Saul Marcus, ND
New York City
Naturopathic Doctor

Hypothyroidism Guide Page 2

These pages originally written in 2010 for my first website. I have posted them here for educational purposes. For general information on how natural health can help with thyroid conditions please follow this link to the main hypothyroidism page.

5. Low TSH induced hypothyroidism

Secondary and Tertiary hypothyroidism

Primary hypothyroidism means that there is a problem with the thyroid gland itself. It is unable to make enough thyroid hormone.

The term secondary hypothyroidism refers to a disease of the pituitary gland. If the pituitary does not making enough TSH to stimulate the thyroid gland then the thyroid is not going to make enough thyroid hormone.

Tertiary hypothyroidism refers to a disorder of another part of the brain called the hypothalamus. The hypothalamus makes Thyroid Releasing Hormone (TRH) is what tells the pituitary how much TSH to make.

Secondary and tertiary hypothyroidism can be caused by tumors in either the pituitary or hypothalamus. These are very rare conditions, and the treatment is beyond the scope of this guide.

More common are functional problems that interfere in the pituitary’s production of TSH.

Labs which reflect this type of thyroid hormone are:

Low normal TSH (broadly speaking, less than 1.5).
T3 low, or bottom end of reference range.
T4 low or bottom end of reference range.
Reverse T3 may be elevated (indicate issue with thyroid hormone conversion. [20]

This pattern of hypothyroidism often does not respond well to thyroid hormone medications. For more information on, go to the section on Euthyroid Sick Syndrome and Subclinical Hypothyroidism.

6. Iodine deficiency and hypothyroidism

Iodine is needed to make thyroid hormone. Iodine is actually what determines the form of thyroid hormone. T4 is thyroid hormone with 4 iodine’s attached. T3 is thyroid hormone with only 3 iodine’s attached.

In the case of severe iodine deficiency the thyroid gland may swell up in an attempt to pull in as much iodine from the blood stream as possible. This is called a goiter. Decades ago goiters were very common in certain geographic areas with iodine poor soil. Fortifying salt with iodine has been credited with largely reducing this problem. Besides goiter iodine deficiency is associated with impaired mental function and hypothyroidism symptoms. [21][22]

Currently conventional medical dogma is that a typical diet gives people sufficient iodine for thyroid hormone production.

The iodine – thyroid controversy

Some holistic practitioners believe that iodine deficiency is rampart and a major cause for chronic illness. Others are as dismissive as medical doctors and warn that iodine supplementation is dangerous.

With such conflicting information it took me some time to form my current position on iodine. I also understand how this issue can be terribly confusing to lay people who are looking for answers on the Internet. Why do the “experts,” have such different opinions?

A few reasons why we may need more iodine than most people are getting

Current medical thinking on iodine, is based on a 1940’s model, of how much is needed to prevent goiters. However, just because someone does not develop a goiter, does that mean their thyroid really has enough iodine for optimal health? [23] [24]

Iodine may also be needed elsewhere, besides the thyroid. For example, research has shown improvement in fibrocystic breast disease when supplementing with at least 3.0 mg of iodine per day. [25] The current RDA for iodine is 150 mcg. 3 mg equals 3000 mcg. Therefore, research shows possible benefits to supplementing with iodine at doses far above the current RDA.

There is concern that other halogens we are exposed to, bromide (in bread products) and fluoride interfere with iodine function.

Tests for iodine deficiency

Iodine patch test

A two inch square section of skin is painted with liquid iodine solution (sold at any drug store as an antiseptic). In theory if you are iodine deficient, your body needs the iodine, will quickly soak up the iodine and the patch will disappear. On the other hand, if you are not iodine deficient the patch will remain for 24 hours until the iodine is slowly absorbed.

Therefore, the quicker the iodine is absorbed, the more deficient in iodine you are.

Problems with the iodine patch test:

No precise way to measure out how much iodine is applied to the skin.

I have seen this test explained many times. Each time I am told to apply a 2-inch square of iodine. Personal interpretation of how thick the coating to use, patient skin color, concentration of iodine solution, and even altitude (iodine will evaporate more quickly in Denver, then at sea level) may change results.

Everyone fails the iodine patch tests.

How is it possible that everyone is deficient in iodine?

At seminars I’ve basically been told: “Everyone fails the test because everyone is iodine deficient. Everyone is iodine deficient because everyone fails the test.” This is circular logic.

Iodine urine test

50 mg of iodine supplement is ingested followed by a 24 hour urine collection. The theory is that if the body needs the iodine, very little will be excreted in the urine.

This test is still controversial.

The test assumes that absorption of iodine from the digestive tract is always the same. The other assumption is that if the body is not excreting excess iodine in the urine then it must have a need for it. There are many substances that the body doesn’t need (ie. toxins such as lead, mercury, plastics), yet may not be efficient at excreting.

Interfering iodine status from thyroid lab tests

Measuring TSH and T4 (thyroxine) may be a useful marker for iodine status in “children and adolescents, adults, women, and those at moderate thyroxine (T4) status.” However this is not true for all people such as pregnant and lactating women, or those supplementing with “moderate daily supplementation.” [26]

Iodine side effects – why we don’t need more iodine

Many web sites that state iodine supplementation is not dangerous. This simply is not true.

Iodine excess can contribute to numerous health conditions including multi nodular goiter, Graves disease (hyperthyroidism) and Hashimoto’s thyroiditis. Myself and other practitioners in the natural health field see people coming in with such symptoms after taking iodine. [27]

Sometimes people overdose on iodine because a practitioner told them to. Other times they do so after reading up online on how everyone needs iodinet. Iodine itself is not bad, and some people are deficient. However, much of the information you’ll find online about iodine is one sided (all for against supplementation).

Side effects of overdosing on iodine include:

Rashes, itching or lesions on the skin
Heart palpitations
Faster heart rate
Gastrointestinal symptoms such as diarrhea
Hyperthyroidism
Hypothyroidism

Notice both hyperthyroidism and hypothyroidism are side effects of iodine. Not everyone will react the same to it.

How can iodine, which is needed to make thyroid hormone, cause hypothyroidism? This is due to something called the Wolff-Chaikoff Effect. In some people, a sudden increase in iodine will cause the thyroid gland to temporarily stop absorbing iodine. This can cause hypothyroidism.

Other Internet misinformation

It is often repeated that the average daily intake of iodine in Japan is 13.8 mg. Just search the keywords “Japan,” “iodine,” and “13.8.” Countless web sites will pop up parroting this information and convincing people they need to supplement with iodine.

In truth, this number of 13.8mg has been disproved. The average intake of iodine in Japan seems to be only 1 – 5 mg per day. [28] There is also evidence that the increased intake of iodine in Japan has actually led to thyroid dysfunction [29].

How to supplement with iodine?

As mentioned above iodine can cause temporary hypothyroidism due to the Wolf-Chaikoff Effect. This physiological effect is well established in the scientific literature. [30] [31].

Nonetheless, the Wolf-Chaikoff Effect is not very common, short term (only about 24 to 48 hours) and has not stopped researchers from supporting iodine supplementation when appropriate. [32]

Depending on dose, everything no matter how natural is dangerous. For example, when the titanic sunk, hundreds of people died from an overdose of water. In other words they drowned. Of course that doesn’t mean water is bad. It simply means that like everything else, water is dose dependant. Iodine and all other supplements are no exceptions. [33]

If labs and clinical history indicate possible need for iodine then dosing should start low, and gradually increased. Thyroid labs such as TSH and T4 can be used to help, in addition to the overall clinical picture. [34]

7. Autoimmune Hypothyroidism (Hashimoto’s thyroiditis)

An autoimmune disease is when the immune system attacks the body’s cells.

When the immune system attacks the thyroid, causing decreased amounts of thyroid hormone this is called autoimmune hypothyroidism, or Hashimoto’s thyroiditis.

Sometimes the immune system causes the thyroid to produce too much hormone (hyperthyroidism). This is called graves disease.

Tests for autoimmune thyroid disease

Antibody tests for autoimmune hypothyroidism are:

Anti-thyroid peroxidase antibody (anti-TPO)
Anti-thyroglobulin antibody

Generally anti-TPO is more likely to be elevated. Both tests should be run because it’s possible that only anti-thyroglobulin is positive.

Often conventional doctors do not run antibody tests. From their perspective they are just going to prescribe thyroid hormone based upon TSH so it does not matter. From a holistic perspective these tests do matter. They show a possible cause of hypothyroidism, but also antibody levels may improve with proper treatment of the immune system.

Additional antibody tests:

Thyroid stimulating immunoglobulin is increased in autoimmune hyperthyroidism (Graves Disease).

Frequently Graves Disease patients will have the other antibodies elevated also. Therefore in hyperthyroidism all the antibodies should be tested. Patients often need to ask to have this tested as well.

Conventional treatment for autoimmune hypothyroidism

Conventional treatment for autoimmune thyroid disease (either hypo or hyper) is directed at symptoms only. There is no conventional treatment for the autoimmune disorder itself.

Often autoimmune disease indicates a body burdened with poor digestion and/or toxicity. If these are not resolved, then often another autoimmune disease develops. See the page on Autoimmune Polyendocrine Syndromes.

Molecular mimicry and leaky gut syndrome

The immune system has to tell the difference between cells of our own body (self), and anything else that doesn’t belong (non-self). Bacteria, viruses or certain large food particles that pass through the GI system are recognized as non-self. Anything that is non-self and triggers an immune system response is called an antigen. Antibodies latch onto antigens and trigger the immune systems response.

Sometimes antigens look a lot like some of our own cells (self). The immune looses the ability to tell self from non-self. It creates autoantibodies. Autoantibodies are antidbodies which are targeted against the individual’s own proteins. This whole process is called molecular mimicry.

Molecular mimicry is a major cause of autoimmune disease in general. [35]

Autoimmune thyroid disease and “leaky gut” syndrome

In the gastrointestinal tract nutrients are absorbed from the outside world into the body. Along with needed nutrients, bacteria, toxins and large undigested food particles are also absorbed. These things really don’t belong in our bodies. They become antigens, which the immune system recognizes as non-self.

The body makes various types of antibodies to target and eliminate antigens. Ones relevant to this autoimmune process are:

Secretory IgA – Secreted along mucosal border of the GI tract. Represents an immune system response in the digestive system.
Secretory IgG – Secreted in the blood. Represents an internal immune system response. IgG antibodies are elevated in autoimmune disease.

As in the picture above, a small number of antigens cross the gastrointestinal mucosa in a health digestive system.

However, in an unhealthy digestive system people have what is called “leaky gut syndrome.” This means that the mucosa border is too permeable. Large numbers of antigens leak across into the body. This causes an increase in IgG antibodies and over activates the immune system.

This large stimulation of IgG antibodies deregulates the immune system. Through the process of molecular mimicry it starts to make antibodies against certain tissues of the body. [36]

Some antigens are more specific to certain auto-immune disease. For example, overgrowth of gut bacteria Yersinia enterocolitica lead to formation of antibodies found in autoimmune thyroid disease. [37]

Common causes of leaky gut and poor digestive health include:

Stress (this means emotional and physical stress) [38] [39]
Aspirin and NSAIDS (non steroidal anti-inflammatory drugs) such as ibuprofen. [40]
Alcohol [41]
Viral, bacterial, yeast and protozoan infection [42]

Celiac disease [43]

The consequences of leaky gut:

Large food particles, bacteria, and viruses enter the blood stream, triggering allergic reactions and increased inflammation.
The increased stress on the body triggers the release of the stress hormone cortisol. This may lead to fatigue, blood sugar disorders, and depressed immune function. .
Toxic chemicals in the GI tract that would normally be excreted with stool are absorbed and sent to the liver. This puts more of a burden on the liver, which has to eliminate these toxins. [44]. Go here for more information on liver function and detoxification.
Auto-immune diseases such as Hashimoto’s thyroiditis, Graves disease, rheumatoid arthritis, multiple sclerosis, and lupus. [45]
Allergies, chemical sensitivities, migraine headaches, and chronic fatigue are other common symptoms of leaky gut syndrome. [46]

Treatment of Leaky Gut Syndrome:

There are many programs and supplements that help restore function to the gastrointestinal tract. Among the most well known and used among holistic practitioners is the “Four R program”

Remove
Anything damaging to the gastrointestinal tract should be removed. This includes overgrowth of bad bacteria, viruses, fungi and parasites. This can often be done with herbs such as garlic, wormwood and black walnut. Allergenic foods should also be removed as well too.
Replace
There are often over growths of dysbiotic organisms because the digestive system is lacking in enzymes and hydrochloric acid. Hydrochloric acid is produced by the stomach to help digest food. It is extremely acidic. Nothing we eat is truly sterile. There are some bacteria on just about anything we eat. A major role of hydrochloric acid in our stomachs is to help to sterilize food. Therefore, part of a GI restoration program may include supplementing the body with HCL. Digestive enzymes are released by the pancreas and help to chemically break down food as part of digestion. If the body is not making enough HCL or digestive enzymes, replacing them with supplements can help restore proper digestive function.
Re-inoculate
Supplementing with probiotics often helps to restore balance to the intestinal gut flora.
Repair
There are many supplements and herbs that help soothe and repair damage to the gastrointestinal lining. [47] Glutamine, N-acetyl glucosamine, DGL licorice, aloe vera leaf and Althea officinalis among the most efficacious and used.

Since emotional stress plays a huge role in digestive system function, a holistic assessment will consider it as well. Therapies such as calming supplements, herbs, homeopathy, or neuoemotional technique (go to netmindbody.com for more information) can help with this aspect.

Often it is just as essential to work on the emotional component besides the physical.

8. Gluten sensitivity, celiac disease and autoimmune thyroid disease

What is celiac disease?

Celiac disease is a caused by gluten sensitivity. The immune system creates an inflammatory cascade in response to reacts to a protein in wheat and other grains (gluten). People with celiac disease need to avoid all gluten containing foods for life. Celiac disease may cause destruction (the phrase used in medicine is “villous atrophy”) of the lining of the small intestine. Therefore celiac disease has generally been recognized as a digestive disorder.

Your doctor may have been trained that celiac disease is a rare genetic diseases usually diagnosed in childhood. This view is totally outdated. Research over the last 20 years has shown celiac disease is a complex, auto-immune disease that can injure other systems other than the gastrointestinal tract. Often the digestive system is uninjured, while damage occurs elsewhere. [48]

From the The New England Journal of medicine:

The clinical presentation of this condition [celiac disease] can range from the typical syndrome of malabsorption (chronic diarrhea, weight loss, and abdominal distention) to symptoms and conditions that can affect any organ system. [49]

It has been estimated that for every person diagnosed with celiac, 14 others have it who are not diagnosed. [50] In another study it was estimated that for every symptomatic patient with celiac disease, there are 8 patients with celiac and no gastrointestinal symptoms. [51]

They thyroid is one of the most common targets of celiac disease. [52] Celiac patients have approximately 10 times more auto-immune thyroid disease than people without celiac disease. [53]

Other common targets of gluten sensitivity include:

Dermatitis herpetiformis, IgA deficiency, type 1 diabetes, sjogren’s syndrome, microscopic colitis, rheumatoid arthritis, down syndrome, IgA nephropathy, anemia, osteoporosis/osteopenia, dental enamel hypoplasia, vitamin K deficiency, hypertransaminasemia, thrombocytosis, arthralgia, poly neuropathy, ataxia, epilepsy, infertility, anxiety and depression, follicular keratosis, alopecia. There are also possible associates with congenital heart disease, recurrent pericarditis, sarcoidosis, cystic fibrosis, fibrosing alveolitis, lung cavities. pulmonary hemosiderosis, inflammatory bowel disease, autoimmune hepatitis, primary biliary cirrhosis, Addison’s disease, systemic lupus erythematosus, vasculitis, polymyositis, myasthenia gravis, schizophrenia. [54]

To spell it out in other words, celiac disease is an under appreciated killer. It should be a consideration in any inflammatory or auto-immune disease that has no other explained cause.

The web site celiac.com has more information on this illness and all it’s complications.

Gluten free (wheat free) diet

Patients with auto immune hypothyroidism have celiac disease so often that a gluten free diet is always a consideration.

“This diet unfortunately takes some effort, as it mean absolutely no gluten in any amount. All it takes is a grain of an offending food to set of the auto immune reaction. One study has even said, “non adherence to the gluten free diet, defined as eating gluten once per month, increased the relative risk of death 600%” From Mortality in Patients with Coeliac Disease and Their Relatives: a Cohort Study. Lancet 2001 [55]

Most sources recommend that only the following grains need to be avoided:

Wheat
Barley
Spelt
Rye
Oats

However, there are different gliadins in all grains. It’s possible to have an immune system response to other grains as well. So the list of foods that need to be avoided can be larger.

Endoscopy

If you ask a gastro-enterologist how to diagnose celiac disease, you will probably be told that a doctor must do an invasive procedure called an endoscopy. Then they can then visualize damage with a camera, and remove a small sample of tissue (called a biopsy) for examination.

In certain cases this may be an important procedure. However, in some people (especially as we get older) celiac disease affects other organs, and may leave the digestive tract alone. Therefore, just because someone does not have celiac disease based on a biopsy that does not mean they do not have celiac disease. [56]

Lab tests to diagnose celiac and gluten sensitivity

IgA and IgG anti-gliadin antibodies
Tissue trans-glutaminase antibodies
IgA anti-endomysial antibodies
HLA DDQ2 and HLA DQ8 are genetic tests that are positive in 95% of people with celiac disease [57]

Celiac disease is just one possible symptoms of gluten sensitivity. A sensitivity to gluten could contribute to autoimmune disease without necessarily effecting the entire digestivesystem. Genetic testing is the best way to identify Gluten Sensitivity. Other tests look for specific immune system markers, which may not be present despite an overall immune system response.

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