure out why.
Often, only TSH and maybe T4 were previously checked. In these cases, I will order additional labs to get a more complete look at thyroid function. Occasionally, their thyroid labs really are at optimal levels and the cause of their symptoms lies elsewhere. Either way, I'll help them figure out the underlying problem.
While every case is different, in general, the labs I look at to assess thyroid function are TSH, free and total T4, free and total T3, reverse T3, and thyroid antibodies when indicated. I typically evaluate adrenal status for these patients too because of the close relationship between thyroid hormones and adrenal function. I also check serum iron, ferritin, and iodine levels along with Vitamin D status for most of my patients with thyroid conditions.
TREATMENT & MANAGEMENT
Before deciding on the best treatment option for patients, I review all lab results with them in detail. As a naturopathic doctor, it is important to me that I empower my patients through docere (doctor as teacher). By taking the time to discuss their lab results and diagnosis in an understandable manner, patients better understand their condition and prognosis.
The next step is to develop an individualized treatment plan. I often utilize shared decision making with my patients. While I may be the medical expert in the doctor-patient relationship, the patient is an expert of themselves and I value their input when choosing treatments.
We’ll discuss the different treatment approaches I typically offer patients for thyroid conditions throughout the rest of this series.
For the majority of my patients with thyroid conditions, regular follow up to assess their response to the treatment is necessary, at least in the short-term. Sometimes adjustments or tweaks to their treatment plan are needed based on lab results and any remaining symptoms.
I rely on the combination of how the patient feels and what their labs reveal to guide long-term management.
Each thyroid disorder has its own possible complications, especially if left untreated. In addition to repeating thyroid hormone labs to monitor their response to treatment, I often look at other labs to assess their individual risk for development of future conditions. Prevention of future illness is a core principle of naturopathic medicine, and a goal for all my patients.
Want to learn more about thyroid disorders? Check out the rest of this blog series:
Do you already suspect or know you have a thyroid disorder and aren't feeling heard by your current healthcare provider? Are you ready to finally feel like yourself again?
Know that you deserve to be heard, be healthy, and be well.
 Midgley, J.E.M., Toft, A.D., Larisch, R. et al. Time for a reassessment of the treatment of hypothyroidism. BMC Endocr Disord 19, 37 (2019). https://doi.org/10.1186/s12902-019-0365-4