Virtually every day I see patients who have been under the care of other physicians. They come in with recent blood-work that was done to try and figure out why they have fatigue, weight gain, etc. Inevitably when looking at these labs I will see TSH, or "thyroid stimulating hormone" as the only test for function of this important organ. However, there are other essential labs that need to be run to better understand and treat thyroid issues.
Before going further, let's talk briefly about your sweet little thyroid gland. It spends it's days and nights doing so many things behind the scenes with very little appreciation. Healthy metabolism, proper bowel function, thick hair, healthy skin, proper hormone function. These and many more are the domains of the little thyroid, which sits like a little butterfly resting at the base of your neck. Thyroid hormones are part of a loop. The brain produces the TSH which, as the name implies, stimulates the thyroid. The thyroid gland then produces a hormone called T4, which you make a decent amount of but it is not very active. This is then converted to a hormone called T3, of which you have a lot less than the T4 but it is more highly active. This is the main hormone that acts on your various body systems. When there is enough in your system the brain slows down production of TSH. When levels drop the brain tries to increase it by producing more Thyroid Stimulating Hormone.
I often use the analogy of trying to wake a child up on a school day. The parent is the brain and the volume of their voice is the TSH level. At first it/they will gently whisper "Wake up honey... good morning!" with low (volume) TSH levels. If the child is reluctant the volume (TSH) will increase and they will then firmly say "Ok, sweetie. It's time to get up now please." If the child/ thyroid is still not responding (waking up/ making T4, T3) then the TSH/ volume will get even higher as the brain/ parent starts yelling "Get! Out! Of! Bed! NOW!" Therefore, when the thyroid is functioning at too low of a level, known as hypothyroid, the TSH will actually be elevated and if TSH is low then it shows that the thyroid is acting a little too well and the patient is experiencing hyperthyroid. Confusing, I know...
So what's the deal with the thryoid hormones? Why can we not just test TSH? Well, mostly because we need to understand WHY a thyroid is unhappy. If the child isn't getting out of bed is it because they are being stubborn, maybe honestly didn't hear you, or perhaps because they are sick? There are various causes. This is the same with the thyroid. Sometimes the thyroid is producing too little T4. Sometimes it's making plenty of T4 but this isn't converting to T3. Much of the time the issue doesn't stem from the thyroid but from the immune system in conditions like Hashimoto's Thyroiditis and Grave's Disease.
The adrenal glands also play a part in all of this and I always recommend looking at them, as well. Adrenal glands are kind of your thyroid's besties. They are small glands that sit on top of your kidneys like little party hats and help regulate stress hormones. Cortisol and ACTH can be at abnormal levels with high stress, which can then affect the thyroid. Treating the adrenals should be a standard practice when the thyroid function is not optimal.
Standard treatment for low thyroid function is levothyroxine, or synthetic T4. Why isn't this appropriate for all patients? Well, as stated above, what if their issue isn't with making T4 but with converting it? What if the issue doesn't lie with the thyroid at all but with the immune system. What if the thyroid is just responding to the adrenals, which are responding to a high level of stress in life? I like to think of the body's functions as a cart and the thyroid is a horse pulling it. If the horse/ thyroid is tired then simply using levothyroxine (or dessicated thyroid products that contain porcine thyroid gland with T4/T3) is like whipping the tired horse. The metabolism will continue and the end destination/ results met but it won't get any healthier or more rested. By treating the adrenal glands, as well, it's like hooking up a fresh horse to the cart to help carry the load.
When the malfunction lies with the thyroid and adrenals then treating these two organs is the treatment of choice, because this is the source of the issue. Diet, lifestyle, and thyroid and adrenal supportive supplements can do wonders. Sometimes for the sake of the patient's quality of life a prescription thyroid medication can be used while the other treatments begin and most often patients will find that after a time they need to taper down in their dosage as things return to balance.
Other times, the issue stems from the immune system. With Hashimoto's and Grave's the treatment needs to focus on this system instead of on the thyroid. This is why labs matter! Adding in additional support such as low dose naltrexone, along with diet, lifestyle, and other supportive measures can have a profound impact on patient health. I have seen so many individuals who still felt awful even on thyroid medication until we began shifting our focus to the immune system. Antibodies, which are elevated in autoimmune diseases such as these, will often begin to fall once the root cause is addressed. I've seen patients with all perfectly normal thyroid levels except their antibodies were off the chart. One even had a visible goiter and was told by several physicians that they were fine because their TSH (the only thing tested) was normal.
Another reason why distinguishing between the two is because this can greatly determine which dietary and supplement recommendations are made. Iodine is necessary for proper thyroid function and higher levels can help with frank hypothyroidism. With Hashimoto's Thyroiditis, though, studies now show typical supplemental amounts can actually just add "fuel to the fire" and make things worse. Too many times I've seen people trying to self-treat by taking a thyroid support supplement that is full of iodine and just making their symptoms worse. With autoimmune thyroid issues it may also be more necessary to implement a gluten-free diet, which has been shown to lower antibody levels (although I generally recommend this to anyone with thyroid issues).
So which labs should you test (at minimum) if you think you might have thyroid issues?
2) free T3
3) free T4
4) thyroid peroxidase antibodies
5) thyroglobulin antibodies
6) cortisol (morning and afternoon measurements)
If your health care provider is not willing to order these for you, it is likely because of insurance reasons. Ask if they are willing to order it if you are ok with paying cash or, better yet, find a provider who is open to working with you to better understand your health. There are also some labs these days that allow patients to order their own labs. I also recommend not testing your thyroid within 24 hrs of having it palpated by either yourself or your health practitioner because this can falsely elevate levels.
It's vital in all aspects of health to think of your body as a complex web instead of isolated organs working alone. It is also to your great benefit to make sure that you feel heard, are comfortable asking questions, and are able to understand the recommendations of your healthcare provider. Empower yourself and take the steps you need to in order to help your thyroid help you once again
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