Could You Have Thyroid Dysfunction Even If Your Labs Are Normal?

Transcription

1 Could You Have Thyroid Dysfunction Even If Your Labs Are Normal? Guest: Mary Shomon The contents of presentation are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. This presentation does not provide medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Dr. Myers: Hi, everybody. It s Dr. Amy Myers with The Thyroid Connection Summit: Why you feel tired, brain-fogged, overweight, and how to get your life back. Today, I have Mary Shomon with us. And for those of you who are not familiar with her in the thyroid community, she is a brilliant advocate of those with thyroid disease, those with hormonal dysfunctions. She is a New York Times bestselling author of 12 different books. She has a new book coming out, Your Healthy Pregnancy with Thyroid Disease, which I m so excited about and I was fortunate to be able to be interviewed for the book. She is also the thyroid expert for verywell.com, which is formerly about.com. And she sees patients through phone consultations, as well. So, welcome, Mary. It s such a privilege to have you here. Mary: Thank you, Dr. Myers. It s really exciting to be part of this summit. Dr. Myers: Well, great. Well, no better person to sort of ask about thyroid conditions than you. You ve written so many books and, as I mentioned, it wasn t just part of your bio, you really are such an advocate for those with thyroid disease. And actually maybe we should back up and, if you don t mind, maybe just sharing your own story about how you got into this. Amy Myers MD. All rights reserved. 1

2 Mary: Sure. Absolutely. I was not a Science major. Science was not something that I studied or Medicine or Biology. I was involved in Communications and Writing. And I was getting ready to get married. I was engaged and it was the early 1990s and all of a sudden, over the course of several months, I noticed that I was gaining weight without any change in my diet or exercise. I was feeling depressed and blue, which is not normal for someone who is getting married, who s going to be a new bride. And I started to feel extremely exhausted. And every time I went for a dress fitting for my wedding dress I was actually having to let out the dress, which is one of the greatest horrors for a bride. Dr. Myers: Absolutely. Mary: So I was lucky enough to have a great integrative doctor. And the first time I complained about the fatigue, she said, Well, maybe you re not getting enough sleep or you re getting over a virus or something like that. Then I went in and complained about the weight. And she said, Maybe your diet needs to be tweaked. But when I went in and said I was feeling depressed and this was about a course of four or five months, she said, Bingo, I better check your thyroid. And she went ahead and ran the tests and called in and said, Yeah, your thyroid s a little low and I m calling in a prescription. And again I was lucky because a lot of people go through five years or five decades with that same struggle. So it only made Dr. Myers: Yes. And many doctors. Mary: Exactly. So, I was lucky in that sense. But I thought this was the end of that problem. And, actually, it was the beginning of a very long and really interesting and fulfilling journey for me. Because what I discovered was, it was not just take a pill and you ll be great. And my doctor actually was my partner in the journey to learn. So I started to learn about what was going on because all of my symptoms were not resolved by taking that pill. And at that point, they had put me on a synthetic thyroid hormone like so many millions of people are given as well. And it wasn t cutting it. And I had to really jump in to the trenches, this was the early days of the Internet and started reading and researching and talking with other people until I started to realize there is more to this story. And I started to put Amy Myers MD. All rights reserved. 2

3 together just some simple web pages and I found that people were absolutely desperate for this information. And that led to my creating the thyroid page at what became about.com. And then it started me off on the book process of creating books for people who didn t have access to the Internet or who wanted more comprehensive information. And here I am two decades later, a thyroid advocate and it s become a calling and a mission for me. And my goal, fast-forward people up the learning curve. I don t want people to have to spend two years, three years like I did wandering around in the wilderness trying to figure out what s going on, what I m supposed to do, how do I feel well, how do I get my hair back, how do I lose weight, how do I get pregnant. All of these questions and problems that so many people struggle with, I want them to have all the information in hand so they don t have to spend months, or years, or decades getting the answers. Dr. Myers: Well, certainly, thank you on behalf of all of our listeners for all your hard work doing that. And it is amazing I had the same experience in a certain sense with my Graves disease. I don t know how much you know about me but I had Graves disease and my thyroid ablated. And it s like, they ablated my thyroid and then put me on synthetic hormone. And you think that that s the end of the story, right? They ve solved the problem. And certainly when it comes to low thyroid and Hashimoto s, the number of people that don t even know if it s Hashimoto s, they re just Oh thank God! You can t blame people because you and I are lucky because we went to one doctor and got the answer. As opposed to many people who are going years, like you said, many different doctors. By the time they finally get that answer, they re just so happy. They re not even like, well, what does this mean? Is there anything I can do about it? Is that the right supplemental thyroid hormone? Are those the right tests? What more can I do? What can I do to make it not get worse? What can I do to reverse it? And you re not asking those questions because you re just so thrilled after five doctors and five years that somebody found the answer. And you re getting something and you re at least feeling better for the most part, hopefully, for people. Mary: Exactly. There are certainly doctors who can finally get to the diagnosis but those doctors are not always the doctors who can optimize the treatment. And that s the challenge for a lot of people is, they get to the diagnosis, which is already climbing up a mountain and reaching the top. But they don t realize that, in many cases, the doctors that they re talking to may not be in the position or capable of actually optimizing your treatment so Amy Myers MD. All rights reserved. 3

4 that you feel well, live well, resolve symptoms, and set up your body and your wellness so that you don t go down that road of high cholesterol and more weight gain and more depression and then having to throw many other medicines at all the side effects and symptoms that aren t being resolved because your thyroid treatment isn t really doing its job. Dr. Myers: Right. Well, let s get in to some of those ways in which doctors sort of just miss the boat on diagnosing the people with thyroid disease to begin with. Mary: Sure. Well, one of the biggest challenges is that we have so many millions of thyroid patients. The minimum estimate at this point, according to the American Thyroid Association, is about 27 million in the United States. And, actually, many of the integrative doctors that I talked to feel that the number is closer to 60 million, which is close to one in five Americans. The vast majority of those people are women because women are eight to 10 times more likely to be affected by thyroid disease. And the majority of the people with a thyroid condition walking around in the United States right now, undiagnosed. So we have a huge population of millions of people who have thyroid problems and don t know it and the majority of them are women. And I think one of the biggest challenges and there are plenty of medical literature to show it is that when women complain about what are called vague or unspecific symptoms, fatigue, weight gain, depression, moodiness, low sex drive, hair loss, feeling brain foggy, can t remember things, we oftentimes go in and we complain about these symptoms and sometimes in a very emotional way, which is understandable, because we feel terrible. But doctors are often trained and you can probably confirm this to hear these types of symptoms when expressed by women as related to a mental health issue. This woman is anxious. This woman is depressed. This woman is stressed. In some cases, they may go the next step and say, Well, this is hormonal. It s stress, depressed, PMS, perimenopause, menopause, postpartum. But it s very common for those doctors to jump to the conclusions of handing out antidepressants or anti-anxiety medicines or advise like get off the couch and stop eating so much instead of doing a comprehensive thyroid panel. So one of the biggest challenges we re dealing with is that we have all these millions of people that are undiagnosed who can t even get past that first gauntlet of getting the proper testing and getting diagnosed and treated because their doctors are looking at their symptoms and many times the women themselves are looking at these symptoms and saying, Well of course I m tired, I m 50, or Of course I m feeling depressed, I got a lot of stress in my Amy Myers MD. All rights reserved. 4

5 life, or Yeah, I m gaining weight, I need to improve my diet, I don t exercise enough. Dr. Myers: Yeah. And when I had Graves disease, I went to the doctor and that s exactly what I was told. This is just medical school stress and you are just thinking that you have every disease that you re learning about in medical school. Mary: Right. Dr. Myers: And I said, No, this is not what that is. And I mean, A, persistent person and I speak my mind; and, B, I was in medical school. So I mean, usually, and now of course being a doctor, when I go to a doctor, I m treated vastly different than someone who s not. And so I think because I spoke up and I said, No, this is not stress and I need a full workup, and then being a medical student, I got that. But if I had been a woman who had been and my doctor was a woman and if I had been a woman who didn t have the personality of speaking up or maybe wasn t a medical school student, I would have gone who knows how much longer and how many other doctors before I got diagnosed. Mary: Absolutely. And that s one of the missions that I have, which is to help women understand that we are customers and we are clients out there in the medical world and the world of medical services. The attitude in the past of putting our Dr. Marcus Welby up on the pedestal is an old model that doesn t work in today s seven-minute visits and HMOs that want to control the number of tests that we have and insurance programs that don t want to cover things. We have to be our own best advocates. And that doesn t mean that we need to go in guns blazing. But we need to go in very assertive and very strong and very professional about it and be insistent and persistent because, otherwise, we are going to oftentimes get shoveled off with the diagnosis of stress, depressed, and PMS. And we re never going to get to the root of the issue and deal with the symptoms and the problems that the thyroid can cause. Dr. Myers: Absolutely. So the first step is we re not being heard or because so many of these thyroid symptoms can be vague or can have many root causes. Fatigue can be a multitude of things that we get brushed off. And then if the person s lucky enough to actually get some testing by their doctor for the thyroid, let s talk about the problems with the testing. Amy Myers MD. All rights reserved. 5

6 Mary: Well, that s the second challenge, really. Because if you are lucky enough to have the doctor take you seriously and say, Okay, let me check your thyroid. Typically, most physicians, especially if you re dealing with your primary care or maybe your GYN or a family doctor, they re going to run one test. They re going to run the TSH, the thyroid stimulating hormone test. And this test is considered, on a conventional medical standard, to be the gold standard, the ultimate test that tells us what s going on with the thyroid. The challenge there is that this is a measurement of a pituitary hormone. It s a messenger hormone that s talking to your thyroid. It s not a measure of what is actually going on in your bloodstream as far as your thyroid hormones themselves nor is it measuring the antibodies or inflammation or involvement of an autoimmune process that may be causing symptoms and slowing your thyroid down and even gradually destroying it or speeding it up to the point where it becomes a danger to your heart and blood pressure and other issues in your body. So we are looking at this overreliance on the TSH test. Some of the doctors often call it the tyranny of the TSH. Because this test is not enough to really get a complete picture of whether you have a problem or whether it can be ruled out. And many of the integrative doctors, and I know that you advocate this as well, would like to see also a free T4 and a free T3 because these are measurement of the two key thyroid hormones. T4 being the storage hormone and T3 being the active hormone at the cellular level that delivers oxygen and energy all around the body to every gland, organ, cell, tissue throughout the body. We also, in many cases, when were dealing with symptoms that would suggest hypothyroidism or an underactive thyroid, many doctors are also including a thyroid peroxidase antibodies, or TPO test, to pick up on whether or not you have the autoimmune condition known as Hashimoto s disease or Hashimoto s thyroiditis, which is the most common cause of thyroid problems in the United States. If you are losing weight, insomnia, stressed out, very startled, hyper, having a lot of signs that everything is speeding up, doctors will often add the thyroid stimulating immunoglobulins, TSI test, to pick up on those antibodies that might suggest you have Graves disease situation where the thyroid becomes overactive due to autoimmunity. These tests are so important to get to the bottom of what s going on. And in some cases, we also want to make sure that some imaging is done. Because people can have symptoms and tests may look fairly normal but they may have nodules in their thyroid that are acting up. They can be producing bursts Amy Myers MD. All rights reserved. 6

7 of thyroid hormone or slowing the thyroid down in some ways. So, in some cases, ultrasound or MRI or some sort of imaging is important. Also, uptake tests for the thyroid to take a look at what the thyroid is actually doing. Is it producing hormone? Is it absorbing iodine? Are there nodules or bumps or lumps that are suspicious? But the basic, basic issue is a complete thyroid panel is not a TSH test. It s at least TSH, free T4, free T3, and an antibody test that matches up with some of the symptomatology that you re going through. And it is not enough to just have these TSH tests being run because they are only looking at one element of the picture. And in conjunction with that, we also need the doctor to actually put hands on and do a clinical examination. I want the doctor to feel my neck. I want the doctor to listen to my heart, to check my reflexes, to look at my eyes and hands and feet and see if there is puffiness, to ask me about my hair, to check my blood pressure, to talk to me about a family history or a personal history of autoimmune disease or thyroid conditions. This is also part of the diagnostic picture. So we can t rely just on one test or blood tests without a clinical examination and a discussion with the patient. And in some cases, we also need to bring in the imaging tests to get the picture of what s going on. But that brings up what I would consider the third issue, which is what do you do with the test? Dr. Myers: Yeah, for sure. And before we jump into that, one more that I personally do, and I know it s even less common certainly in the conventional world and not even everybody does it in the functional or integrative world, but I also do a reverse T3. So it s really looking at when we talk about T3, as you mentioned, going into every receptor and every cell, a lot of people think about that as the gas, and the reverse T3 is the brake. So somebody could particularly, if you re only getting total T3s and will just back up and say, what s bound to proteins and free is what our body can do actually something with. And T3 can go into free T3 or reverse T3. So I typically, at least at the first visit, do a free T3 and a reverse T3 so I can see if people are more in that stressed out, starvation, have heavy metals, a lot of different things that can affect. And so part of the reason they might have a low T3 is either they re not converting from T4 or they might have a low T3 because what they are converting, they re converting it all into that brake. So I don t check that every single time I check the thyroid. But I do check it at least the first visit. And if we re having problems or if anything s changed, I will go back and revisit that. And I d check another antibody too, the Amy Myers MD. All rights reserved. 7

8 thyroglobulin antibody. So those are two additional tests that I do that, just in my practice, personally, at least on the first visit. Mary: And I would say your patients are lucky because that is very thorough and, unfortunately, it s also very unusual because many people are not going to get those test. And I guess what I m wanting people to know is what the minimum they need to push forward. And absolutely once you re with a smart, integrative, or functional medicine MD, or DO, or a naturopathic physician who really gets to the issue of this, they re going to know to do reverse T3 test and other antibody tests and even nutritional tests: Sex hormone-binding globulin, vitamin D levels, selenium levels, all these other related issues. If they re seeing evidence of adrenal stress or you are struggling with weight or you re a very stressed out person in general, then reverse T3 is going to be an automatic test for some of them to do. But we ve got doctors out there who are battling just doing TSH tests. Dr. Myers: Right. And then maybe you re lucky to get the free T4. And in the conventional world, you re beyond lucky if you get the free T3. So getting the reverse T3 is usually like no go. Mary: A lot of them don t even know what it is. Dr. Myers: Yeah, exactly. Just wanted to bring it up for people that, that is just another test out there. Mary: Absolutely. And ultimately, as part of my information process, I always suggest that the reverse T3 be part of a comprehensive panel. But when you are really at battle with your HMO or your insurance company or your doctor, you go for what you can get. Dr. Myers: Absolutely. Right. Right. Mary: And oftentimes that s TSH, the free T4. And again, free T3 and antibodies if you re lucky. Dr. Myers: Right. And I would say, out of all of those, the free T3 is probably the most important. Mary: Exactly. Dr. Myers: Because the problem that I see in my practice is that most people or not most people, I certainly see most people with overt or what I would consider overt disease and we ll get into that in a second with the reference ranges. But, really, the problem is in converting their T4 to the T3. Amy Myers MD. All rights reserved. 8

9 And since the T3 is the most active form going to every cell, that s the one that really counts. So yes, if you re taking home one thing in all of this that Mary is saying and you re prioritizing and your doctor s only willing to do one or two things, the T3, in my opinion, is probably the most crucial of the thyroid tests. Mary: Yes. Absolutely, I agree because TSH, also, can be degraded by sitting out on a table. It depends on what time of day you re taking it. If it s not handled properly, the numbers can get very out of whack. Or there are variety of things like heterophile antibodies and other types of issues in the system that can completely shift your TSH levels and have them be non-reflective of what is actually going on. We have women that had hemorrhages after pregnancy and had Sheehan s syndrome where the TSH has no connection whatsoever to the thyroid function. So there are a number of situations and enough circumstances that are corrupting what supposed to be an accurate result but isn t, that really looking at a pituitary hormone that can sometimes get messed up is not the accurate way to pick this up. We really need to know what is going on in your bloodstream with the active available thyroid hormones. And that s the T3, the active hormone, and the free T3 and the free T4, which is I call it the cake mix. And T3 is the cake because we can t use the cake mix and eat it. It just needs to be baked into something we can actually use. And that s the T3. Dr. Myers: Right. So we have doctors not listening to us and even ordering the test to begin with or thinking our symptoms are something else. Then we have they re ordering the test, but they re not necessarily the right test or certainly a complete test for most people from the beginning. And then you finally get the test. And what s the problem there? Mary: Well, the problem there is what are they doing with the numbers and what do they believe versus the reality of the numbers? And let s talk about the TSH test. So this is this gold standard test that the conventional medical world thinks is the end-all, be-all diagnosing and managing thyroid disease. Well, at different labs, the reference ranges, they vary a bit. But let s use the 0.5 to 4.5 range or 0.3 to 4.0. It s generally going to be somewhere in that vicinity depending on the lab that you re going to. And if you are anywhere in that reference range, according to very conventional approaches and even the official guidelines of the American Thyroid Association, American Association of Clinical Endocrinologist, you are normal. You are what they call euthyroid. You do not have a thyroid condition. You could have no T4; no T3; thyroid antibodies through the roof; and frankly, Amy Myers MD. All rights reserved. 9

10 a goiter that s visible on the side of your neck. And if you have a TSH level that falls within the reference range, there are doctors who will say you do not have a thyroid problem. And this is the challenge because about 10 years ago, the American Association of Clinical Endocrinologist said that reference range was far too broad. And that, really, to reflect growing disease or insipient disease or people with autoimmune problems that were going to become overtly hypothyroid, we needed to narrow that range and basically say anyone above 3.0, not 4, 4.5, 5 or 6 but over 3 should be considered hypothyroid. And this was a firm recommendation that came out to about actually now it s almost 13 years ago. Dr. Myers: 2002, right. Mary: Yeah, 2002 or And now, over time, it sort of faded away and they took the press releases off and the information came off the website. And now were back to the reference range rules all. And if you fall in the range, you are normal. And the problem here is that there are doctors that are savvy enough to understand that what they had recommended over 10 years ago was actually more accurate. So there are endocrinologists You could actually go to a medical building with your test result that says, My TSH is 4, and go to Dr. A. And then Dr. A will say, Your TSH is 4. You re in the reference range. You re fine. Any symptoms you have are not related to your thyroid. And you go across the hall to Dr. B with that same lab test and Dr. B is going to say, Oh, your TSH is 4. And you re gaining weight. You have a family history of thyroid problems. Your hair is very brittle. Your skin s dry. And you re feeling depressed and brain fogged. I m going to try you on a trial dose of thyroid medication because you re probably borderline hypothyroid. Now you can take that same test result across the street to the integrative doctor. And that doctor is going to do free T4, free T3, antibodies, probably reverse T3. And they re going to say, Holy cow, you ve got a TSH of 4. But you have no T3, no T4. Your antibodies are through the roof. You have Hashimoto s. And we need to treat this now or you re going to have a TSH of 10 or 12 or 20. And you re going to become profoundly hypothyroid. So, we have all sorts of different ways of looking at it. And again, even among the doctors you say, This is the gold standard and this is the only test we use, they don t even agree. You could get multiple opinions. So that is the key challenge I see because a lot of medical insurance companies and HMOs will only cover the TSH test for diagnosis of thyroid. I just did a review of Cigna, Amy Myers MD. All rights reserved. 10

11 United Healthcare, a couple of different health insurers and HMOs, Kaiser Permanente, and if they were really open-minded they were adding free T4. But the antibodies were not considered part of any standard workup. And you never saw the word T3 anywhere. Dr. Myers: Yeah. My father has a history of I don t think he actually has Hashimoto s, he actually just has hypothyroidism that he s had for a while. And he s on Synthroid. And of course I ve written this book and I ve sent him a copy and he s been feeling fatigued lately. So I said, Well, Dad, go to your doctor. Take a copy. I don t have the official book yet but I have a galley copy. I said, Take it with you and ask him to run all of these tests. I ll write them out for you. And they run this TSH. And it s 2, which actually was pretty decent. And they said, well, because he s nearly 80 now and on Medicare, they said, Since your TSH is so good, we will not authorize running any of the other labs. They just absolutely refused. So for those people, you can check my website because the book coming out, we know this is going to be a huge problem for a lot of people and we did not want people just to feel like Great, I ve read this book and I have nobody that will help me and my insurance company won t do it. We ve partnered with a lab that you can go to my website where you can get order it off the internet and go to a local Quest lab and pay out of pocket. It s significantly cheaper than if you were to try to go in I mean what most people don t realize is, one, in Texas at least, you don t have to have a doctor s order. You can walk in to any lab and order whatever you want. But it s going to be ungodly expensive. And so there are labs popping up around the country and places on the Internet that will kind of order labs for you under the supervision of a doctor or something where you can pay out of pocket. And I think this is almost where, unfortunately, where medicine is going because you cannot be beholden to these insurance companies. You ve got to get the labs that you need to really get your diagnosis. Mary: Right. Dr. Myers: And to get help and to get to feel better. Mary: Unfortunately, there are a few states in the country that don t allow this self-ordering or patient-directed lab testing. New York; New Jersey; Massachusetts; Maryland, where I m located; and I think Rhode Island are the five that don t allow it. But the rest of the country does allow a direct-toconsumer lab testing. Amy Myers MD. All rights reserved. 11

12 And for people who are struggling with their insurers or their HMOs or their doctors refusing to check these other issues, it is a very viable and helpful alternative to get information, which you can then use to advocate for yourself well because this kind of information is power for thyroid patients. I don t care whether you re 20 or you re 80, you re going to need to advocate for yourself or have some smart family members or friends in there with you helping you advocate. Dr. Myers: Right. Then you do need to go to somebody who s educated because I even see people coming in. Finally, their doctor and I, of course, talked about this on my book. Their doctor was willing to do the free T4, the free T3, even the integrative doctor was willing to do the free T3. But then they still don t know really how to interpret that because there s within normal range and then there s optimal range. And a 2.3 or a 2.5 might be a totally normal within reference range free T3 but far less than optical. I mean I like it up over 3 at least. So that s the whole reason I wrote the book because I see people coming in from every walk of life having been to 10 different doctors. Some of which were even people who are in the alternative space and know to order these labs but still don t really understand how to interpret it. So not to be overwhelming to people, that s what you do. It s what I do. It s like we re trying to give you information to empower you and give you the information so that you can either keep going back to your doctor or an integrative doctor or finding somebody else who will really be able to put these pieces together. And I know you do a great job of it and all the articles in your books. So there are these references that people can go to, to really get the right information. Because even though you are with what might seem like an open-minded practitioner, they were not trained all the same. Mary: Right. Dr. Myers: And I, myself, had my thyroid ablated. So I get it from a personal patient perspective as well. In fact, I ve had this recent toxic exposure and I suddenly was like getting hyperthyroid and I had to lower my dose and I don t have a thyroid and I m kind of like, what is going on here? So even your circumstances in life can change and kick something up or down and this really needs to be continued to be monitored. Shall we talk kind of quickly also just about the different kinds of thyroid I call it supplemental thyroid hormone, because I think when we refer to it as thyroid medication people hear these success stories of people getting off of their supplemental thyroid hormone. But a lot of people can t and I don t want Amy Myers MD. All rights reserved. 12

13 them to feel beating themselves up, that I saw this person and they did this juice cleanse and then they got off of it. If you don t think of it as a medication and you think of it like a diabetic with insulin and it s a lifesaving medication. If I didn t take my supplemental thyroid hormone, I literally, over time, would die because I don t have a thyroid. So I am trying to educate people to think of it as supplemental thyroid hormone because that s what it is, not a medication. And it s not like you have high blood pressure and there are things that you can do to get that to go away. If there are things, which are what I write about and do in my practice, to reverse thyroid disease, there are. And if it s caught early enough, the thyroid is resilient and you can get those to go away. Or it might be as simple as we haven t gotten into some of the nutritional deficiencies with zinc and iodine and vitamin D and vitamin A and the things you need to make your thyroid hormone. But if you re coming into this five, 10, 15, 20 years later, your thyroid is a gland that can be damaged and does not get to rejuvenate. And so those people are going to need to be on supplemental thyroid hormone. So I don t want anybody to feel bad that they re on a medication and they can t get off of it because there are people who it is a lifesaving hormone for. Mary: Sure. Dr. Myers: So maybe you could kind of address that and talk about the different, just briefly, sort of synthetic versus desiccated or that plain T4 versus T3. Mary: Absolutely. And just to start, though, I agree with you completely. And I oftentimes describe the same. Because I have people that say, Well, I don t want to take a medication. And I d say, This is different. What we re doing is replacing something that is native to the body. And again, it s like a diabetic. We would never tell a type 1 diabetic who was insulin-dependent, Oh you don t need insulin, you can do a juice cleanse and cure your diabetes. Not going to happen when the pancreas is permanently damaged. Well, the thyroid, when it s permanently damaged by years of Hashimoto s, destruction, or radioactive iodine, or it s been surgically removed, in part or in whole, we are not talking about a thyroid that s going to magically regrow itself and repair and restore. So what we re doing then is replacing the missing hormone in the body. And then looking at all of the other cofactors to make sure that our body is using that hormone well and relieving symptoms and keeping us feeling great. Amy Myers MD. All rights reserved. 13

14 Because you don t even need to have a thyroid to get that thyroid hormone, you can get it from these external medications. But even getting that thyroid hormone in your body, whether it s naturally produced or taken via pill, is only the first step towards the thyroid hormone working well in the body. And that really leads us into the discussion of the different types of treatment options. The most conventional approach and the most standard approach and the one that is recommended by the official guidelines for hypothyroidism treatment is levothyroxine or often called L-Thyroxine. It s a synthetic form of the T4 hormone. That s that storage hormone, the cake mix I was talking about that s produced by the thyroid gland. So what we re doing is we re mimicking that hormone in a synthetic form. And the assumption by a lot of the conventional medical world is that we take in that T4, that synthetic form of T4, and the body will convert it into the T3, which is the active thyroid hormone as we talked about. And then deliver that out to the cells and tissues with the energy and oxygen our body needs. Now, for a subset of people, that works perfectly. They can take a synthetic T4. Their body converts well, does what it needs to do. They feel well. No complaints. No side effects and symptoms. And they are out there feeling good and they say, I ve no trouble, I just take my Synthroid pill or Levoxyl pill every day and I feel great. And I say more power to them. I m so excited they found something that worked for them. Unfortunately, that option is not the endpoint even though many physicians don t have anything else in their toolbox to offer patients. Beyond that, there are other options and many of us Dr. Myers: And just real quick, it s the number one prescribed medication in the United States, just for people who don t know that. That s how common this is. Mary: Right. So many people are taking levothyroxine. And again, some of them are feeling great but a lot of the research and studies have shown that the majority of them do not feel well on levothyroxine or T4 only treatment. And there we enter into the issue of some people for various reasons. There may be genetic polymorphisms. There may be nutritional deficiencies. There may be stressors and other hormones that are involved in blocking the body s ability. But for a variety of reasons, they are not converting the T4 into T3 effectively. Either they re not converting enough. Or because they re in a stressed situation like we talked about, they re diverting some of their T4 production over to this reverse T3, which is a useless, inactive form of T3. Except the only Amy Myers MD. All rights reserved. 14

15 action it does do is it sometimes it can actually block the body s ability to effectively absorb the T3 that we do have. So we have this additional issue going on that is completely complicating the process for some people. And what we have found through a number of studies, going back two decades, is that a substantial percentage of patients feel better and report better quality of life and improvement in their symptoms on a T4 plus T3 combination therapy. And the way that this can be accomplished is a number of ways. For some people, it s a levothyroxine drug like Synthroid, Unithroid, Tirosint, Levoxyl, Eltroxin from other countries plus a T3 drug, which would be the brand name in the U.S. is Cytomel but there is also a generic form of this T3 in a tablet form. Other doctors like to mimic the body s release of T3 more closely and would recommend a time-released form of a T3 or a sustained release so that it s not all hitting your bloodstream at once. It s more of a slower release because T3 is very fast acting and it can be over-stimulatory to some people when it s done in a plain tablet form. But if it s done in a time-released capsule, it maybe more easily absorbed and cause less problems like heart racing or feeling nervous, etcetera. The other option is the use of natural desiccated thyroid. And natural desiccated thyroid is a whole different kind of drug in a sense that it s been on the market for over a hundred years. It is the dried or desiccated thyroid gland of pigs. It s called porcine thyroid. And the most popular brand names that people would know would be Armour Thyroid, Nature-Throid, WP Thyroid. In Canada, there s ERFA. And here in the U.S., we also have a generic NP Thyroid made by a company called Acella. And these products, they re FDA regulated but they are not FDA approved because they were on the market so long ago that they were here before the FDA. So the FDA has never gone through a formal approval process for the natural thyroid drugs. But because so many people have used them and they ve been safe and effective for over a century, they have not required them to go through that formal approval process, which is a multimillion dollar, multiyear process. People often say, what is the best thyroid medication? They ll say to me, Mary, you know. Tell me the secret. You know. And I m sure you got the same question, Dr. Myers, what really is the best thyroid medicine? And I say, Look, the best thyroid medicine is the one that works safely best for you. Dr. Myers: Absolutely, totally agree. Amy Myers MD. All rights reserved. 15

16 Mary: I do not care which medicine brand it is, which combination. I don t care whether you re doing natural thyroid plus a little T3 or Levoxyl plus a little natural thyroid or Tirosint alone, which is the hypoallergenic absorption problem version of levothyroxine for people that have a lot of Crohn s disease or IBS or other issues with allergies. I don t care which combination of these medicines or which dosages, etcetera, are working for you. As long as they re working for you and they re safely working for you, that is the best thyroid medicine for you. That said, a lot of the research and a lot of the studies are now backing up that, at minimum, a subset of the population does seem to have either a genetic propensity or some other nutritional or stress or even factors yet to be determined, some issues that are making it apparent that they need T3 as well as T4. And for some of those people, the synthetic combination does beautifully. Others seem to do better and respond better with natural thyroid. So I really just want drive home that point that the levothyroxine that many conventional doctors offer you may work but its only step one in an investigated trial-and-error process. And that s the challenge right now is we can t look at you and say, Oh, absolutely, you are somebody who s going to respond beautifully to this brand of medication at this dose. It s trial and error. It takes time. There is, excitingly right now, a study going on that is looking at comparing levothyroxine to a levothyroxine plus T3 synthetic compared to a natural thyroid combination. Dr. Myers: That s great. Yeah. Mary: And they re testing for the genetic polymorphisms that may make us more susceptible to needing T3. So we may, at some point down the road, be able to have an additional test that you re going to run on your patients when you re prescribing that looks for the genetic polymorphism and says, Ok, you got that. I m going to have to give you some T3 along with your thyroid medicine. And obviously, that s something that you would already be keeping in mind without having that genetic test. But it may become so commonplace that we can actually start seeing it coming into the HMOs and the insurance companies and become part of the standard practice. Dr. Myers: Yeah. And that would be really helpful because the studies out there right now, at least that I looked at when I was writing my book, really just comparing the levothyroxine with one of the desiccated pills and being that this is one of the reasons that most conventional doctors at least say that they don t prescribe it is because it hasn t gone through that FDA approval, so Amy Myers MD. All rights reserved. 16

17 they are unlikely to prescribe it. And the studies show that, as you have already alluded to, many, many people do better on that desiccated thyroid. But my question and what I actually write in my book is, well, is it actually the fact that desiccated thyroid that has T1, T2, T3, and T4 or is it just the fact that these people are getting some T3? And my belief is that likely it s just the fact that people are getting some T3. Because it s really the big problem that I see since I am testing all those, there are so many people that are not converting. And there may be some genetic polymorphism but I think it s probably a little bit more simple. And it s really nutrient deficiencies that then goes back to we bombarded our bodies with chlorine, fluoride, and all the halides displacing the iodine. We re not digesting and absorbing our food. We have leaky guts. We are eating processed foods. And so we re not getting all those rich sources of vitamin A. We re all vitamin D deficient. So likely they might find some polymorphism that makes you even that much more susceptible to all these nutritional deficiencies. But it s probably more that there is just a lot of nutritional deficiencies going on with people not making that conversion or high-stress levels making them converting to reverse T3. Mary: Exactly. Right. Dr. Myers: So that will be great to have that study because then at least the T3 will get into mainstream. I know, again, when I was starting out on this journey and I had my thyroid ablated, I ve heard about T3, I didn t know anything about optimal levels or anything. But I was able to convince my conventional doctor-endocrinologist to give me some Cytomel. And I don t think he would even because I have my old labs. It s kind of crazy to look back at them. But he would do a T3 uptake. He never would do a free T3. But he did let me go on well, I was on Synthroid and Cytomel. But I eventually got off of it because I would feel that jittery feeling like coffee. Eventually moved in to compounded T3 and now I do desiccated T3 and I actually take a little Tirosint on top of that because that s just what I need. But to your point and this is what I do, a lot of people in the conventional can t fit into, It s Synthroid. It s Synthroid or some form of T3. Those in alternative or functional medicine or integrative medicine are like, It s desiccated thyroid. It s dessicated thyroid. And you have to be leery if your practitioner is fitting into it s one or the other. I feel exactly like you do. I ve been through this myself as a patient. Amy Myers MD. All rights reserved. 17

18 I have tried them all. And I have been through this as a physician, working with patients. I have people who do fine on Synthroid. I have people who do better on Tirosint. I have people who do better on Westrhoid Pureand those that do better on Armour and those who do better on us doing a compounded formula of crazy, itty, bitty, teeny, tiny dosages. And there is no one size fits all. I can say that the vast majority of people do better on something with T3. And typically, it is one of the desiccated. I could tell you that I have far more people on desiccated in my practice than not. But I think you just need to be careful and you need to interview that practitioner before you re going in of how do you feel? What do you typically use? Because I look at a person s labs and I listen to them. And I treat the person, not the labs. So the labs are there as a guide to know why this person isn t converting to T3. But if they tell me there are already tendencies towards anxiety or something, we might just start with the T4 and see do they convert fine afterwards? So that probably for me would be one of the biggest take homes or another sort of point is asking your I m assuming it s some doctor of some sort if they re prescribing, maybe it s a nurse practitioner or what not, but that they are listening to you and not saying, Oh everybody does better on this or that. If anybody fits into one camp or another, I m not saying run, but you definitely might want to be looking around. Mary: I agree 100%. As a patient advocate, I get so frustrated when we see guidelines come out or I see endocrinologists quoted in the media saying, No one needs T3. No one needs anything but a TSH test. And levothyroxine is the gold standard and that s all we need. And get everybody into the reference range and after that their problems are in their head. It s infuriating to me. But it s equally infuriating to me to see integrative or holistic doctors that say, Everyone with a thyroid problems needs huge quantities of iodine. Or everyone with a thyroid problem needs adrenal support and hydrocortisone. Or everyone with a thyroid problem has to be gluten free, it s required, otherwise you re never going to feel well. Any time you see a one-size-fits-all approach, where someone says this is the solution or the only solution, I agree with you, run. Because I don t think that it s taking into account the fact that we are individuals. We have different physiology. We have different nutritional issues, different genetics. Amy Myers MD. All rights reserved. 18

19 And I can talk to 20 thyroid patients and some of them will go gluten free and it s great. They feel wonderful. Their antibodies drop to nothing, and they re back to normal. And another group of them, it has absolutely no effect on anything and they still need to be looking at other options. So any of these categorical blanket statement one-size-fits-all, This is what you have to do, beyond some of the most basic things, like you need to get good sleep, you need to take good care of yourself, you need to reduce your stress and eat well, I mean, those are the general guidelines. But when we start talking about everybody needs iodine, everybody needs adrenal support, everybody needs to do this, that, and the other. Or the only drug is natural thyroid or the only drug is Synthroid, then we ve got a problem and you re dealing with someone who s in a box and can t get out. Dr. Myers: Yeah. I would just make a comment about gluten because I m kind of a gluten nazi. Those who do have autoimmune thyroid or any autoimmune disease because of the research, I absolutely would urge everyone to be 100% gluten free. If your antibodies aren t coming down, it doesn t mean you have gluten issue, it just probably means that there s mercury or mold. There s something leaky gut, Candida. There are some other reason. And through that molecular mimicry process that we ve talked about some in the summit, and I certainly talked about it in the book, I would urge those with any type of thyroid condition to consider giving up gluten as well. But that s just I agree with you. In general, anybody that s one-size-fits-all, we are all individuals, for sure. And what works for your brother, your mother, and your sister might be completely different that works for you. So just because you and your best friend both have Hashimoto s and she s taking one thing and you re taking something else does not mean somebody is right or wrong. It means you re an individual and what s working for you is working for you. Mary: Right. And I guess, my point there is that I had even heard some functional practitioners tell people who had thyroid cancer and do not have thyroid gland anymore that if they go gluten free that they can get off their thyroid medicine. This is not coming from MDs. I am seeing it more from the chiropractor community who have these thyroid programs to cure and resolve things that don t involve medication because they can t prescribe it. But I ve heard some really wacky things that involve everything from iodine to gluten free to adrenal support, etcetera, that are not they re not reality. Dr. Myers: Yeah. There are wacky people in every profession. So you just have to be educated, reading your material, reading my material, get good quality Amy Myers MD. All rights reserved. 19

20 material. People are advocating for you, they know what they re talking about, supporting you. And the main thing is there are people, I mean obviously I wrote The Autoimmune Solution, there are people who can reverse their autoimmune diseases. However, when it comes to the thyroid and of course the pancreas, these are vital organs that if there has been enough damage and you who haven t caught it early, you may not be able to fully reverse that condition to the point that you no longer need to take any supplemental thyroid hormone. So don t be beating yourself up when you hear success stories of someone who did catch it early and was able to spare themselves from getting on it or was able to get off. I just don t want people thinking everybody can do that because most people can t because of the fact that they have gone years without a diagnosis. They ve gone to multiple doctors. Then they re getting to run around with the labs. It could be several years to many years before you actually land a place and get your diagnosis. And if that s the case, I just don t want anybody beating themselves up that they re not going to be able to have a life, potentially, free of supplemental thyroid hormone. Mary: Exactly. And I think one of the most important things here is to look at your overall treatment and approach as a pie, in a sense. And each slice of that pie is going to be an important component. So if you absolutely require medication to support your thyroid, that s part of the pie. And again, we re replacing the missing hormone. We re not adding in drug like statin drugs or antidepressant. No one has an antidepressant deficiency. No one has a statin deficiency. But you can have a thyroid deficiency and you need to replace that hormone. But we re also including nutritional issues. We re including lifestyle issues. We re including supplements and other types of support for the glands. We re looking at the changes in diet that can lower autoimmunity. And in some cases, we re looking at what I consider sort of the cutting edge approaches to dealing with inflammation and autoimmunity when autoimmunity is the cause of your thyroid issue such as drugs as low-dose naltrexone, which can help some people with autoimmune diseases including some of the thyroid diseases, lower their antibodies. In some cases, back into the normal range but maybe enough to lower their dose of thyroid medicine but perhaps not to the point where they can get off their thyroid medicine completely. Amy Myers MD. All rights reserved. 20