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DESCRIPTION

Hypothyroidism occurs when the thyroid gland produces too little thyroid hormone, resulting in an underactive metabolic state. All of the body's processes slow down with this disorder. Thyroid hormones regulate your metabolism—how your body burns calories to produce energy—and influence all of your body processes, including heart rate, digestion, muscle and bone strength, and cholesterol levels.

The thyroid is a small, butterfly-shaped gland located in the front of the neck, which produces thyroid hormones, or “chemical messengers,” that signal cells throughout the body to increase oxygen use. The two key thyroid hormones are L-triiodothyronine (T3)—the more biologically active thyroid hormone—and thyroxine (T4).

Hypothyroidism affects about 5 million people in the United States, about 90 percent of which are women. Thyroid problems can cause many recurring illnesses and fatigue.

Hypothyroidism Facts:

• Hypothyroidism is present in 1 out of every 5000 newborns.
• Impairment of thyroid function affects about 2% of adult women and about 0.1% to 0.2% of adult men in North America.
• As many as 25% of patients with hypothyroidism have normal levels of T3.
• Symptoms of thyroid dysfunction can have a significant impact on behavior such as mental confusion and memory problems.

Hypothyroidism can be associated with depression and its symptoms:

• Decreased interest in daily activities.
• Concentration difficulties.
• Sleep disturbances.
• Reduced sexual interest.

Hypothyroidism can be associated with certain heart problems and mild high blood pressure. Even mild thyroid failure can have harmful effects.

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CAUSES

The thyroid gland is the body's internal thermostat. It regulates the temperature by secreting two hormones that control how quickly the body burns calories and uses energy. If the thyroid secrets too much hormone, hyperthyroidism results; too little hormone results in hypothyroidism. Many cases of hypothyroidism and hyperthyroidism are believed to result from an abnormal immune response. The exact cause is not understood, but the immune system can produce antibodies that invade and attack the thyroid, disrupting hormone production.

A condition called Hashimoto's disease is believed to be the most common cause of underactive thyroid. In this disorder, the body in effect becomes allergic to thyroid hormone. Hashimoto's thyroiditis develops when the immune system produces antibodies that destroy thyroid tissue and thus reduce the thyroid's ability to produce thyroid hormone. Hashimoto's disease is a common cause of goiter, a swelling of the thyroid gland, among adults.

Other causes of hypothyroidism include the surgical removal of the thyroid gland and radioactive iodine therapy.

• Thyroid surgery. Part or all of the thyroid gland may be removed to treat disorders such as hyperthyroidism, an enlarged thyroid gland (goiter) that makes swallowing difficult, thyroid cancer, or thyroid nodules that may be overactive or cancerous. Hypothyroidism results when the thyroid gland is removed or when remaining thyroid tissue does not function properly.
• Radioactive iodine therapy, which is often used to treat hyperthyroidism, and Hodgkin's disease. Radioactive iodine therapy can destroy the thyroid gland, leading to hypothyroidism.

Less common causes of hypothyroidism include:

• Infections. Viral and bacterial infections can temporarily damage the thyroid gland, resulting in a short-term form of the condition. Hypothyroidism caused by infection usually does not result in permanent hypothyroidism.
• Medications. Some medications can interfere with normal production of thyroid hormone. Lithium carbonate, a medication used to treat people with bipolar disorder, is one of the most common medications that causes hypothyroidism. Others include amiodarone hydrochloride (such as Amiodarone, Cordarone, and Pacerone) and interferon-alfa (such as Infergen, Rebetron, and Wellferon).
• Rarely, disorders of the pituitary gland or the hypothalamus (secondary and tertiary forms of hypothyroidism). The pituitary gland and hypothalamus produce hormones that control the thyroid and, as a result, affect its ability to produce thyroid hormone.
• Excessive iodine, which, in food or medications, can reduce the function of the thyroid gland (usually temporarily).
• Congenital hypothyroidism. About 1 in 4,000 infants is born without a properly functioning thyroid gland. All children born in a hospital in the United States are tested for hypothyroidism at birth.

Mild (subclinical) hypothyroidism is most often caused by inadequate treatment of hypothyroidism, Hashimoto's thyroiditis, or radioactive iodine therapy. However, it may be caused by anything that causes hypothyroidism.

Pregnancy, which requires an increased production of thyroid hormone, can cause hypothyroidism. About 3% of pregnant women in the United States develop hypothyroidism.

Hyperthyroidism is not as common as hypothyroidism. Both of these thyroid disorders affect women more often than men. A malfunctioning thyroid can be the underlying cause of many recurring illnesses.

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SIGNS & SYMPTOMS

The symptoms of hypothyroidism are seen throughout the body. In adults, they usually develop slowly and are often considered part of the aging process. Symptoms of hypothyroidism in adults include:

• Inability to tolerate cold temperatures.
• Fatigue and feeling sluggish.
• Loss of appetite.
• Painful pre-menstrual periods.
• Heavy or irregular menstrual periods that may last longer than 5 to 7 days.
• Fertility problems.
• Hair loss (including the eyebrows), coarse, dry, and thinning hair.
• Weight gain.
• Muscle weakness.
• Muscle cramps and aches.
• Slow body movements.
• Slow heart rate.
• A milky white discharge from the breasts.
• Dry and scaly skin.
• Brittle nails.
• A yellow-orange coloration in the skin (particularly on the palms of the hands).
• Goiter.
• Yellow bumps on the eyelids.
• Recurrent infections.
• Constipation.
• Depression.
• Difficulty concentrating, memory problems.
• Slow speech. Hoarseness.
• Drooping, swollen eyes.
• Facial puffiness.
• Swelling of the arms, hands, legs, and feet.

The most common symptoms are fatigue and intolerance to cold. If you consistently feel cold while others around you are hot, you may be suffering from reduced thyroid function.

The progression of hypothyroidism depends on its cause and your age. Hypothyroidism caused by Hashimoto's thyroiditis occasionally will disappear on its own. More often, you will experience a gradual loss of thyroid function, although the symptoms may develop slowly and be so mild that they go unnoticed for years. The older you are, the more you will probably notice the symptoms. This condition is also called Hashimoto's disease or chronic autoimmune thyroiditis.

Hashimoto's Disease

Hashimoto's thyroiditis is the most common form of autoimmune thyroid disease. It develops when the body's natural defense system (immune system) makes antibodies that attack and eventually destroy the thyroid gland. This results in a gradual loss of thyroid tissue and thyroid gland function.

Hashimoto's thyroiditis is also associated with other conditions, including diabetes, Addison's disease, rheumatoid arthritis, pernicious anemia, and premature menopause.

Hashimoto's thyroiditis occurs most often in women and older adults. The disease does not cause any pain and often goes unnoticed for years.

Treatment may be needed if symptoms of low thyroid production (hypothyroidism) develop or if the thyroid gland becomes inflamed and enlarged. If the disease does not cause these problems, treatment may not be necessary.

Although rare, hypothyroidism is seen in infants and children. In infants, if hypothyroidism is treated within the first month of life, the child grows and develops normally. Untreated hypothyroidism in infants can cause brain damage, leading to mental retardation and developmental delays. Every state in the United States tests newborns for hypothyroidism.

If hypothyroidism develops after age 3, mental retardation usually does not occur. However, untreated childhood hypothyroidism usually delays a child's physical growth and sexual development, including the onset of puberty.

Teens with hypothyroidism typically look much younger than their age. With adequate treatment, the teen's height and weight will catch up to those of healthy teens of the same age.

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RISK FACTORS

Risk factors for hypothyroidism include:

• Age. Older adults are more likely to develop hypothyroidism.
• Female gender. Women are 3 to 4 times more likely to develop hypothyroidism than men.
• Family history. People who have close relatives with thyroid disorders are more likely to develop this condition.
• Previous thyroid problems. Thyroid disease, goiter, and surgery or radiation therapy to treat thyroid problems increase the likelihood of developing hypothyroidism in the future.
• Having an autoimmune disease, such as Addison's disease, type 1 diabetes, rheumatoid arthritis, or pernicious anemia. An autoimmune disease that causes patches of light skin (vitiligo), and premature gray hear (leukotrichia) are seen more often in people with hypothyroidism.
• Iodine deficiency. This is rare in the United States but common in areas where iodine is not added to salt, food, and water.
• Medications. Some medications can interfere with normal thyroid function, particularly lithium carbonate (used to treat bipolar disorder), amiodarone hydrochloride (such as Amiodarone, Cordarone, and Pacerone), and interferon-alfa (such as Infergen, Rebetron, Wellferon).

As many as 17% of women over age 60 are at risk for developing mild (subclinical) hypothyroidism. Many of the same factors that increase a person's risk for hypothyroidism also increase the risk for mild hypothyroidism.

Subclinical Hypothyroidism

Subclinical (mild) hypothyroidism is diagnosed though a medical history and physical exam. If your health professional suspects subclinical hypothyroidism based on findings from the history and physical exam, lab tests are done to confirm the diagnosis.

Subclinical hypothyroidism is diagnosed when a person has:
• No or mild symptoms of hypothyroidism (such as fatigue, cold intolerance, consistent weight gain, depression, or memory problems).
• A mildly elevated thyroid-stimulating hormone (TSH) level.
• A normal or only slightly decreased thyroxine (T4) level.
Some people with subclinical hypothyroidism may test positive for antithyroid antibodies, which indicates they have Hashimoto's thyroiditis, a condition that may cause a gradual loss of thyroid gland function. Subclinical hypothyroidism affects 5% to 10% of men and 5% to 17% of women over the age of 60. About 5% of this group develop hypothyroidism per year. Subclinical hypothyroidism should be closely monitored.

Current research does not provide clear evidence to support treatment of every person with subclinical hypothyroidism, and many doctors disagree about whether it should be treated. When making the decision to treat subclinical hypothyroidism, the benefits of treatment (possible lowering of cholesterol levels and reduced symptoms) must be balanced with the cost of medication and monitoring.

References:
Hershman JM, Singh N (2002). Hypothyroidism. In RE Rakel, DT Bope, eds., Conn's Current Therapy, pp. 646–648. Philadelphia: W.B. Saunders.

The progression of hypothyroidism depends on its cause and the age of the person.

Hypothyroidism In Adults

Hypothyroidism caused by Hashimoto's thyroiditis occasionally will disappear on its own. More often, the disorder causes a gradual loss of thyroid function, so your symptoms may develop slowly and be so mild that you do not notice them for years. However, symptoms usually grow worse, and health problems may develop as the disease progresses.

If untreated, hypothyroidism may lead to:

• Myxedema, a condition characterized by swelling of tissues, increased fluid around the heart and lungs, slowed muscle reflexes, and a slowed ability to think.
• Myxedema coma, a rare, life-threatening condition. This can occur in a person who has had hypothyroidism for many years that becomes markedly worse. It usually occurs when older adults who have severe hypothyroidism become ill with another condition, suffer from cold exposure, or take pain killers or sleeping pills. A person with myxedema coma shows signs of mental deterioration, such as apathy, confusion, and psychosis. He or she may lose consciousness (coma) and may have an extremely low body temperature (hypothermia), slow heartbeat (fewer than 60 beats per minute), heart failure, and difficulty breathing (respiratory failure).

Complications, such as:

• Increased levels of cholesterol and triglycerides (increasing the risk of coronary artery disease and stroke).
• Fluid around the heart (pericardial effusion).
• Sleep apnea.
• Forgetfulness and dementia.

People with mild (subclinical) hypothyroidism have only slightly abnormal thyroid hormone blood test results and often do not develop obvious symptoms or health problems seen in hypothyroidism. Some people with mild hypothyroidism regain normal thyroid function, but 5% to 20% of them develop hypothyroidism.

If your thyroid gland has been removed during surgery, hypothyroidism will occur within a month. If you have been treated with radioactive iodine therapy, hypothyroidism often occurs within a year. In these cases, thyroid function generally will not return, and thyroid hormone medication must be taken for the rest of your life.

Hypothyroidism During & After Pregnancy

Women who have hypothyroidism or mild hypothyroidism before they become pregnant are more apt to develop more severe hypothyroidism during their pregnancy. If left untreated, pregnant women with hypothyroidism can develop high blood pressure (preeclampsia) and have a premature delivery. Children born to women with untreated hypothyroidism during pregnancy are at risk for having hypothyroidism at birth and may score lower on intelligence tests than children of healthy mothers.

After delivery, women may develop a thyroid disorder called postpartum thyroiditis. This condition occurs in about 5% of women who do not have a history of thyroid disease. It is often confused with depression.

Women with postpartum thyroiditis often first develop hyperthyroidism about 1 to 4 months after delivery. In the second phase of postpartum thyroiditis, which usually develops 4 to 8 months after delivery, these women develop hypothyroidism that usually lasts 2 to 8 weeks but may last up to 12 weeks. In about 25% to 50% of women with postpartum thyroiditis, permanent hypothyroidism develops. Even if thyroid gland function returns to normal, postpartum thyroiditis usually comes back during later pregnancies.

Hypothyroidism In Infants, Children, & Teens

Although rare, hypothyroidism is seen in infants and children. In infants, if hypothyroidism is treated within the first month of life, the child grows and develops normally. Untreated hypothyroidism in infants can cause brain damage, leading to mental retardation and developmental delays. In the United States, all children are tested for hypothyroidism at birth.

If hypothyroidism develops after age 3, mental retardation usually does not occur. However, untreated childhood hypothyroidism typically delays a child's physical growth and sexual development, including the onset of puberty. Children may also gain weight and yet have a slowed growth rate.

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PREVENTION

Hyperthyroidism cannot be prevented.

Since hypothyroidism cannot be prevented, you can watch for signs of the disease so it can be treated promptly. The American Thyroid Association recommends that all adults be tested beginning at age 35 and continuing every 5 years thereafter. Older adults, especially women older than 50, those with a strong family history of hypothyroidism, and those with Addison's disease, rheumatoid arthritis, pernicious anemia, and type 1 diabetes should also be tested.

TREATMENT

DIAGNOSIS & TESTS

Exams and Tests

A thorough medical history and physical exam are the first steps in diagnosing hypothyroidism or mild (subclinical) hypothyroidism. If your health professional suspects hypothyroidism or subclinical hypothyroidism based on findings from the history and physical exam, lab tests are done to confirm the diagnosis.

Blood tests are always used to confirm a diagnosis of hypothyroidism or mild hypothyroidism. The tests used most often include:

• Thyroid-stimulating hormone (TSH) assay.

Thyroid-Stimulating Hormone (TSH) Test Overview: A test for thyroid-stimulating hormone (TSH) is often used to detect a problem affecting the thyroid gland. TSH is produced when the hypothalamus releases a substance called thyrotropin-releasing hormone (TRH). Thyrotropin-releasing hormone then triggers the pituitary gland to release TSH. See an illustration of the thyroid gland and the pituitary gland. TSH causes the thyroid gland to produce two hormones: triiodothyronine (T3) and thyroxine (T4). T3 and T4 help control your body's metabolism. Triiodothyronine (T3) and thyroxine (T4) are needed for normal development of the brain, especially during the first 3 years of life. An infant whose thyroid gland does not produce enough thyroid hormone (congenital hypothyroidism) may, in severe cases, become mentally retarded. Older children also need thyroid hormones to grow and develop normally. A test for thyroid-stimulating hormone is done on a blood sample taken from a vein. This test may be done at the same time as tests to measure T3 and T4. For more information about T3 and T4 testing, see the medical test Thyroid Hormones Tests. A test for thyroid-stimulating hormone (TSH) is done to: Determine if the thyroid gland is functioning properly. An underactive thyroid gland (hypothyroidism) can cause symptoms such as weight gain, tiredness, dry skin, constipation, a feeling of being too cold, or frequent menstrual periods. An overactive thyroid (hyperthyroidism) can cause symptoms such as weight loss, rapid heart rate, nervousness, diarrhea, a feeling of being too hot, or irregular menstrual periods. Determine the cause of an underactive thyroid gland (hypothyroidism). TSH levels can help determine whether hypothyroidism is due to damage of the thyroid gland itself or due to some other cause (such as a problem with the pituitary gland or the hypothalamus). Monitor treatment with thyroid replacement medications for people who have an underactive thyroid gland (hypothyroidism). Monitor thyroid gland function in people who are being treated for an overactive thyroid gland (hyperthyroidism). This treatment may include antithyroid medications, surgery, or radiation therapy. Confirm the diagnosis of an underactive thyroid gland in a newborn (congenital hypothyroidism). Test Preparation: Inform your health care provider if you have recently (within 4 to 6 weeks) had any tests in which you were given radioactive materials or had X-rays that used iodine dye. Receiving iodine contrast material prior to a thyroid-stimulating hormone (TSH) test can affect with test results. Test Procedure: The health professional drawing blood will wrap an elastic band around your upper arm to temporarily stop the flow of blood through the veins in your arm. This makes it easier to put a needle into a vein properly because the veins below the band get larger and do not collapse easily. The needle site is cleaned with alcohol and the needle is inserted. More than one needle stick may be needed if the needle does not get placed correctly or if the vein cannot supply enough blood. When the needle is properly placed in the vein, a collection tube will be attached to the needle and blood will flow into it. Sometimes more than one tube of blood is collected. When enough blood has been collected, the band around your arm will be removed. A gauze pad or cotton ball is placed over the puncture site as the needle is withdrawn. Pressure is applied to the puncture site for several minutes and then a small bandage is often placed over it. You may feel nothing at all from the needle puncture, or you may feel a brief sting or pinch as the needle goes through the skin. Some people feel a stinging pain while the needle is in the vein. However, many people do not feel any pain (or have only minor discomfort) once the needle is positioned in the vein. The amount of pain you feel depends on the skill of the health professional drawing the blood, the condition of your veins, and your sensitivity to pain. Test Risks: There is very little risk of complications from having blood drawn from a vein. You may develop a small bruise at the puncture site. You can reduce the risk of bruising by keeping pressure on the site for several minutes after the needle is withdrawn. Rarely, the vein may become inflamed after the blood sample is taken. This condition is called phlebitis and is usually treated with a warm compress applied several times daily. Continued bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medications can also make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medication, tell the health professional before your blood is drawn. Test Results: Results of a thyroid-stimulating hormone (TSH) test are usually available within several days. Normal Thyroid-stimulating hormone (TSH) Newborns: 3–20 mIU/L Normal Thyroid-stimulating hormone (TSH) Adults: 0.4–5 mIU/L Greater-than-normal values may mean: A high thyroid-stimulating hormone (TSH) test result often indicates an underactive thyroid gland caused by failure of the thyroid gland (primary hypothyroidism). Hashimoto's thyroiditis is the most common cause of primary hypothyroidism. Rarely, a high TSH value can occur from a pituitary gland tumor that is producing excess amounts of TSH. In this case, the person usually has symptoms of hyperthyroidism such as weight loss, rapid heart rate, nervousness, diarrhea, a feeling of being too hot, or irregular menstrual periods. A high TSH value can also occur in people who have an underactive thyroid gland and are receiving too little thyroid hormone medication. Lower-than-normal values may mean: A low thyroid-stimulating hormone (TSH) value can indicate an overactive thyroid gland (hyperthyroidism). Causes of hyperthyroidism include Graves' disease, a type of goiter (multi-nodular goiter), or a non-cancerous (benign) tumor called a toxic nodule. A low TSH value can also indicate damage to the pituitary gland that prevents it from producing TSH (secondary hypothyroidism). In this case, the person usually has symptoms of hypothyroidism such as weight gain, tiredness, dry skin, constipation, a feeling of being too cold, or frequent menstrual periods. A low TSH value can occur in people who have an underactive thyroid gland and are receiving too much thyroid hormone medication. Things That Can Effect Test Results: Many medications can interfere with thyroid gland function test results, including corticosteroids, levodopa, dopamine, lithium (such as Eskalith, Lithonate, Cibalith-S), methimazole (Tapazole), and propylthiouracil. Recently undergoing tests in which you were given radioactive materials or had X-rays that used iodine dye can affect thyroid-stimulating (TSH) results. Severe stress or long-term (chronic) illness may interfere with test results. TSH levels may be low during the first trimester of pregnancy. Rough handling, contamination, or inadequate refrigeration of the blood sample can cause inaccurate test results. Test Considerations: The thyroid-stimulating hormone (TSH) test is the best screening test for conditions that can affect the thyroid gland. The results of a TSH test should be considered along with the results of thyroid hormone tests, especially thyroxine (T4) results. Another test that measures TSH levels in the blood is called the thyrotropin-releasing hormone (TRH) challenge test. TSH blood levels are measured before and after an injection of TRH. Normally the injection causes the pituitary gland to release TSH. TSH levels that do not rise after the injection can indicate the presence of conditions such as a damaged pituitary gland (secondary hypothyroidism), Graves' disease, or any condition that causes an overactive thyroid gland (hyperthyroidism).

Thyroxine (T4) measurement.

Thyroid Hormone Test Test Overview: The thyroid is a butterfly-shaped gland that lies in front of the windpipe (trachea), just below the voice box (larynx). The thyroid gland uses iodine from food to make two thyroid hormones, thyroxine (T4) and triiodothyronine (T3). The thyroid gland stores these thyroid hormones and releases them as they are needed. Thyroxine (T4) is produced by the thyroid gland when the pituitary gland releases thyroid-stimulating hormone (see above: Thyroid-Stimulating Hormone). Almost all of the triiodothyronine is made from thyroxine released by the thyroid gland, with only a small amount produced directly by the thyroid gland itself. T3 and T4 help control the body's metabolism. Special cells within the thyroid gland (called parafollicular cells, or “C” cells) also produce a hormone, calcitonin. Calcitonin may help to regulate use of calcium in the bones. Thyroid hormones are needed for normal development of the brain, especially during the first three years of life. An infant whose thyroid gland does not produce enough thyroid hormone (congenital hypothyroidism) may, in severe cases, become mentally retarded. Older children also need thyroid hormones to grow and develop normally. The most common blood tests to evaluate thyroid function are: Thyroxine (T4). Most of the T4 in blood is attached to a protein (called thyroxine-binding globulin). Less than 1% of the T4 is unattached. This is called free T4 or FT4, and it affects metabolism. Triiodothyronine (T3). T3 has a greater effect on metabolism than T4, even though T3 is normally present in lower amounts than T4. Most T3 is made from T4 by body tissues after T4 is released from the thyroid gland. The rest of the T3 is produced directly by the thyroid gland. The total amount of T3 in the blood or the amount of free T3 (FT3) can be measured. Normally, less than 1% of the T3 is free. Triiodothyronine uptake (T3U). The T3U test is an indirect measurement of the amount of the protein (thyroxine-binding globulin) that can bind to T3 and T4. The results of this test are useful only when evaluated along with other thyroid function tests. Free thyroxine index (FTI or FT4). The FTI is a measure of the amount of T4 in relation to the amount of thyroxine-binding globulin present. The FTI is calculated from the T4 and T3U values. The FTI value can indicate when an abnormal level of T4 is due to an abnormal level of thyroxin-binding globulin in the blood. This test is done on a blood sample taken from a vein. Thyroid hormone tests are done to: Determine whether the thyroid gland is functioning properly. An underactive thyroid gland (hypothyroidism) can cause symptoms such as weight gain, tiredness, dry skin, constipation, a feeling of being too cold, or frequent menstrual periods. An overactive thyroid (hyperthyroidism) can cause symptoms such as weight loss, rapid heart rate, nervousness, diarrhea, a feeling of being too hot, or irregular menstrual periods. Help evaluate an enlarged thyroid gland (goiter). Screen newborns for underactive thyroid gland function, a condition called congenital hypothyroidism. This condition can interfere with normal growth and development and can cause other severe problems (such as mental retardation) if not discovered soon after birth. Monitor the effects of treatment for thyroid disease (such as Graves' disease). The total thyroxine (T4), free thyroxine (FT4), and free thyroxine index (FTI) values are often used to monitor treatment for hyperthyroidism or to guide thyroid hormone replacement for hypothyroidism. Preparing For Test: No special preparation is required before having this test. The person drawing blood will wrap an elastic band around your upper arm to temporarily stop the flow of blood through the veins in your arm. This makes it easier to put a needle into a vein properly because the veins below the band get larger and do not collapse easily. The needle site is cleaned with alcohol and the needle is inserted. More than one needle stick may be needed if the needle does not get placed correctly or if the vein cannot supply enough blood. When the needle is properly placed in the vein, a collection tube will be attached to the needle. Blood will flow into the collection tube. Sometimes more than one tube of blood is collected. When enough blood has been collected, the band around your arm will be removed. A gauze pad or cotton ball is placed over the puncture site as the needle is withdrawn. Pressure is applied to the puncture site for several minutes and then a small bandage is often placed over it. You may feel nothing at all from the needle puncture, or you may feel a brief sting or pinch as the needle goes through the skin. Some people feel a stinging pain while the needle is in the vein. However, many people do not feel any pain (or have only minor discomfort) once the needle is positioned in the vein. The amount of pain you feel depends on the skill of the person drawing the blood, the condition of your veins, and your sensitivity to pain. Test Risks: There is very little risk of complications from having blood drawn from a vein. You may develop a small bruise at the puncture site. You can reduce the risk of bruising by keeping pressure on the site for several minutes after the needle is withdrawn. Rarely, the vein may become inflamed after the blood sample is taken. This condition is called phlebitis and is usually treated with a warm compress applied several times daily. Continued bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medications can also make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medication, tell the person before your blood is drawn. Test Results: Normal values may vary from lab to lab. Labs generally measure free T4 (FT4) levels, but may measure total thyroxine (T4) and T3 uptake (T3U) as well. Thyroid hormone tests Total thyroxine (T4): 5–12 micrograms per deciliter (µg/dL) Free thyroxine (FT4): 0.9–2.4 nanograms per deciliter (ng/dL) Total triiodothyronine (T3): 70–195 ng/dL Free triiodothyronine (FT3): 0.2–0.6 ng/dL Free Thyroxine Index (FTI): 4–11 Greater than normal values may mean: High values for these tests may indicate hyperthyroidism. This can be caused by Graves' disease, thyroiditis, a goiter that contains one or more abnormal growths (nodules), or from receiving too much thyroid hormone medication. Lower than normal values may mean: Low values for these tests may indicate hypothyroidism. This can be caused by thyroid disease (such as thyroiditis), pituitary gland disease, or destruction of the thyroid gland by surgery or radiation. T3 uptake (T3U) - Normal: 24%–34% The T3U value may be useful in interpreting the other thyroid hormone test results. A higher-than-normal T4 value combined with a high T3U value usually confirms the presence of hyperthyroidism. A higher-than-normal T4 value combined with a low T3U value often occurs during pregnancy or in women who take birth control pills. A lower-than-normal T4 value combined with a low T3U value usually confirms the presence of hypothyroidism. A lower-than-normal T4 value combined with an increased T3U value may indicate kidney disease or long-term (chronic) illness. This can also occur normally in some healthy individuals. Test Result Interferences: Many medications can interfere with thyroid function test results, including: Corticosteroids and hormones such as estrogen, progesterone, and birth control pills. Large doses of aspirin. Warfarin (Coumadin), diphenylhydantoin (Dilantin), carbamazepine (such as Tegretol), amiodarone (Cordarone), lithium (such as Eskalith, Lithonate), clofibrate (Atromid-S, Abitrate), phenytoin (Dilantin), heparin, propranolol (such as Corgard, Inderal, Tenormin), and phenylbutazone. Contrast material used for certain X-ray imaging tests may affect T4 results. Pregnancy can affect thyroid function tests results. Rough handling, contamination, or inadequate refrigeration of the blood sample can cause inaccurate test results.

Other blood tests to help evaluate the thyroid gland include:

• A thyroid-stimulating hormone (TSH) test. TSH is a hormone released by the pituitary gland that triggers the thyroid gland to produce thyroid hormones. A TSH test measures the amount of TSH in the blood and is considered the most reliable method of detecting a thyroid problem. For more information, see the medical test Thyroid-Stimulating Hormone.
• A thyroid antibodies test. This test measures the presence of antibodies against thyroid tissue. If antibodies are detected, an autoimmune disease (such as Hashimoto's thyroiditis or Graves' disease) that may cause the body to attack its own thyroid gland may be present.
• A thyroxine-binding globulin (TBG) test. TBG is an important protein in the blood that carries the thyroid hormones T3 and T4. TBG testing is rarely needed and is done only after more commonly used thyroid tests produce abnormal results.

Problems with the thyroid gland can be further investigated by a thyroid scan, ultrasound, or biopsy.

If the above tests are abnormal, the following test may be used to determine if a person has Hashimoto's thyroiditis:

• Antithyroid antibodies and test for hypothyroidism: The immune system may produce antithyroid antibodies that destroy thyroid tissue. An antithyroid antibody test determines if these antibodies are present. If you test positive for antithyroid antibodies, you may have Hashimoto's thyroiditis, the most common cause of hypothyroidism. However, many people with hypothyroidism never test positive for antithyroid antibodies. Conversely, people who test positive for antithyroid antibodies may never develop hypothyroidism. Also, some people who test positive for antithyroid antibodies develop hyperthyroidism (Graves' disease). The presence of antithyroid antibodies in a person with mild (subclinical) hypothyroidism can help predict how likely it is that a person will develop hypothyroidism that eventually causes symptoms.

The following tests may be used to evaluate a thyroid gland that appears to be abnormal during physical exam:

• Thyroid ultrasound
• Thyroid scan and radioactive iodine uptake (RAIU) test

A blood test, called the thyrotropin-releasing hormone (TRH) stimulation test, is sometimes used to diagnose other rare forms of hypothyroidism caused by diseases affecting the hypothalamus or the pituitary gland. A computed tomography (CT) scan or magnetic resonance imaging (MRI) of the hypothalamus or pituitary gland may also be done to look for any changes in these areas of the brain.

Early Detection: Because of the possibility of mental retardation in infants with hypothyroidism, every state in the United States tests newborns for hypothyroidism. If your baby was not born in a hospital, or if you believe your baby may not have been tested, talk to your health care provider. Screening tests for hypothyroidism are not always accurate. Watch your child for symptoms of hypothyroidism, even if test results are negative.

Some health care providers now recommend routine testing for people at risk for hypothyroidism, including:

• People age 35 and older. The American Thyroid Association guidelines recommend that screening begin at age 35 and continue every 5 years thereafter. Older adults, especially women older than 50, should be tested if they have never been tested.
• People with a strong family history of hypothyroidism.
• People with conditions associated with Hashimoto's thyroiditis, including Addison's disease, rheumatoid arthritis, pernicious anemia, and type 1 diabetes.
• Pregnant women.
• Pregnant women known to have hypothyroidism. Tests should be done at regular intervals to determine if the dosage of thyroid hormone medication is adequate.
• Women who are having symptoms of hypothyroidism after pregnancy (postpartum hypothyroidism), such as depression, memory and concentration problems, or thyroid enlargement (goiter). Women who have had hypothyroidism during or after pregnancy should be retested if they become pregnant again.

Screening is important for people who fall into the above groups because the signs and symptoms of hypothyroidism may not become apparent until the illness has become more advanced.

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CONVENTIONAL MEDICAL TREATMENT

The goals of thyroid hormone replacement therapy are to normalize thyroid hormone levels and to provide symptomatic relief. Although there are several types of thyroid hormone replacement available, not any one type is optimal therapy for everyone. As a result, treatment options may vary from person to person.

Hypothyroidism can be easily treated using thyroid hormone medication. The most effective and reliable thyroid replacement hormone is man-made (synthetic).

• If your hypothyroidism is caused by Hashimoto's thyroiditis, you most likely need treatment for the rest of your life. Occasionally, thyroid gland function returns on its own.
• If your thyroid gland has been removed during surgery, or if you have been treated with radiation therapy, you usually need treatment for the rest of your life.
• If your hypothyroidism is triggered by a serious illness or infection, thyroid function most likely will return to normal when you recover. To determine if thyroid function has returned to normal, thyroid hormone medication may be stopped for a short time. In most people, there is a brief period of hypothyroidism after medication is stopped. This occurs because there is often a delay in the body's signals that tell the thyroid to start working again.
• If the thyroid can produce enough thyroid hormone on its own, treatment is no longer needed.
• If hormone levels remain too low, thyroid hormone medication is restarted.
• If you have mild (subclinical) hypothyroidism, you may not need treatment but should be watched for signs of worsening hypothyroidism. Current research does not provide clear evidence to support treatment, and many doctors disagree about whether mild hypothyroidism should be treated. When making the decision to treat mild hypothyroidism, the benefits—possible lowering of cholesterol levels and improved symptoms—must be balanced with the cost of medication and monitoring.

Myxedema coma is a rare, life-threatening condition that requires immediate treatment. A person with myxedema coma usually needs to receive care in an intensive care unit (ICU). If the person is having trouble breathing, a machine called a ventilator may be used. The person should also be monitored for heart problems, including heart attack, and treated if necessary. Thyroid hormone is given intravenously (IV). Because myxedema coma is often caused by infection, antibiotics are given. The corticosteroid hydrocortisone may be given until it can be established that the adrenal glands are functioning adequately. Signs of improvement are a rise in body temperature, the ability to breathe without a machine, and mental alertness.

Treatment during pregnancy is especially important because hypothyroidism can harm the developing fetus. If a woman is found to have hypothyroidism during pregnancy, treatment should be started immediately. If she is known to have hypothyroidism before she becomes pregnant, her thyroid hormone levels need to be carefully monitored to determine whether the dosage of thyroid hormone medication needs to be adjusted. Women who develop hypothyroidism after pregnancy (postpartum hypothyroidism) also may need treatment. These women should to be retested for hypothyroidism if they become pregnant again. In some cases, hypothyroidism will go away on its own; in other cases, it is permanent and will need lifetime treatment.

Infants and children with hypothyroidism should always be treated. An infant with hypothyroidism who is treated using an appropriate dose of replacement thyroid hormone within the first month of life will grow and develop normally. Without such treatment, significant mental retardation usually results. Treatment must be continued for life. Children who develop hypothyroidism will start growing normally again once they start receiving the correct dose of replacement thyroid hormone.

Conventional Treatment Considerations:

In most cases, symptoms of hypothyroidism start to improve within the first week after the therapy is begun. All symptoms usually disappear within a few months.

Some people who take thyroid hormone medication develop symptoms of hyperthyroidism, such as nervousness, palpitations, insomnia, or tremors, if their dosage is too high. Conversely, if the thyroid hormone medication dosage is not adequate, some symptoms may continue (for example, feeling tired and cold, and memory problems).

People who have other health conditions, particularly coronary artery disease, may sometimes develop problems if they are started on a large dose of thyroid hormone medication. These people are often started on a lower dose that is gradually increased over time.

Older adults and people who are in poor health may take longer to respond to thyroid hormone medication. Lower doses of thyroid hormone may be needed.

For some people, hypothyroidism is a progressive disease and the dosage of thyroid hormone medication may have to be increased gradually as the thyroid continues to slow down.

Most people with hypothyroidism treated with thyroid hormone medications develop symptoms again if their medication is stopped. If this occurs, medication needs to be restarted.

Thyroid Hormone Medications:

Thyroid hormone medication is the only effective way to treat hypothyroidism. In most cases, thyroid hormone medication:

• Reduces or eliminates symptoms of hypothyroidism. In most cases, symptoms of hypothyroidism start to improve within the first week after therapy is begun. All symptoms usually disappear within a few months.
• May reduce the risk of developing coronary artery disease (CAD) by decreasing levels of cholesterol and triglycerides.
• May reduce the risk of slowed physical growth, mental retardation, and behavioral problems in infants and children.
• Thyroid hormone medication does not cause side effects when the correct dose is being taken on a regular basis.

Medication Choices:

Hypothyroidism is treated with thyroid hormone medication, such as levothyroxine sodium (for example, Synthroid, Levoxyl, or Levothroid).

Medication Considerations:

People with hypothyroidism need treatment with thyroid hormone medication. Depending on the cause of their hypothyroidism, treatment may be needed for the rest of their lives.

Taking calcium supplements and thyroid hormone medication at the same time may reduce the amount of thyroid hormone medication absorbed by the body. It is recommended that people take calcium supplements at least 4 hours before or after taking thyroid hormone medication to make sure they receive the full benefit of their medication.

If you are using estrogen or hormone replacement therapy (ERT or HRT), take birth control pills, or are pregnant, you may need more thyroid hormone medication. If you have recently stopped ERT or HRT or taking birth control pills, you may need less thyroid hormone medication. Talk to your health care provider about the possible need to adjust your dosage.

The dosage of thyroid hormone depends upon the severity of the condition, age and body size, and other medical conditions.

People who have other health conditions in addition to hypothyroidism, particularly coronary artery disease, may sometimes develop problems if they are initially started on a large dose of thyroid hormone. These people are often started on a lower dose that is carefully increased over time.

In older adults, too much thyroid hormone medication can cause the rate of bone loss to speed up (osteoporosis). Lower doses of the medication may be needed.

Follow-up visits with your health care provider are important for monitoring treatment. The health care provider will ensure that the medication is being taken correctly and adjust the dose when necessary. Most people return to their health care providers for blood tests to measure thyroid hormone levels 6 to 8 weeks after starting therapy. After thyroid hormone levels have normalized, thyroid function tests are rechecked in 6 months and then once a year thereafter.

Some people with mild (subclinical) hypothyroidism may prefer not to receive treatment. Such people should watch closely for any symptoms of hypothyroidism. Their health care providers will also usually want to do regular (yearly) thyroid function blood tests to check for worsening thyroid gland function.

For More Information About Thyroid Disorders:

American Thyroid Association
6066 Leesburg Pike
Suite 650
Falls Church, VA 22041
Phone: (703) 998-8890
Fax: (703) 998-8893
E-mail: admin@thyroid.org
Web Address: http://www.thyroid.org

The American Thyroid Association is a professional society of physicians and scientists. Its mission is to promote scientific and public understanding of the thyroid disorders. The association publishes a monthly journal and manages an informational Web site.

National Health Information Center (NHIC)
P.O. Box 1133
Washington, DC 20013–1133
Toll-Free Phone: 1-800-336-4797
Phone: (301) 565-4167
Fax: (301) 984-4256
E-mail: info@nhic.org
Web Address: http://www.health.gov/nhic/

The National Health Information Center (NHIC) is a health information referral service. NHIC puts health professionals and consumers who have health questions in touch with those organizations that are best able to provide answers. It also distributes publications and directories on health promotion and disease prevention topics.

The Thyroid Society for Education and Research
7515 South Main Street
Suite 545
Houston, TX 77030
Toll Free Phone: 1-800-THYROID (1-800-849-7643)
Phone: (713) 799-9909
E-mail: help@the-thyroid-society.org
Web Address: http://the-thyroid-society.org/

The mission of this national nonprofit organization is to pursue the prevention, treatment, and cure of thyroid disease. It provides information (including a book entitled Could It Be My Thyroid?) to both the general public and health professionals.

BOOKS ABOUT THYROID DISORDERS

Could It Be My Thyroid?

-- By Sheldon Rubenfeld MD, George H.W. Bush

Living Well With Hypothyroidism: What Your Doctor Doesn't Tell You...That You Need To Know

-- By Mary J. Shomon

The Thyroid Solution: A Mind-Body Program for Beating Depression and Regaining Your Emotional and Physical Health

-- By Arem Ridha

Thyroid Power: Ten Steps to Total Health

-- By Richard Shames, Karilee H. Shames

How I Reversed My Hashimoto's Thyroiditis Hypothyroidism

-- By Robert T. Dirgo

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HOME TREATMENT

If you have hypothyroidism, see your health professional on a regular basis so that your condition can be closely monitored and your treatment adjusted, if necessary. It is very important to take thyroid hormone medication correctly. Talk with your health professional if you do not understand the reason for taking medication regularly or if you think you have any side effects from the medication. You usually need to have regular blood tests to determine if you are receiving the correct amount of thyroid hormone.

Children with hypothyroidism need to see a health professional on a regular basis because the amount of thyroid hormone medication they need changes as they grow. Untreated hypothyroidism in infants and very young children can have severe consequences. As soon as you think your child is old enough to share the responsibility for his or her own health care (usually around age 9 or 10), teach him or her about hypothyroidism, the importance of taking medication correctly, and why regular health checkups are important.

Some health food stores in the United States sell "natural" forms of thyroid. The quality and effectiveness of these natural agents are unregulated. Some may not work at all. Others may have an active ingredient that does work but that may be dangerous to certain people. Be sure to read labels and obtain natural products through reliable sources.

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COMPLEMENTARY & ALTERNATIVE THERAPIES

Alternative medicine has the same goal. Holistic methods also aim to increase the amount of thyroid hormone produced by the gland. However, alternative methods also target the immune system which is the underlying source of the problem.

REVIVING YOUR THYROID By Joseph Debé, D.C., D.A.C.B.N., C.C.S.P., C.C.N. ( Full Article: Reviving Your Thyroid!) There are many different factors that can contribute to hypothyroidism. These include: genetics, aging, stress, surgical or pharmaceutical treatment of hyperthyroidism, anorexia nervosa, fasting, malnutrition, nutrient insufficiencies, systemic illness, insulin resistance, inflammation, autoimmunity, physical trauma, smoking, radiation, iron-deficiency anemia, imbalance of other hormones including estrogen and progesterone, exposure to environmental pollutants and other toxins, some medications, inactivity, and even certain foods. Sluggish thyroid activity can result from impairment of any of a number of steps in thyroid hormone metabolism. These steps include: stimulation of the thyroid by TSH (thyroid stimulating hormone) from the pituitary gland, accumulation of iodine within the thyroid gland; production of thyroid hormone; release of hormone from the thyroid gland into the blood; transport of thyroid hormone within the bloodstream; conversion of T4 to the more active thyroid hormone, T3; binding of thyroid hormone to cell receptors; transport of thyroid hormone into the cells (where it produces its activity); elimination of thyroid hormone from the body. Much of your thyroid rejuvenation program will need to be customized based on results of special laboratory tests. However, we feel that some recommendations apply to virtually all patients with an underactive thyroid. Because certain foods impair thyroid function, we suggest that you consume only small amounts of these until your thyroid is normalized. These foods include: cabbage, Brussels sprouts, broccoli, kale, cauliflower, maize, turnips, sweet potatoes, lima beans, bamboo shoots, mustard greens, onions, peanuts, pinenuts, walnuts, almonds, sorghum, cassava, millet, grapefruit and apples. Although many of these foods have a reputation for being health promoting, they can be counterproductive for the individual striving to boost a sluggish thyroid. Cooking these foods may minimize their negative effects. Other foods that should be limited include those foods rich in saturated fats (beef, lamb, pork, dairy, organ meats, processed coconut and palm oils); trans fatty acid-containing, partially hydrogenated vegetable oils (found in margarine and most processed foods); and refined carbohydrates (table sugar, candy, cookies, crackers, muffins, bagels, cakes, pasta, most cereals and breads). Eat mostly whole, unrefined foods the way nature provides them. For example, eat baked potatoes, rather than French-fries. Assure adequate protein intake. Eat liberal amounts of vegetables, legumes, fruits, nuts, seeds, fish and eggs. Consume smaller amounts of lean meats, poultry, dairy products, whole grains, whole grain breads and pastas. Cold water fish such as mackerel, salmon, and sardines should be consumed at least several times per week. Larger fish, such as tuna and swordfish, as well as shellfish and sea vegetables, often are contaminated with high levels of mercury, which can suppress thyroid function. Limit consumption of these foods, as well as fresh water fish, which are often contaminated with thyroid-suppressing PCBs. For those who will not eat fish, other options, in declining order of preference, are supplements of fish oil (available in capsule or powdered form), algal oil, or flaxseed oil. Choose "organic" produce and "free range" animal products whenever possible, in order to lower possible exposure to pollutants which poison thyroid metabolism. Further reduce pollution exposure by using a good quality water filter. A special filter to remove fluoride is required for those water supplies where fluoride is added. Chlorine and fluoride both substitute for iodine within molecules of thyroid hormone and alter its function. Not only is chlorine ingested in drinking water, it also enters the body through the skin and is inhaled in water vapor while showering. For those whose water supply has added chlorine, a shower filter to remove chlorine is also necessary. A whole house filter, to remove impurities in all the water supplied to your home, is something to consider. Several natural supplements are worthy of consideration by any person with hypothyroidism. Guggulsterone, a plant-derived Ayurvedic remedy, aids in the stimulation of thyroid function, weight loss, and lowering of elevated blood cholesterol and triglycerides (which often result from hypothyroidism). Supplements of mixed mineral phosphates have been shown to prevent weight loss-induced drops in T3 levels. So, for those attempting to lose weight, mineral phosphates are a good choice. "Thyro-Stim" and "GTA" are nutritional products formulated to support thyroid function. Ask us if they are appropriate in your particular case. (They are not suitable for vegetarians). Supplemental vitamin B2 can help drive a cellular energy-producing chemical reaction that becomes sluggish in hypothyroidism. This can make a difference for those hypothyroid individuals not using thyroid hormone replacement therapy. Individuals whose hypothyroidism is autoimmune in origin (Hashimoto's Thyroiditis) may benefit from arachidonic acid, colostrum, lactoferrin, and whey. Additionally, omega 3 fatty acids, vitamins A and D, all need to be ingested in adequate quantities. I suggest using Pacific Research Labs cod liver oil to supply all three of these. Supplements of quercetin, P.A.B.A. and melatonin should be used with caution, as these have the potential to suppress thyroid activity. Melatonin is a hormone produced by the body. Its production increases in response to darkness. That is one of the reasons people tend to gain more weight in the winter. To guard against melatonin suppressing your thyroid function, make sure to get regular exposure to sunlight (a good fifteen minutes a day). When this is not possible, an option is to sit within six feet of a special 10,000-lux lamp for half an hour or more on a daily basis. Exercise stimulates thyroid hormone secretion and improves tissue sensitivity to the hormone. Regular exercise needs to be a part of your program. It is important to realize that weight loss programs that do not incorporate exercise can result in blunting of thyroid activity and excessive loss of healthy lean body tissue. Ideally, exercise should include muscle strengthening, stretching, and cardio-respiratory conditioning. If exercise is something new for you, ask us for some help in getting started on a regular program. LABORATORY INVESTIGATION OF HYPOTHYROIDISM Hopefully, by now, you are gaining an appreciation for the fact that the thyroid is not an isolated gland, functioning autonomously, without connection to other parts of the body. To get a better feel for just how complex thyroid metabolism (and metabolism in general) is, let's take a look at the influence of a single compound on thyroid function. Reduced glutathione is a tripeptide (composed of three amino acids), produced by the body, which plays a role in the conversion of T4 to T3. Low levels of reduced glutathione can result in impaired thyroid function. Now take a look at all the things that can result in inadequate levels of reduced glutathione in the body: deficiencies of vitamins B2, B3, C, E, alpha-lipoic acid, and good quality protein; toxins from diverse sources such as medications (including acetaminophen), environmental pollutants, and heavy metals (lead, mercury, etc.); oxidative stress (imbalance of free radicals in relation to antioxidants); heavy alcohol consumption; and insulin resistance. These influences on levels of reduced glutathione are, in turn, affected by other factors such as: genetics, aging, inactivity, nutrient deficiencies, smoking, infection, inflammation, impaired detoxication, poor dietary choices, stress, suboptimal digestion and absorption function. Sound complex? It is. That is why we need to take a holistic approach and leave no stone unturned in our quest to normalize your thyroid and improve your health in general. Many nutrients are required for proper thyroid function. Insufficiencies of any of these could result in impaired thyroid metabolism. These include: iodine, selenium, cobalt, zinc, rubidium, copper, reduced glutathione, L-tyrosine, and vitamins A, B2, B3, B6, C, D and E. Although we advocate testing for deficiencies of these nutrients, an alternate approach is to simply take them all in supplemental form. We do, in fact, often recommend a formula called "Thyro-Stim" which contains many of these compounds. Computerized dietary analysis can be used to identify suboptimal dietary intake of any of these nutrients. More accurate evaluation, however, involves analysis of blood and hair samples to assess your status of these nutrients. Hair analysis provides other important information, including the presence of toxic heavy metals that can impair thyroid function. The results of these tests lead to tailored nutritional supplementation. The Comprehensive Digestive Stool Analysis is another important test for the hypothyroid individual. This test involves analysis of a stool specimen for two dozen different compounds. You may be eating the proper foods and consuming the right nutrients, but if you have suboptimal digestion or absorption, your body, including the thyroid, will suffer. The Comprehensive Digestive Stool Analysis gives a good indication as to your body's ability to digest and absorb food. This test gives additional information that can have a bearing on thyroid function, including the make-up of the different species of bacteria and yeast inhabiting your intestinal tract. Certain bacteria, parasites and yeast can provoke an inflammatory response by the body that can result in reduced thyroid function. Additionally, The body's immune system can sometimes produce antibodies against yeast, which cross-react with the thyroid gland. This results in autoimmune hypothyroidism. Incidentally, the environmental pollutants PBBs and PCBs, the grain protein gluten, as well as anti-psychotic medications like phenothiazines, have also been implicated in autoimmune hypothyroidism. However, even without evoking an immune response, waste products from toxic organisms in the intestinal tract pass into the bloodstream and can poison various biochemical reactions and suppress thyroid metabolism. What's more, abnormal intestinal flora, vegetarian diets, and rapid transit time (speed at which food passes through the gastrointestinal tract) can all contribute to reduced enterohepatic circulation of thyroid hormones. Enterohepatic circulation can be simply viewed as a way the body conserves thyroid hormones. Treatment to improve digestion, absorption, and bowel ecology is customized from results of the Comprehensive Digestive Stool Analysis. Obviously, toxicity is a potential contributor to hypothyroidism. We therefore advocate evaluation of the body's ability to detoxify itself. The liver is the main organ of detoxication and the site of greatest production of T3. The test we use to assess the body's detoxication capacity is The Comprehensive Detoxification Profile. This test involves analysis of saliva, urine, and blood specimens after "challenging" the body to detoxify caffeine, Tylenol, and aspirin. The Comprehensive Detoxification Profile gives detailed information about the body's ability to process toxins, its current load of toxins and free radicals, and the status of its antioxidant defense system. Results from this test allow for recommendation of specific nutrients and foods to improve detoxication. In fact, one of the most important therapies for improving thyroid function, and health in general, is an individually tailored metabolic detoxification program. Many people think of detoxification as simply colon cleansing. Metabolic detoxification is far more comprehensive. It involves use of food, scientifically proven detoxification supplements, and other natural therapies to help the body process and eliminate toxins from every cell, tissue and organ, not just the intestines. Metabolic detoxification is the single most powerful therapy we have. It often produces a significant reduction in chronic symptoms in a matter of weeks. We strongly encourage you to allow us to coach you through a metabolic detoxification program in order to rid the body of thyroid-suppressing toxins. Metabolic detoxification is an excellent way to start a weight loss program, as the loss of body fat liberates stored toxins and introduces them into circulation. Without proper detoxication, these toxins can produce damage throughout the body, including the thyroid. Another test we recommend for our hypothyroid patients is The Adrenal Stress Index. This test involves analysis of saliva samples for levels of the stress hormones, cortisol and DHEA. Cortisol and DHEA are largely antagonistic to each other, and must be in proper balance for good health. Prolonged stress results in elevation of cortisol and suppression of DHEA. This causes breakdown throughout the body. High cortisol to DHEA ratios suppress TSH (thyroid stimulating hormone) levels. TSH, produced by the pituitary gland, which is located at the base of the brain, stimulates the thyroid to manufacture and release thyroid hormones. Therefore, suppression of TSH results in lower thyroid activity. Elevated cortisol to DHEA levels also impair the conversion of T4 to T3. The body makes less T3 and more reverse (r) T3 in response to high cortisol to DHEA ratios. Reverse T3 is slightly different in structure from T3 and does not appropriately bind to receptor sites, as does T3. The rT3 blocks T3 from binding to receptor sites and exerting biologic activity, and fails to exert thyroid action of its own. The result is a slowing of metabolism. It is important to realize that the stress that can cause cortisol-DHEA imbalance is not only mental-emotional strain. These hormones also become altered by: excessive levels of sound and light, certain chemicals, fatigue, starvation, acute illness, pain, tissue injury, trauma, surgery, long airplane flights, heat, cold, and rapid fluctuations in blood sugar levels. The three most common stressors appear to be mental-emotional, tissue injury, and rapid fluctuations in blood sugar levels. The results of The Adrenal Stress Index test reveal whether imbalance of cortisol and DHEA may be impacting your health. The exact nature of abnormal values leads us to appropriate therapies to restore a normal stress response and, thus, "unstress" the thyroid. Laboratory blood tests that identify inflammation are also important. These include SED rate, C-reactive protein, white blood cell count, basophil cell count, and cytokines (IL-1, IL-6, TNF). Inflammation is another cause of low thyroid function. When present, the cause of the inflammation needs to be sought and dealt with appropriately. Common causes are infection, food antigens, nutritional imbalances, stress and toxicity. Other tests may be indicated in any given case of hypothyroidism. For example, some women may have suppressed thyroid function due in part to elevated estrogen and/or low progesterone levels. These hormones are best evaluated with a "Female Hormone Panel". This is a laboratory test that measures these hormones from saliva samples. The results lead to customized treatment. However, to summarize, our general work-up for most individuals with hypothyroidism includes: 1. Testing of blood samples for vitamin deficiencies. 2. Hair Mineral Analysis 3. Comprehensive Digestive Stool Analysis 4. Comprehensive Detoxification Profile 5. Adrenal Stress Index 6. Tests to identify inflammation Results of these tests lead to customized treatment, which can correct the underlying causes of your slow metabolism. Please do not get stressed out over the complexity of this program. We are here to help you through it, step by step. THYROID SUPPRESSING ENVIRONMENTAL CHEMICALS As you read this list, think carefully about any possible exposure to these chemicals, past or present. You can contact Dr. Debé if you think there is even a remote chance of any exposure (excluding food sources) and/or if you have questions. (Most of the following information on sources of chemicals and medications comes from The Merck Index, Twelfth Edition, 1996) Methimazole and Carbimazole - used in silver electroplating; also used as antihyperthyroid medicine. Goitrin - found in cruciferous vegetables. Dichlorodiphenyltrichloroethane (DDT) - insecticide still in wide use in other countries; absorbed by ingestion, through the skin, and by inhalation. Resorcinol - may be present in community water supplies, particularly in coal-rich areas of the world; used in tanning, resin adhesives, dyes, explosives, cosmetics, dyeing and printing textiles. Present in cigarette smoke. Pyridines – found in coal and in cigarette smoke. Phthalate esters and phthalaitic acids and their metabolites- found naturally in plants, fungal metabolites, shale, crude oil, and petroleum; common industrial water pollutants; used in varnishes and perfumes. As compounds that impart flexibility to plastics (comprising up to 40% of the weight of plastic), polyvinylchloride polymers (PVC) are widely used, including: in building and construction, home furnishings, cars, clothing and food wrappings. The thyroid-suppressing effect of these compounds results when they are chemically modified by certain types of bacteria (Gram-negative) which may contaminate drinking water or inhabit your intestinal tract! Thiocyanate -found in brassica vegetables and cigarette smoke. Fisetin, Kaemferol, Naringenin, and Quercetin- among the most potent of the thyroid – suppressing flavonoids, found in plants. Onions are a rich source of quercetin, grapefruits contain naringenin. P-aminobenzoic acid (PABA) - used in sunscreens; a B vitamin co-factor. Lithium - found in food; used in the production of alloys for aircrafts and aerospace; used in the plastics industry, ceramics, electrochemical cells, batteries, lubricating greases. Excess dietary iodine - found in commercial iodized salt, baked goods, seafood. Nabam - agricultural fungicide. Zineb - agricultural fungicide. Ziram - agricultural fungicide; rubber vulcanization accelerator. Aromatic Amines - fungicide, emulsifier, soil stabilizer. Barbituric Acid - used in manufacture of plastics, pharmaceuticals. Ethylene thiourea - accelerator in synthetic rubber production. Polychlorinated biphenyls (PCBs) and Polybrominated biphenyls (PBBs) - once widely used industrial chemicals whose high stability contributed to long term deleterious environmental and health effects. Airborne PCBs accumulate in foliage. Used in electrical capacitors, electrical transformers, gas transmission turbines, vacuum pumps. Formerly used in the U.S. as hydraulic fluids, plasticizers, adhesives, fire retardants, wax extenders, dedusting agents, pesticide extenders, inks, lubricants, cutting oils, in heat transfer systems, carbonless reproducing paper. Uracil - used in biochemical research. Amphenone - used in biological research. Meta-aminophenol - dye intermediate. 3-Methylcholanthrene - used in cancer research. Phloroglucinol - used in chemistry, printing, and textile dyeing. Rotenone - insecticide. 2,4-dinitrophenol - insecticide; herbicide; fungicide; wood preservative; used in the manufacture of dyes. Quinone - used in the manufacture of dyes; in photography; tanning hides. Perchlorate - salts for explosives and for plating of metals. Thiourea - used in manufacture of resins; photographic fixing agent; used to remove stains from negatives. Pentachlorophenol - wood and leather preservative. Found in the urine of 71% of Americans in a random sample. Fluoride - added to some water supplies (all of New York City), and toothpaste. Chlorine - added to most water supplies, including all of New York City. MEDICATIONS KNOWN TO IMPAIR THYROID FUNCTION The following list shows first, the class of medication. In most cases this is followed by additional information: the chemical name of the medication and then the brand names. You can contact Dr. Debé if you have used any of these medications and/or you have any questions. Non-Steroidal Anti-Inflammatory Drugs Antiarrhythmic - Amiodarone - Amiordar, Ancoron, Angiodarona, Attansil, Cordarex, Cordarone, Cordarone X, Miocard, Miodacon, Ortacrone, Ritmocardyl, Rythmarone, Trangorex. - Propranolol - Inderal Antianginal - Amiodarone (see above) and 2-Thiouracil Antihypertensive – Propranolol - Inderal Tranquilizer – Chloropromazine – Thorazine Antimalarial - Chloroquine - Arechin, Avloclor, Imagon, Malaquin, Resochin, Tresochin. Antiamebic - Chloroquine (see above). Antirheumatic - Chloroquine (see above). Lupus Erythematosus suppressant - Chloroquine (see above). Antibacterial - P-aminosalicylic acid - Aminocil, Aminopar, Bactylan, Entepas, Gabbropas, Osacyl, Pamisyl Sodium, Paracipan, Paramisan Sodium, Pasid, Pasara Sodium, Pasmed Sodium, Salvis. Antibacterial - Sulfadiazine - Adiazine, Diazyl, Sulfolex. - Sulfathiazole - Thiazamide, Cibazol, Duatok, Enterobiocine, Sulfamul, Sulfavitina, Sulzol. Tuberculostatic - P-aminosalicylic acid (see above). Antidepressants - Amitriptyline –Flavil - Clomipramine –Anafranil Doxepin – Adapin, Sinequan Imipramine – Tofranil Trimipramine – Surmontil Amoxapine – Asendin Desipramine – Norpramin, Pertrofrane Maprotiline – Ludiomil Nortriptyline – Pamelor Protriptyline – Vivactil Antihelmintic - 4-hexylresorcinol - Ascaryl, Caprokol, Crystoids, Gelovermin, Sucrets, Worm-Agen. Topical Antiseptic - 4-hexylresorcinol (see above). Topical Antiseptic - Substituted phenols Kerotolytic - Resorcinol Antiseborrheic - Resorcinol Antihyperthyroid - Methimazole - Carbimazole - Thiouracil - Aminothiazole - Propylthiouracil Analgesic - Antipyrine - Analgesine, Anodynine, Parodyne, Phenylone, Sedatine. - Methadone Antispasmodic - Phloroglucinol Sedative - Amobarbital - Somnal, Dormytal, Isomytal, Eunoctal, Amal, Mylodorm, Sednotic, Amasust, Stadadorm, Amytal. Hypnotic - Amobarbital (see above) Antifungal - Oligomycin Anticoagulant - Dicumarol - Dicoumarol, Dicoumarin, Dicumol, Dufalone, Melitoxin. Glucocorticoids - Betamethasone – Celestone Soluspan - Cortisone Acetate - Cortone Acetate - Dexamethasone – Dalalone D.P., Decadron - Prednisolone – Hydeltrasol, Hydeltra-T.B.A., Pediapred, Prelone - Hydrocortisone - Hydrocortone Antihypotensive – Dopamine – Intropin, Dopastat Cardiotonic - Ouabain Topical Anti Pruritic - Substituted phenols Ultraviolet Screen - P-aminobenzoic acid (PABA) - Amben, Paraminol, Sunbrella. Ingredient in Pobanol, Presun. Topical Anesthetic - Substituted phenols Congestive Heart Failure Medication - 2-Thiouracil Radiocontrast Agents Interferon-a – used in cases of hepatitis C and some cancers Estrogen (oral, not vaginal or transdermal) – Premarin and others Cholesterol-Lowering – Clofibrate Anti-Cancer - 5-fluorouraci – Efudex - Tamoxifen - Nolvadex Anticonvusant - Phenytoin – Dilantin - Carbamazepine - Tegretol

Sufficient rest to help promote health and healing.

Laughter, every time you laugh or smile, your immune system cells show changes that are beneficial to immune system health. Dr. Norman Cousins reversed his own autoimmune disorder with a combination of humor and biofeedback.

Allow your pets to heal you and give you pleasure.

Holistic Health Topics: Hypothyroidism


An interesting article about Hypothyroidism, Hypothyroid Hormone Tests, and Thyroxine Resistance. A "must read" for people having problems with hypothyroidism, inaccurate test results, and medication issues.

Thyroid Disorders and Alternative Therapies
Alternative Medicine Approaches for Hypothyroidism
Alternative Medicine and Natural Hormone Approaches for Hypothyroidism
Recommendations for Healthy Thyroid Function
Alternative Medicine: Reviving the Thyroid
Diagnosis: Hypothyroidism - Answers to Some Common Questions
Savvy Patients - Hypothyroidism

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CONSIDERATIONS

Treatment for a regular morning temperature of 96°F is 3 to 4 grains of Armour Thyroid Tablets daily (available by prescription). A person with a regular morning temperature of 97°F should take 1 to 2 grains. If you have side effects, speak to your health care provider about reducing the dosage.

A study done at the University of Massachusetts revealed that levothyroxine (Synthroid and others), a drug commonly used to treat thyroid conditions, can cause a loss of as much as 13 percent of bone mass. An estimated 19 million people in the United States take this drug for enlarged thyroid or thyroid cancer.

Wilson's syndrome is a condition that results from a problem in the conversion of one thyroid hormone, thyroxine (T4), to another thyroid hormone, triiodothyromine (T3). This causes symptoms of decreased thyroid function, especially triggered by significant physical or emotional stress. These symptoms can be debilitating, and may persist even after the stress has passed. People with Wilson's syndrome have many of the symptoms of hypothyroidism, including low body temperature, fatigue, headaches, menstrual dysfunction, memory loss, loss of concentration, loss of sex drive, anxiety and panic attacks, depression, insomnia, intolerances to cold, and lack of energy and motivation. Their blood test results are often normal, however. For more information on Wilson's syndrome or to obtain the highly recommended Wilson's Syndrome Doctor's Manual, call the Wilson's Syndrome Foundation at 800-621-7006.

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DIETARY RECOMMENDATIONS

Include in the diet molasses, egg yolks, parsley, apricots, dates, and prunes. Eat fish or chicken and raw milk and cheeses.

Eat these foods in moderation: Brussels sprouts, peaches, pears, spinach, turnips, and cruciferous vegetables such as cabbage, broccoli, kale, and mustard greens. If you have severe symptoms, omit these foods entirely. They may further suppress thyroid function.

Avoid processed and refined foods, including white flour and sugar.

Drink quality water, steam-distilled is preferred if possible.

Do not take sulfa drugs or antihistamines unless specifically directed to do so by a health care provider.

Avoid fluoride (including that found in toothpaste and tap water) and chlorine (also found in tap water). Chlorine, fluoride, and iodine are chemically related. Chlorine and fluoride block iodine receptors in the thyroid gland, resulting in reduced iodine-containing hormone production and finally in hypothyroidism.

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HERBS

Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day.

Bayberry bark, black cohosh, and goldenseal can help this thyroid condition. Caution: Do not take goldenseal internally on a daily basis for more than one week at a time, do not use it during pregnancy, and use it with caution if you are allergic to ragweed.

This combination supports thyroid function: Combine equal parts of the following herbs for a tea (3 to 4 cups per day) or tincture (20 to 30 drops three times per day) — horsetail (Equisetum arvense), oatstraw (Avena sativa), alfalfa (Medicago sativa), and gotu kola (Centella asiatica).

Kelp (Laminaria hyperborea), bladderwrack (Fucus vesiculosus), and Irish moss (Chondrus crispus) may be taken as foods or in capsule form.

Coleus foreskohlii (1 to 2 ml three times a day) stimulates thyroid function with an increase in thyroid hormone production. Also, herbs such as guggul (Commiphora mikul) (25 mg of guggulsterones three times a day) and hawthorne (Crataegus monogyna) (500 mg twice a day) are taken to counteract high cholesterol, which often accompanies hypothyroidism.

HERBAL & ALTERNATIVE THERAPY LINKS

HerbChina2000.com - Herbal Therapies - Hypothyroidism
HealthWorldOnline - Herbal Medicine - Hypothyroidism
Health & Age: Hypothyroidism
HealthWorldOnline - The Diagnosis And Treatment of Hypothyroidism
Hypothyroidism Research: Alternative/Complementary Therapies - Acupuncture & Traditional Chinese Medicine
Alternative Medicine Approaches for Hypothyroidism
The Yin and Yang of the Thyroid: A Look at Traditional Chinese Medicine
A Look at South American Medicinal Herbs & Hormonal Health
Thyroid Disease Information Source - Articles

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NUTRITIONAL SUPPLEMENTS

Unless otherwise specified, the dosages recommended here are for adults. For a child between the ages of 12 and 17 years, reduce the dose to 3/4 the recommended amount. For a child between the ages of 6 and 12, use 1/2 the recommended dose, and for a child under the age of 6, use 1/4 the recommended amount.

NUTRIENTS
Supplement	Suggested Dosage	Comments
Essential
Kelp	2,000-3,000 mg daily.	Contains iodine, the basic substance of thyroid hormone. Kelp Seaweed Norwegian, Now Foods, 100% Natural Acophyllum nonosum, 550 mg, 250 Caps
L-Tyrosine	500 mg twice daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B6 and 100 mg vitamin C for better absorption.	Low plasma levels have bee associated with hypothyroidism. See Amino Acids for more information. L-Tyrosine, Pharmaceutical Grade, Free Form, Now Foods, 500 mg, 120 Caps
Very Important
Raw Thyroid Glandular	As prescribed by a health care provider.	To replace deficient thyroid hormone. Natural thyroid extract such as Armour Thyroid Tablets is best. Available by prescription only. See Glandular Therapy for more information.
Important
Vitamin B complex And Vitamin B2 (riboflavin)	100 mg 3 times daily, with meals. 50 mg twice daily.	Needed for thyroid function. B vitamins improve cellular oxygenation and energy and are needed for proper digestion, immune function, red blood cell formation. Vitamin B - 100 Complex w/Coenzyme B-2, Natures Way, 631 mg, 100 Caps, Ultimate B (Vitamin B Complex Formula), 60 Tabs
And Vitamin B12	1500 mcg 3 times daily, on an empty stomach.	use a lozenge or sublingual form for better absorption. B-12 is a necessary vitamin for nearly every cell in the body and the nervous system uses a great quantity. B-12 is also the hardest vitamin to absorb. Occasionally, oral supplementation will not suffice to replace the deficiency. However, start taking 1000 mcg a month and recheck your levels in 3 months or so. If still low, you will need monthly injections (a real pain but necessary). It will take six months before your see the complete benefit from replacement and you can't overdose yourself with this vitamin. Ultra B-12, Now Foods, 4 oz, 5,000 mcg/teaspoon, Vitamin B-12, California Natural, 1000 mcg, 60 Caps
Helpful
Brewer's Yeast	1 to 3 tablespoons daily and up or as directed on label.	Rich in many basic nutrients, especially the B vitamins. A natural source of the B vitamins. Brewers Yeast, Now Foods, 650 mg, 300 Tabs
Essential fatty acids	As directed on label.	Needed for proper functioning of the thyroid gland. Omega 3,6,9 Oil, Mega EFA Blend, Lime Flavor, Natures Way, 1350 mg, 90 Softgels
Iron	As directed by a health care provider. Take with 100 mg vitamin C for better absorption.	Essential for enzyme and hemoglobin production. Use ferrous chelate form. Caution: Do not take iron unless anemia has been diagnosed. Iron Ionic Mineral Supplement, Fully Absorbable, 20 +/- ppm, 16 fl oz, Alive! Whole Food Energizer Multivitamin & Mineral with Iron, Nature's Way, 90 Vcaps
Or Iron + Herbs Supplement	As directed on label.	A natural, nontoxic form of iron from food sources. Alive! Whole Food Energizer Multivitamin & Mineral with Iron, Nature's Way, 90 Vcaps
Vitamin A	15,000 IU daily. If you are pregnant, do not exceed 10,000 IU daily.	Needed for proper immune function and for healthy eyes, skin, and hair. May be taken in a multivitamin complex. Vitamin A, 10,000 IU, 100% Natural, Natures Way, 100 Softgels, Multi-Carotene Antioxidant, Natures Way, 60 Softgels, Beta-Carotene, Natural Dunaliella salina, Natures Way, 100% Natural, 25,000 IU, 100 Softgels
Plus Natural Beta-carotene Or Carotenoid complex (Betatene)	15,000 IU daily. As directed on label.	Antioxidant and precursor to vitamin A. Note: If you have diabetes, omit the beta-carotene; people with diabetes cannot convert beta-carotene into vitamin A. Multi-Carotene Antioxidant, Natures Way, 60 Softgels, Beta-Carotene, Natural Dunaliella salina, Natures Way, 100% Natural, 25,000 IU, 100 Softgels
Vitamin C	500 mg 4 times daily. Do not exceed this amount.	Needed for immune function and stress hormone production. Caution: Do not take extremely high doses of vitamin C - this may affect the production of thyroid hormone. Vitamin C 1000 w/Rosehips, 100% Natural, 1000 mg, 250 Caps, Vitamin C Complex Powder w/Bioflavonoids, Now Foods, Vegetarian Formula, 8 oz
Vitamin E	400 IU daily. Do not exceed this amount.	An important antioxidant that improves circulation and immune response. Vitamin E, d-alpha tocopherol, 400 IU, 100 Softgels
Zinc	50 mg daily. Do not exceed a total of 100 mg daily from all supplements.	An immune system stimulant. Use zinc gluconate lozenges or OptiZinc for best absorption. Zinc (Chelated), 100% Natural, Natures Way 30 mg, 100 Caps, Zinc Lozenges w/Echinacea & Vitamin C, Natures Way, 23 mg, 60 Lozenges
Calcium	2,000 mg daily.	A for healthy bones. If you take thyroid medication, wait 4 hours before taking calcium supplements since calcium can interfere with the uptake of your thyroid medication. Calcium-Magnesium Liquid, Almond Flavor, 16 oz, Dosage: 1 Tbsp = 1200mg/600mg, Calcium Citrate-Malate Complex, Nature's Way, 500 mg, 250 Caps, Calcium Gluconate Powder, Now Foods, 100% Pure, 7 oz, 2 level tsp = 240 mg
Magnesium	600-1,000 mg daily.	To taken in combination with calcium. Calcium-Magnesium Liquid, Almond Flavor, 16 oz, Dosage: 1 Tbsp = 1200mg/600mg, Magnesium Citrate Complex, Nature's Way, 250 mg, 100 Caps

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NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...

Call 911 or other emergency services immediately if you or a person you know has hypothyroidism and develops signs of myxedema coma, such as:

• Mental deterioration, such as apathy, confusion, and psychosis.
• Extreme weakness and fatigue that progress to loss of consciousness (coma).
• Severe breathing difficulties, slow heart rate (less than 60 beats per minute), or low body temperature [95°F (35°C) or below].

See your health professional if you have any persistent symptoms, including:

• Feeling tired, sluggish, or weak.
• Memory problems, depression, or difficulty concentrating.
• An inability to tolerate cold temperatures.
• Dry skin, brittle nails, or a yellowish tint to the skin.
• Constipation.
• Heavy or irregular menstrual periods that may last longer than 5 to 7 days.
• Other symptoms of hypothyroidism. See above in Symptoms.

If you have one or two of the above symptoms that have not changed or have changed very little over a long period of time, it is less likely that the symptoms are caused by hypothyroidism. Consult your health care provider.

If you are pregnant and have some of the above symptoms, talk to your health care provider or midwife. Also, if you have hypothyroidism and are pregnant or you are trying to become pregnant, talk to your health care provider. Your dose of thyroid hormone medication may need to be adjusted.

Watchful waiting is not appropriate for hypothyroidism that is causing symptoms. Treatment should begin as soon as the condition is diagnosed using blood tests.

Watchful waiting may be appropriate for certain adults with mild (subclinical) hypothyroidism whose blood tests show only modest changes. Talk to your health care provider about the treatment, its cost, and possible benefits. Watch for any signs that you may be developing hypothyroidism. Health care providers often want people to have yearly thyroid function blood tests to diagnose and treat worsening thyroid hormone production.

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Prescription for Nutritional Healing: The A-To-Z Guide To Supplements

-- by Phyllis A. Balch, James F. Balch

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