Thyroid Patterns. 1. Hypothyroidism

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1 Thyroid Patterns We can simplify altered thyroid metabolism into seven patterns. These patterns include expression of altered thyroid metabolism from primary thyroid deficits and alterations in thyroid metabolism secondary to other metabolic shifts. Please note that sometimes two patterns may coexist at the same time. For example, a patient may have thyroid underconversion at the same time as secondary hypothyroidism due to primary pituitary hypofunction. It is not realistic in the clinical setting to order a thyroid panel with all of the markers for thyroid results. So, the clinician must make decisions based on history, medication use, and possible influences of other metabolic shifts on the thyroid. For example, if a patient is on oral contraceptives the panel must include a TSH and T3U and or FT4 and/or FT3. It is always necessary to order a TSH with all panels, since it is the key marker that will distinguish primary thyroid tissue deficits from secondary influences from other metabolic disorders. Please also note that positive antibodies may be concomitantly involved with any one of these thyroid patterns, although it is always positive with thyroid hyperfunction. 1. Hypothyroidism Thyroid Stimulating Hormone (TSH) = Elevated Total T4 (TT4) = Normal or Low Free T4 (FT4) = Normal or Low Free Thyroxine Index (FTI) = Normal or Low Resin T3 Uptake (T3U) = Normal or Low Free T3 (FT3) = Normal or Low Thyroid Antibodies = Negative or Positive Commentary: An elevated TSH is all that is required to diagnose primary hypothyroidism. The T3 and T4 levels are either protein bound or free fraction or irrelevant. Remember the pituitary will increase its TSH release if the thyroid tissue is dysfunctional. Many times the thyroid may compensate at the time of the test by presenting normal T3 and T4 levels, but if the TSH is elevated, it is a primary hypothyroid case because the pituitary is overworking in attempt to improve thyroid output. Nutritional Considerations with Primary Hypothyroidism: 1. Thyroxal: two capsules, three times a day 2. Thyro-CNV: Two capsules, three times a day Commentary: Many thyroid hypofunction patterns may be managed functionally with proper nutritional support. The clinician must repeat the TSH in 30 days while the patient is on the above protocol to make sure the patient is capable of functional management. If the TSH is reduced to a normal limit, the patient may decrease the dosage of the above protocol and have repeat testing of TSH. At some point the clinician should be able to determine the proper dosage of supplementation to maintain the TSH. 1

2 At times, the patient may not respond to the above protocol, and the clinician may need to consider natural thyroid replacement, or rule out an autoimmune thyroid. Remember, anytime a patient has positive thyroid antibodies, nutritional or replacement support for the thyroid will not make major changes in reducing thyroid symptoms. Patients with positive antibodies against their thyroid must be treated as an immune patient. Note that the most common cause of hypothyroidism in the United States is secondary to post Hashimoto s. 2. Hyperthyroidism Thyroid Stimulating Hormone (TSH) = Low Total T4 (TT4) = Normal or Elevated Free T4 (FT4) = Normal or Elevated Free Thyroxine Index (FTI) = Normal or Elevated Resin T3 Uptake (T3U) = Normal Free T3 (FT3) = Normal or Elevated Thyroid Antibodies = Positive Commentary: A patient that presents with hyperthyroidism must be co-managed by a physician with the scope of practice to manage the acute thyroid pharmaceutically. The clinician that ignores the progression of hypothyroidism may be putting the patient at increased risk for complications such as thyrotoxicosis. Also if the patient s autoinflammatory reaction is not quenched immediately the patient will have an increased potential to lose thyroid tissue. Natural agents may be used adjunctively with appropriate medical management based on individual cases. Nutritional Adjunct Support: 1. Testanex: ½ teaspoon, three to six times a day 2. Super Oxicell: ½ teaspoon, three to six times a day 3. Secondary Hypothyroidism to Primary Pituitary Hypofunction Thyroid Stimulating Hormone (TSH) = Salivary is below reference range or serum is below 1.8 Total T4 (TT4) = Normal or Low Free T4 (FT4) = Normal or Low Free Thyroxine Index (FTI) = Normal or Low Resin T3 Uptake (T3U) = Normal Free T3 (FT3) = Normal or Low Thyroid Antibodies = Negative Commentary: These patterns are common with many patients with subtle symptoms of low thyroid function. These patterns are usually related to one of four causes. First and most common cause is from chronic adrenal axis dysregulation. Elevations in cortisol 2

3 have been found to have suppressive impacts on the pituitary. Many times patients with adrenal exhaustion (low cortisol) have this thyroid/pituitary pattern because on their way to adrenal exhaustion their pituitary was exposed to chronic elevations of cortisol in the alarm and maladaptation phases. Clinically, it appears in addition to supporting their thyroid/pituitary axis, the adrenal disorder (hyper or hypofunction) must be resolved. A second cause of this pattern is related to post-partum expression. During pregnancy there are fluctuation and demands place on all hormones and feedback loops sometimes women will have this pattern develop after a pregnancy. In their history they will usually exhibit symptoms of low thyroid function and metabolism after the birth of their child. A third cause of this pattern is a patient that was inappropriately placed on thyroid hormones. Many doctors today are placing patients on thyroid hormones to manage symptoms of slow metabolism, despite a normal thyroid panel. Their logic being that they low thyroid symptoms are subclinical and therefore the labs are not demonstrating the thyroid dysfunction. Many of these patients feel better initially but after several months many of them develop thyroid receptor site resistance and have a reoccurrence of their symptoms and therefore stop replacement. Some of these patients in the process develop an altered pituitary/thyroid feedback loop that does not resolve normal function again and therefore develop this pattern. A fourth cause of this pattern is secondary to heavy metal toxicity, but it is not a common cause of this pattern. It would be wise for the clinician to investigate and manage the three previous patterns before attempting to identify and manage patterns of heavy metal burden. Not to say that the management of heavy metal burdens is not common or important, but rather the three previous causes are more common for the expression of this pattern. Nutritional Support: 1. Thyraxis-PT: 2 capsules, three times a day *** modulate the stress response clinically and with lifestyle*** 4. Thyroid Underconversion Thyroid Stimulating Hormone (TSH) = Normal Total T4 (TT4) = Normal, High End of Normal Range or High Free T4 (FT4) = Normal, High End of Normal Range or High Free Thyroxine Index (FTI) = Normal, High End of Normal Range or High Resin T3 Uptake (T3U) = Low Free T3 (FT3) = Low Reverse T3 (rt3) = Low Thyroid Antibodies = Negative Nutritional Support: 1. Oxicell: ¼ to ½ teaspoon, three times a day 2. Thyro-CNv: 2 capsules, three times a day 3. Adrenacalm: ¼ to ½ teaspoon, three times a day 3

4 Commentary: Thyroid underconversion is a very common pattern and it is usually found with elevations of cortisol or increased lipid perioxidation. Elevations of cortisol are found in adrenal alarm and maladaptation patterns. However, if a patient is found in adrenal exhaustion many times the 5 diodinase enzyme has been down-regulated from prior expressions of elevated cortisol. Increased lipid perioxidation also has the potential to exhibit an underconversion pattern. Lipid perioxidation is a consequence of an inflammatory event or reduced antioxidant status. The Oxidata Test from Apex Energetics can be used to measure MDA levels, which are a marker for lipid perioxidation status. With all patterns in which increased lipid perioxidation is suspected, until the source of infection/inflammation is identified and managed, Oxicell is recommended. 5. Thyroid Overconversion Thyroid Stimulating Hormone (TSH) = Normal Total T4 (TT4) = Normal, Low End of Normal Range, or Low Free T4 (FT4) = Normal, Low End of Normal Range, or Low Free Thyroxine Index (FTI) = Normal, Low End of Normal Range, or Low Resin T3 Uptake (T3U) = High or High End of Normal Range Free T3 (FT3) = High or High End of Normal Range Thyroid Antibodies = Negative Nutritional Support (Manage Insulin Resistance) 1. Glysen: two to three tablets, three times a day with meals 2. Omega Co-3: two tablespoons, three times a day 3. Adaptocrine: two tablets, three timesa day 4. Adrenacalm: ¼ to ½ teaspoon, three times a day Nutritional Support (Manage Androgen Replacement Overload) 1. Metacrin-DX: two tablets, three times a day 2. Bilemin: two tablets, three times a day 3. Methyl-SP: two tablets, three times a day Commentary: Androgenic overexposure tends to up-regulate the expression of 5 diodinase, the enzyme responsible for converting T4 into T3. Chronic elevations of T3 have been found clinically to cause thyroid resistance syndromes, therefore although the elevation of T3 may seem beneficial, the patient presents with symptoms of low thyroid function due to resistance from increased in T3 production. This pattern is usually found in women suffering from the androgenic drives caused by insulin resistance in polycystic ovary syndrome (PCOS). Chronic elevations of insulin tend to up-regulate the enzyme 17,20 lyase in the theca cells of the ovaries and promote androgenic drives. The management of this thyroid disorder is to manage the insulin resistance. 4

5 If a patient is type II diabetic and on exogenous insulin replacement, this pattern is also possible. With these patients, attempts to decrease their insulin needs via diet, nutritional supplementation, and exercise is crucial. Sometimes the elevations of androgens causing this pattern is not from androgenic drives from hyperinsulinemia, but rather from increased intake of exogenous testosterone or precursors such as testosterone. In these cases, the dosage needs to be modified and support of both phase I and II liver detoxification is recommended. 6. Thyroid Biding Hormone Elevations Thyroid Stimulating Hormone (TSH) = Normal Total T4 (TT4) = Normal Free T4 (FT4) = Low Free Thyroxine Index (FTI) = Low or Normal Resin T3 Uptake (T3U) = Low Free T3 (FT3) = Low Thyroid Antibodies = Negative Nutritional Support: 1. Estravite: two capsules, three times a day 2. Methyl-SP: two capsules, three times a day 3. Metacrin-DX: two capsules, three times a day 4. Bilemin: two capsules, three times a day *** Eliminating exposure to exogenous estrogens needs to be considered *** Commentary: This pattern is common from elevations of estrogens. It is usually from exogenous estrogen exposure such as oral contraceptives or hormone replacement therapy. Elevations of estrogen increase thyroid hormone binding and therefore the free T3, T4 and T3 Uptake are reduced. At times this pattern may be found in males if they are aromatizing their testosterone into estrogens, but it is not common. 7. Thyroid Resistance Thyroid Stimulating Hormone (TSH) = Normal Total T4 (TT4) = Normal Free T4 (FT4) = Normal Free Thyroxine Index (FTI) = Normal Resin T3 Uptake (T3U) = Normal Free T3 (FT3) = Normal Thyroid Antibodies = Normal Commentary: This pattern is found in patients that present with symptoms of low thyroid hormone function but with perfectly normal lab tests. These patterns are usually caused by elevations in cortisol. Elevations in cortisol down-regulate the thyroid alpha 1 and 3 5

6 receptor sites. Management of these patterns require correction of the adrenal axis drive and adjunct support to decrease cortisol like Adrenacalm. Thyroid resistance is also created if patient s exogenous replacement of thyroid hormones is not appropriately monitored. 6

7 Step-by-Step Approach for Assessing the Thyroid Panel 1. Evaluate TSH: A) If TSH is elevated with decreased or normal T3 and/or T4 = primary hypothyroidism B) If TSH is elevated with elevated T4 and T3 rule out pituitary hypofunction or adenoma (request serum prolactin) C) If TSH is decreased with elevated T4 and/or T3 = thyroid hyperfunction (monitor thyroid antibodies) or pattern may be present from excess exogenous replacement D) If TSH is decreased with decrease or low normal T4 and/or T3 = pituitary hypofunction, secondary hypothyroidism E) If TSH is decreased with normal protein bound serum T4 and T3 and symptoms of thyroid hyperfunction request free thyroid antibodies, free T4 and T3 to rule out subclinical hyperthyroidism. If the above pattern is not present = potential pituitary suppression from elevations of cortisol. F) If TSH is decreased with low T3 Uptake and/or low free T3 and/or low free T4 = potential thyroid underconversion secondary to cortisol elevations from adrenal alarm reaction or maladaptation. 2. Evaluate T3 Uptake: A) If T3 Uptake is decreased = potential estrogen elevations physiologically, oral contraceptives or estrogen replacement therapy B) If T3 Uptake is increased = potential androgenic dominance from PCOS or testosterone replacement therapy 3. Evaluate Free T3: A) If free T3 is low decreased free T4 = increase binding proteins from physiological estrogen elevations, oral contraceptives or estrogen replacement therapy B) If free T3 is low with normal protein bound or free T4 = thyroid underconversion secondary to adrenal hyperfunction or maladaptation C) If free T3 is elevated with suppressed TSH = thyroid hyperfunction or thyroid replacement therapy overdose 4. Evaluate Serum (protein bound) T4 and/or free T4: 7

8 A) If T4 is increased with suppressed TSH = thyroid hyperfunction or thyroid replacement therapy overdose B) If T4 is decreased with elevated TSH = primary hypothyroidism C) If the T4 is decreased with suppressed TSH = primary pituitary hypofunciton secondary hypothyroidism 5. Evaluate Thyroid Antibodies A) If positive, consider the patient an autoimmune case 8