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Thyroid Disease and What You Need To Know - December 2011
Statistics show that one in eight women between the ages of 35 and 65 and one in five women over the age of 65 have some form of thyroid disease. Hyperthyroidism results from the body producing too much thyroid hormone, but far more common is hypothyroidism, the result of not making enough thyroid hormone. About 26 percent of women in or near perimenopause are diagnosed with this condition.1
The thyroid is a butterfly-shaped gland located in the area of your neck just below the Adam’s apple. It’s part of the endocrine system, and it secretes the hormones thyroxine (T4) and triiodothyroxine (T3), which regulate the body’s metabolic rate. Thyroid function is very complex and exerts a profound effect on the function of nearly every other organ in the body. Therefore, smooth functioning of the overall body chemistry depends on the health of your thyroid gland. It is not uncommon for women with thyroid problems to suffer from depression.
One explanation for this is that the most biologically active form of thyroid hormone, T3, is actually a bona fide neurotransmitter that regulates the action of serotonin, norepinephrine, and GABA (gamma aminobutyric acid), an inhibitory neurotransmitter that is important for quelling anxiety. Even if supplemental thyroid hormone does help alleviate the existing hypothyroidism in a depressed patient, the symptom of depression often persists for a separate and rather surprising reason: depression itself can result in thyroid dysfunction.
Treating the hypothyroidism, in other words, may be treating a symptom rather than the underlying cause. T3 is found in large quantities in the limbic system of the brain, the area that is important for emotions such as joy, panic, anger, and fear. If you don’t have enough T3, or if its action is blocked, an entire cascade of neurotransmitter abnormalities may ensue and can lead to mood and energy changes, including depression.
Hypothyroidism and depression are related on many levels. The main building block for the neurotransmitter serotonin and for thyroid hormone (both T3 and T4) is the amino acid tyrosine, the same amino acid needed for the neurotransmitter norepinephrine, which stabilizes mood and anxiety. This means it is quite possible that low thyroid function can deplete your body of serotonin and other mood-stabilizing neurotransmitters.
It also means that chronic depression and sadness may deplete your body of tyrosine stores and T3, which is also necessary to maintain healthy mood and energy. Which comes first, the depression or the low thyroid? I suspect they occur simultaneously. While one does not cause the other, per se, it appears that similar emotional or behavioral patterns—such as learned helplessness or not believing you can have your say—may predispose you to both low thyroid and depression. (On the other hand, an overdeveloped will and the exertion of one’s intellectual will without acknowledging "higher will" or "higher power" can result in hyperthyroidism; an example is the mindset, "I don’t care what my body is telling me, I’m going to do it anyway.")
For many individuals, the depression and the thyroid have to be treated at the same time in order for thyroid function and mood to return to normal. But it can be a vicious cycle. Psychiatrists say that over time many patients who are treated for depression or anxiety with medications can eventually develop thyroid problems. No one knows why this is so (I suspect it is because antidepressants deplete neurotransmitter levels over time), but scientists are beginning to realize that thyroid disease is really a mind–body disease—its symptoms occur simultaneously in the mind (in the form of depression and lack of concentration) as well as in the body. This is why depression so often persists in women with thyroid disease, even after their thyroid hormone levels are corrected. Iodine deficiency is also very common in women. And that alone can lead to hypothyroidism, especially subclinical hypothyroidism—a situation in which you have all the signs of hypothyroidism but your lab tests are essentially normal.
The key is to understand conditions related to the thyroid. Listen To Your Body While many women with these problems are completely asymptomatic, others may have a wide variety of symptoms (most commonly mood disturbances, such as depression and irritability, as well as low energy level, weight gain, mental confusion, and sleep disturbances). Here are more symptoms of clinical and subclinical hypothyroidism:
- Weight gain (minimal)
- Intolerance to cold or heat
- Hair loss or dry hair
- Decreased heart rate
- Problems with attention and concentration
- Shortness of breath
- Heavy menstrual periods, especially early in the disorder
- Scanty or absent menstrual flow, especially later in the disorder
- Tingling in the fingers
- Muscle cramps
- Impaired hearing
- Dry skin and puffiness in the face, hands, and feet
Further complicating the issue, many symptoms of hypothyroidism are the same as those commonly associated with the hormonal fluctuations of perimenopause. Therefore, it is entirely possible to have many of the symptoms of hypothyroidism yet have completely normal thyroid function. To find out if you have a thyroid disorder, work with a physician who understands thyroid problems.
Ask for a full panel of tests, including TSH, free T4, free T3, T3 uptake, and T4 uptake. These tests are considered a complete battery of thyroid function tests. If you can afford only one, however, make it a TSH (thyroid-stimulating hormone). This is the most sensitive test. The following are the conventional lab values for various thyroid hormone markers: TSH: "Normal" / Random 0.3 – 5.0 mU/L (Newer data suggests that the TSH level should be between 0.3 and 1.5. And that 5.0 is far too high. I agree!) TSH: High–Normal 3.0–5.0 mU/L TSH: Following Thyroid-Releasing Hormone (TRH) stimulation at 20–30 min 9 – 30 mU/L TSH: Borderline Increased 5 – 10 mU/L (I believe that borderline is anything over 1.5) TSH: High >10 mU/L Triiodothyronine (T3) 80 – 180 ng/dL Free T3 230 – 619 pg/dL Thyroxine (T4) 4 – 12 mg/dL Free Thyroxine (Free T4) 0.7 – 1.9 ng/dL Thyroid Peroxidase Antibodies (anti-TPO) < 2 IU/mL
Hypothyroidism can be difficult to diagnose, because there is a continuum between overt and subclinical hypothyroidism, with a great deal of overlap between the two. Depending upon which expert you talk with and which criteria are used for the diagnosis, as many as 25 percent of perimenopausal women have some kind of thyroid problem. Most of these are cases of subclinical hypothyroidism: Although symptoms may be present, tests of thyroid function are only slightly abnormal; for example, thyroid stimulating hormone is slightly elevated, with normal levels of T3 and T4.
Some argue that the "normal" range for TSH in most labs (0.5–5.0 mU/L) is too broad and that normal should be only 0.50–2.0 mU/L. I completely agree and would use 1.5 as the cut off. In contrast, 4 out of every 1,000 women have been diagnosed with overt hypothyroidism, defined as a TSH level of 10.0 or greater with concomitant abnormal values of T3 and T4. The average age of diagnosis for this condition is 60, and its prevalence increases with advancing age.
If you have a family history of hypothyroidism, fit the symptom profile for hypothyroidism, or suspect you have a thyroid problem, give yourself the thyroid neck-check. Hold a mirror in your hand and focus on the area of your neck just below the Adam’s apple. Take a drink of water and swallow. As you swallow, look at your neck and check for any bulges or a protrusion in this area. If you see any bulges, contact your physician.
What Causes This?
According to the late clinician John R Lee, M.D., estrogen dominance is behind many cases of midlife hypothyroidism, in which there are inadequate levels of thyroid hormone. When estrogen is not properly counterbalanced with progesterone, Dr. Lee surmised, it can block the action of thyroid hormone, so that even when the thyroid is producing normal levels of the hormone, the hormone is rendered ineffective and the symptoms of hypothyroidism appear. In this case, laboratory tests may show normal thyroid hormone levels in a woman’s system, because the thyroid gland itself is not malfunctioning.
This problem is compounded when a woman is prescribed supplemental estrogen, which then leads to an even greater imbalance. Prescribing supplemental thyroid hormone in that case will fail to correct the underlying problem: estrogen dominance. Common drugs can block thyroid function, including steroids, barbiturates such as Seconal, cholesterol–lowering drugs, the antiepileptic drug Dilantin, and beta blockers such as propranolol. Most cases of hypothyroidism are due to autoimmune disease—the body making antibodies against the thyroid gland. However, it can also be due to the over-treatment of hyperthyroidism or to iodine deficiency.
You can tell if yours is the result of autoimmunity because, in addition to changes in TSH, T4, and T3, a marker known as thyroid peroxidase antibodies (anti-TPO) will be elevated. When a woman has autoimmune hypothyroidism, thyroid function decreases gradually. As the body makes antibodies against the thyroid, the pituitary gland compensates by producing more TSH, which tells the thyroid to pump out more hormone. In the early stages of this process, T4 and T3 levels are normal but TSH is elevated.
If the illness progresses, thyroid hormone levels fall and TSH rises dramatically. Symptoms become more severe, then progress from subclinical to clinical hypothyroidism. There is wide confusion as to whether soy interferes with thyroid function. You may have seen reports on studies done on animal cells in vitro, or on infants using soy-based formulas, suggesting the possible anti-thyroid effect of soy. But some animal studies actually show increased levels of thyroid hormone when on soy (very slight), which would help lower cholesterol. And Asians, who eat one hundred times more soy than Americans, enjoy excellent health.
The bottom line is that no convincing evidence exists that soy intake increases the risk of hypothyroidism during perimenopause. One randomized, double-blind, placebo-controlled study was done at the Health Research and Studies Center in Los Altos, California, on 38 menopausal women between the ages of 64 and 83 who were not on hormone replacement. Over the six-month period during which these women took 90 mg of soy isoflavones per day, no anti-thyroid effect was shown.2
What is true is that women often begin increasing their intake of soy during perimenopause, a time when they often get their thyroid function checked for the first time. And given that fully 25 percent of perimenopausal women have a thyroid problem, many believe that soy is responsible. If you have any doubt about your thyroid function, get it tested. It’s a simple blood test, and it will put your mind at ease. I’ve also been contacted by several women on thyroid medication who noticed that they did better when they weren’t taking soy products.
Trust yourself and your body. And experiment. In many women thyroid dysfunction develops because of an energy blockage in the throat region, the result of a lifetime of "swallowing" words one is aching to say. In the name of preserving harmony, or because these women have learned to live as relatively helpless members of their families or social groups, they have learned to stifle their self-expression. These women may, in fact, have struggled to have their say, only to discover that it doesn’t make any difference — because in their closest relationships they have been defined as insignificant. In order for this complex, entangled state of affairs to be resolved, a woman might need to take not only supplemental progesterone and thyroid hormone, but also an unblinking look at what parts of her life and interpersonal relationships need to change. Healing Alternatives A variety of prescrition thyroid replacement medications are available. I prefer one that has the correct balance of both T4 and T3, the two hormones that you’re trying to replace.
Here are the current choices:
- ArmourTM Thyroid, made by Forrest Pharmaceuticals, is made from dried (dessicated) pork thyroid glands and contains the correct ratio of T3 to T4. It is prepared according to United States Pharmacopeia (USP) standards, which ensures the potency and consistency of the product.
- Synthroid (thyroxine) is the most commonly prescribed thyroid replacement hormone. It is T4 only. Most women do better with a little T3 thrown into the mix, so if you’re on Synthroid only and don’t feel up to par, ask your doctor to add some T3.
Within the medical profession, controversy exists about whether someone with subclinical hypothyroidism should be treated, given that the thyroid is compensating for an autoimmune process.
If a woman is in her eighties or nineties when first diagnosed, studies suggest that she should just watch, wait, and retest because her own thyroid can probably produce enough hormone for the remainder of her life. However, experts suggest that a younger person will often feel better with a trial combination of T4 and T3.
Some patients who have a high–normal TSH of 3.0 or 4.0 feel symptomatic enough to want treatment. However, medication often doesn’t alleviate symptoms such as fatigue, weight gain, and inattentiveness. Instead, thyroid supplementation in these women may result in side effects, such as palpitations and irritability from too much thyroid hormone—a set-up that also increases osteoporosis risk.
The decision whether or not to treat a borderline case with thyroid hormone replacement is ultimately one that a patient and her health care practitioner will need to make together. No matter what dose of thyroid replacement you take, make sure you are on the lowest dose possible for your situation, and follow a sound program for maintaining bone health.
You might also benefit greatly if you supplement with iodine and/or a high-quality seaweed supplement. Spiritual and Holistic Options Addressing adrenal stress, glycemic stress, and estrogen dominance through modalities such as supplementation, adequate rest, and natural light often helps thyroid levels recover.
If your T4 and T3 levels are normal and your TSH is high-normal or slightly higher than normal, natural progesterone and/or iodine may be all you need to balance your thyroid chemistry, especially if you are taking estrogen only or estrogen with a synthetic progestin. If you have any doubts about whether to take natural progesterone, have your progesterone level tested either via blood or saliva one week before your period is due to see if you are deficient.
The dose of natural progesterone that works well for most women is one-quarter teaspoon of a 2% progesterone skin cream, used once to twice per day, or about 20–40 mg/day on days 14 to 28 of your cycle. Once you stop having periods, use this cream daily for three weeks of every month. Repeat your thyroid function tests within a month or two of starting the natural progesterone. If you are taking HRT, note than when you take natural progesterone, you can often cut your estrogen dose in half and get the same benefits.
I’d also recommend substituting natural progesterone for any synthetic progestin you are on. Synthetic progestin can make thyroid deficiency symptoms worse. Common brands of synthetic progestin are Provera, Amen, and the progestin in Prempro. If you are taking Provera, substitute Prometrium instead. It is a prescription–only, natural micronized progesterone. It’s no coincidence that so many more women than men have thyroid problems.
Thyroid disease is related to expressing your feelings, something that until relatively recently had been societally blocked for women for thousands of years. In order to have your say—and maintain your thyroid energy—you must take a fearless inventory of every relationship in which you feel you don’t have a say.
Ask yourself why you don’t.
Are you a silent partner in a relationship?
Does your partner make all the major decisions?
Is it worth it?
Did your mother have her say?
In what ways are you like her?
Depending on your answers, I would urge you to skillfully and empathetically begin to say what is on your mind regarding the decisions that affect your life. Make sure that when you say what's on your mind, you do so at the right time and remain detached from the effects. In other words, try not to force your will on others.
For example, it’s okay to tell your best friend that you are worried about the character of her new boyfriend, but be aware that she may not necessarily be ready to hear your remarks. It’s not appropriate to "turn up the volume" as she’s rushing out the door to meet this new man. As you begin to have your say (which becomes increasingly common during midlife and perimenopause), don’t expect everyone to be happy about your newfound voice. If you used to be silent and submissive, some individuals may not be thrilled about sharing some of the decision-making in your relationship.
Be patient. All the natural energy that surrounds this rite of passage favors it. One more thing, thyroid disorders are also related to our relationship to time. The thyroid is adversely affected by feeling as though there’s never enough time or that you are running out of time. This feeling also results in adrenal burnout (which is related to thyroid disorders.)
Our culture’s relationship to time is very unbalanced. And this is taking a toll on many. A starting point here is to realize that you have all the time there is. Literally. And all the time that anyone else has—24 hours in a day. You can change your relationship to time by changing the way you pay attention. Stop for a moment and put your attention in your feet. Now put it in your heart. Breathe deeply and really feel your lungs. Take regular moments during the day to simply put your attention on something. Notice a beautiful flower. Or a tree. Or the sky. Slow down and pay attention. Eventually this little practice will improve your relationship to time.
And say the following affirmation: “I have all the time in the world to do what really matters.” “I am the source of time. And I can change my relationship to time and rebalance my body.”
Learn More | Recommended Reading or Resources
References 1. Massoudi, M. S., et al. (1995). Prevalence of thyroid antibodies among healthy middle-aged women. Findings from the thyroid study in healthy women. Annals of Epidemiology, 5 (3), 229–233. 2. Bruce, B., Messina, M., & Spiller, G. A. (2003). Isoflavone supplements do not affect thyroid function in iodine-replete postmenopausal women. J. Med. Food, 6 (4), 309–316; Bruce, B., Spiller, G. A., & Holloway, L. (April 15–18, 2000). Soy isoflavones do not have an anti-thyroid effect in postmenopausal women over 64 years of age. Experimental Biology 2000, San Diego, CA, USA; Duncan, A. M., Merz, B. E., Xu, X., Nagel, T. C., Phipps, W. R., & Kurzer, M. S. (1999). Soy isoflavones exert modest hormonal effects in premenopausal women. J. Clin. Endocrinol. Metab., 84 (1), 192–197; Duncan, A. M., Underhill, K. E., Xu, X., Lavalleur, J., Phipps, W. R., & Kurzer, M. S. (1999). Modest hormonal effects of soy isoflavones in postmenopausal women. J. Clin. Endocrinol. Metab., 84 (10), 3479–3484; Horn-Ross, P. L., Hoggatt, K. J., & Lee, M. M. (2002). Phytoestrogens and thyroid cancer risk: The San Francisco Bay area thyroid cancer study. Cancer Epidemiol. Biomarkers Prev., 11 (1), 43–49.
- Awakening Intuition, by Mona Lisa Schulz, MD, PhD.
- The Thyroid Solution by Ridha Arem, MD
- Healing Options: A Report on Graves’ Disease Treatments, by Kate Flax
- Audiotapes Igniting Intuition and Body Talk, with Dr. Northrup and Dr. Mona Lisa Schulz
Dr. Christiane's Bio: Christiane Northrup, M.D. is a visionary pioneer and beloved authority in the field of women’s health and wellness. A board-certified OB/GYN physician who graduated from Dartmouth Medical School and did her residency at Tufts New England Medical Center, Dr. Northrup was also an assistant clinical professor of OB/GYN at Maine Medical Center for 20 years. Recognizing the unity of body, mind, and spirit, Dr. Northrup helps empower women to tune in to their innate inner wisdom to transform their health and truly flourish.
Dr. Northrup is the author of two New York Times best-selling books, Women’s Bodies, Women’s Wisdom, The Wisdom of Menopause and her third book, Mother-Daughter Wisdom. - Dr. Christiane Northrup Website
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