Post on 11-Dec-2015
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TCM Wisdom TubeTM
Hypothyroidism and TCM
by David Frierman, L.Ac.
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POWER POINT
Image 1: Thyroid and Parathyroid Glands
Image 2: The Thyroid and Surrounding Tissues
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
1
Image 3: Histological section through the thyroid of a horse. 1 follicles, 2 follicular epithelial cells, 3
endothelial cells
Table 1: Three Primary Features of the Thyroid at the Microscopic Level1
Feature Description
Follicles The thyroid is composed of spherical follicles that selectively absorb
iodine (as iodide ions, I-) from the blood for production of thyroid
hormones, but also for storage of iodine in thyroglobulin, in fact iodine
is necessary for other important iodine-concentrating organs as breast,
stomach, salivary glands, thymus etc. (see iodine in biology).Twenty-
five percent of all the body's iodide ions are in the thyroid gland. Inside
the follicles, colloid serves as a reservoir of materials for thyroid
hormone production and, to a lesser extent, acts as a reservoir for the
hormones themselves. Colloid is rich in a protein called thyroglobulin.
Thyroid epithelial cells
(or "follicular cells")
The follicles are surrounded by a single layer of thyroid epithelial cells,
which secrete T3 and T4. When the gland is not secreting
T3/T4 (inactive), the epithelial cells range from low columnar to
cuboidal cells. When active, the epithelial cells become tall columnar
cells.
Parafollicular cells
(or "C cells")
Scattered among follicular cells and in spaces between the spherical
follicles are another type of thyroid cell, parafollicular cells, which
secrete calcitonin.
1 Fawcett, Don; Jensh, Ronald (2002). Bloom & Fawcett's Concise Histology. New York: Arnold Publishers. pp. 257–
258. ISBN 0-340-80677-X.
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
2
Image 4: The Thyroid System
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
3
Image 5: Thyroid Gland Physiology
Table 2: Thyroid Hormonal Feedback Loop
T3 and T4 Serum Levels TSH and TRH Output
High Decreases
Low Increases
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
4
Table 2A: Results of Thyroid Function Tests in Various Clinical Situations2
Physiologic State Serum TSH
Serum Free T4 Serum T3 24-Hour Radio-
Iodine Uptake
Hyper-
thyroidism
Untreated Low High High High
T3 toxicosis Low Normal High Normal or
High`
Hypo-
thyroidism
Primary,
untreated
High Low Low or Normal Low or Normal
Secondary to
pituitary disease
Low or
Normal
Low Low or Normal Low or Normal
Euthyroidism Patient taking
iodine
Normal Normal Normal Low
Patient taking
exogenous
thyroid hormone
Normal Normal in patient
taking T4, low in
patient taking T3
High in patient
taking T3, normal
in patient taking T4
Low
Patient taking
estrogen
Normal Normal High Normal
Euthyroid sick
syndrome
Normal,
Low or
High
Normal or Low Low Normal
T3 = triiodothyronine; T4 = thyroxine; TSH =thyroid stimulating hormone
2http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/thyroid_disorders/overview_of_t
hyroid_function.html?qt=thyroid%20tumor&alt=sh
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
5
Diagram 1: The Five Phase-Elements, Engendering and Restraining Cycles
Fire (Heart)
Wood (Liver) Earth (Stomach Spleen)
Water Metal
(Kidneys) (Lung)
Engendering 相生 (xiāng shēng)
Restraining 相克(xiāng kè)
Table 3: Treatment Strategies for Different Stages of Treatment
Stage Yin Shi, Yang Xu Treatment Strategies Yang Shi, Yin Xu Treatment Strategies
1st Stage
Warm Interior and Drain Congested
Fluids, Transform Phlegm, Clear any
Heat and Toxins
Clear Heat and Toxins
2nd
Stage Supplement Yang Drain Damp and Transform Phlegm
3rd
Stage Supplement any Xu
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
6
Table 4: Historical Accounts of Thyroid Disease Rubrics
A. Goiter (瘿 yǐng)
B. Five Slownesses (五迟 wǔ chí)
C. Xu Detriment (虚损 xū sǔn)
D. Diarrhea (便泄 biàn xiè)
E. Fatigue (疲 劳 pí láo)
F. Center Burner Dispersion-Thirst (中消 zhōng xiāo)
G. Palpitations, Heart Palpitations (心悸 xīn jì)
H. Sweating Syndrome (汗证 hàn zhèng)
I. Insomnia (失眠 shī mián)
J. Hand Tremor (手颤 shǒu chàn)
K. Constipation (便秘 biàn bì)
L. Cystitis (膀胱炎 páng guāng yān).
M. Vexation, Agitation, and Irascibility (烦燥易怒 fán zào yì nù)
N. Depression Syndrome (郁证 yù zhèng)
O. Phlegm-Rheum (痰饮 tán yǐn) Diseases
P. Water Swelling (水肿 shuǐ zhǒng)
Q. Bulging Eyes (眼球外突 yǎn qiú wài tū)
R. Weight Gain [Obesity, Fatness] (肥胖 féi pàng)
S. Blood Stasis (血瘀 xuè yū)3
3 I.e., various blood stasis diseases.
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
7
Table A: Important Terms
My Term Common English Translations Chinese
chong mai “penetrating vessel,” thoroughfare vessel” 冲脉 chōng mài
five phases “five elements,” “five phase elements,” “five movements” 五行 wǔ-xíng
jueyin “end of yin,” “terminal yin,” “reverting yin” 厥阴 juéyīn
liu jing “six channels,” “six stages,” “six warps,” “six conformations” 六经 liù jīng
qi “energy,” “ influences” 气 qì
qi “qi [aspect]” 气 qì
shaoyang “small yang,” “lesser yang” 少阳 shàoyáng
shaoyin “small yin,” “lesser yin” 少阴 shàoyīn
shen “spirit” 神 shén
shi “full,” “excess,” “excessive,” “replete,” “repletion” 实 shí
si fen “four divisions,” “four levels,” “four aspects,” 四分 sì fēn
syndrome
differentiation
“pattern,” “pattern identification” 辩证 biàn zhèng
taiyang “big yang,” “great yang,” “greater yang” 太阳 tàiyáng
taiyin “big yin,” “great yin,” “greater yin” 太阴 tàiyīn
wei “defense,” defensive” 卫 wèi
xu “empty,” “deficient,” “deficiency,” “vacuous,” “vacuity” 虚 xū
xue “blood [aspect]” 血 xuè
yangming “yang brightness” 阳明 yángmíng
ying “construction,” “constructive,” “nutritive,” “camp” 营 yíng
yuan qi “source qi,” “original qi,” “congenital qi” 元气 yuán qì
zhen qi “true qi” 真气 zhēn qì
zheng qi “upright qi,” “right qi” 正气 zhèng qì
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
8
Table B: Pulse Nomenclature
Chinese Characters and
Pinyin
English name Other translations
大脉 (dá mài) Big Large
结脉 (jié mài) Bound Slow-irregularly-interrupted, adherent, knotted, nodular
沉脉 (chén mài) Deep Sunken, submerged, sinking
散脉 (sàn mài) Dissipated Dispersed, scattered
革脉 (gé mài) Drum-skin Tympanic, leather
微脉 (wēi mài) Faint Evanescent, minute, diminutive
细脉 (xì mài) Fine Minute, small, thin, thready
牢脉 (láo mài) Firm Fixed, prison, hard
浮脉 (fú mài) Floating Superficial
伏脉 (fú mài) Hidden Recondite
代脉 (dài mài) Intermittent Regularly interrupted
长脉 (cháng mái) Long
缓脉 (huǎn mài) Moderate Languid, slowed-down, leisurely, retarded, relaxed
正常脉 (zhèng cháng mài) Normal
疾脉 (jí mài) Racing Fast, hurried, rushing, swift
数脉 (shuò mài) Rapid Accelerated, quick
实脉 (shí mài) Replete Full, excess, forceful
涩脉 (sè mài) Rough Grating, choppy, difficult, dry
芤脉 (kōu mài) Scallion-stalk Hollow, onion-stalk, leek-stalk
短脉 (duǎn mài) Short Brief
促脉 (cù mài) Skipping Agitated, hasty, accelerated
滑脉 (huá mài) Slippery
迟脉 (chí mài) Slow Slowed-down
软脉 (ruǎn mài) Soft
濡脉 (rú mài) Soggy Frail, weak-floating, soft
动脉 (dòng mài) Stirred Mobile, moving, agitated, spinning bean
弦 脉 (xián mài) String-like Wiry, bowstring, chordal
洪脉 (hóng mài) Surging Flooding, overflowing, tidal
紧脉 (jǐn mài) Tight Tense, taut
虚脉 (xū mài) Vacuous Exhausted, depleted, deficient, empty
弱脉 (ruò mài) Weak Infirm
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
9
Table 5: Hypothyroid Treatment Strategies
Number Type Common Differentiations Strategies
II.B.1 Pure Xu
Without
Heat
Yin, Yang, Qi, and Blood Xu Supplement any Xu: Yang, Yin, Qi, Blood
II.B.2 Xu
Complicated
with Shi
Spleen and Kidney Qi and Yang
Xu with Damp and Phlegm
Stagnation
Supplement any Xu: Yang, Yin, Qi, Blood
Secondarily, Transform Damp and
Phlegm
II.B.3 Xu Cold
Complicated
with Heat
Spleen and Kidney Qi and Yang
Xu and Liver and Kidney Yin Xu
Fire and/or with Damp and
Phlegm Heat Stagnation
Simultaneously Supplement Xu Humors
and Clear Heat and Toxins (While
Safeguarding Yin), and/or Clear and
Transform Phlegm Heat
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
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Table 6: Representative Formulas for Single Medicinals
Medicinal Representative Formula
Shudihuang Jin Kui Shen Qi Wan
Shu Fu Zi 3g
Gui Zhi [now usually replaced with Rou Gui] 3g
Sheng Di Huang [(now usually replaced with Shu Di Huang] 24g
Shan Yao 12g
Shan Zhu Yu 12g
Ze Xie 9g
Fu Ling 9g
Mu Dan Pi 9g
Baishao Xiao Jian Zhong Tang
Yi Tang 20g
Gui Zhi 9g
Bai Shao 18g
Sheng Jiang 6g
Da Zao 5 pieces
Zhi Gan Cao 3g
Si Ni San:
Chai Hu 12g
Zhi Shi 6g
Bai Shao 12g
Zhi Gan Cao 3g
Zhen Wu Tang:
Shu Fu Zi 9g
Bai Zhu 6g
Fu Ling 9g
Bai Shao 9g
Sheng Jiang 9g
Huanglian Huang Lian E Jiao Tang:
Huang Lian 3-6g
E Jiao 9-12g
Huang Qin 9-12g
Bai Shao Yao 9-12g
Ji Zi Huang 2 yolks
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
11
Table 7: Pure Xu without Heat: Yin, Yang, Qi, and Blood Xu Suggested Formulas (to be
modified)
Differentiation Formula and Ingredients
Qi xu, especially spleen qi xu Bu Zhong Yi Qi Tang:
Huang Qi 12g
Ren Shen 9g
Bai Zhu 12g
Zhi Gan Cao 3g
Dang Gui 9g
Chen Pi 6g
Sheng Ma 9g
Chai Hu 6g
Yang xu, especially spleen
and kidney yang xu:
modifications of Er Xian
Tang plus Jin Kui Shen Qi
Wan modified:
Er Xian Tang:
Xian Mao 9g
Yin Yang Huo 9g
Ba Ji Tian 9g
Huang Bai 9g
Zhi Mu 9g
Dang Gui 9g
Jin Kui Shen Qi Wan:
Shu Fu Zi 3g
Gui Zhi [now usually replaced with Rou Gui] 3g
Sheng Di Huang [(now usually replaced with Shu Di Huang] 24g
Shan Yao 12g
Shan Zhu Yu 12g
Ze Xie 9g
Fu Ling 9g
Mu Dan Pi 9g
Blood and yin xu, especially
liver and heart blood xu, and
liver, heart, and kidney yin
xu: modifications of Liu Wei
Di Huang Wan and Si Wu
Tang.
Liu Wei Di Huang Wan:
Shu Di Huang 25g
Shan Zhu Yu 15g
Shan Yao 15g
Ze Xie 12g
Mu Dan Pi 9g
Fu Ling 12g
Si Wu Tang:
Shu Di Huang 12g
Dang Gui 9g
Bai Shao 9g
Chuan Xiong 9g
Acumoxibustion Choose from Pi Shu (Bl 20), Shen Shu (Bl 23), Guan Yuan (CV 4), Qi
Hai (CV 6), Zu San Li (St 36), San Yin Jiao (Sp 6), Xue Hai (Sp 10), Tai
Xi (Ki 3). For spleen qi xu add Tai Bai (Sp 3). For spleen yang xu moxa
Pi Shu (Bl 20), Qi Hai (CV 6), Zu San Li (St 36), and San Yin Jiao (Sp
6). For kidney yang xu moxa Shen Shu (Bl 23), Ming Men (GV 4), Guan
Yuan (CV 4), Tai Xi (Ki 3). For liver blood xu add Qu Quan (Liv 8). For
heart blood xu add Yin Xi (Ht 6).
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
12
Case 1 Prescription
Differentiation Prescription
Qi, blood, yin, and yang xu.
Er Xian Tang, modified:
Ba Ji Tian 6g
Yin Yang Huo 8g
Dang Gui 7g
Chuan Xiong 9g
Bai Shao 9g
Bai Zhu 9g
Shu Di Huang 10g
Chen Pi 6g
Dong Chong Xia Cao Jun Si4 1000mg BID
Case 2 Prescription
Differentiation Prescription
Kidney and spleen qi and yang xu.
Dr. Li’s personal formula Jia Di Fu Yuan Tang (Hypothyroid
Restore the Source Decoction) modified:
Ren Shen 10g
Yin Yang Huo 10g
Bai Zhu 10g
Dang Gui 10g
Chuan Xiong 10g
Huang Qi 20g
Mai Men Dong 10g
He Shou Wu 10g
Dong Chong Xia Cao Jun Si one 1000mg tablet BID
4冬虫夏草菌絲 Dōng Chóng Xià Cǎo Jūn Sī, literally “winter worm, summer grass fungus thread” or “winter worm,
summer grass fungus mycelium” is Cordyceps fungus grown on a medium instead of obtained by collecting infected
caterpillars or other insects. Several companies produce Dong Chong Xia Cao Jun Si and the quality varies. Good
quality encapsulated Dong Chong Xia Cao Jun Si should have a significant and pleasant odor.
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
13
Table 8: Xu complicated with Shi: Spleen and Kidney Qi and Yang Xu with Damp and
Phlegm Stagnation Suggested Formulas (to be modified)
Representative Formula Combination Number 1:
Choose medicinals from Li Zhong Wan, Si Ni Tang,
Er Chen Tang and Bu Zhong Yi Qi Tang
Li Zhong Wan:
Ren Shen 10g
Gan Jiang 10g
Bai Zhu 10g
Gan Cao 3g
Si Ni Tang:
Fu Zi 10g
Gan Jiang 10g
Zhi Gan Cao 6g
Er Chen Tang:
Ban Xia 5g
Chen Pi 4g
Fu Ling 5g
Zhi Gan Cao 1g
Sheng Jiang 3g
Wu Mei 1 piece
Representative Formula Number 2: Dr. Li’s
personal formula Jia Di Fu Yuan Tang
(Hypothyroid Restore the Source Decoction):
Huang Qi 15g
Ren Shen 10g
Zhi Fu Zi 7g
Gan Jiang 4g
Yin Yang Huo 9g
Ba Ji Tian 9g
Shu Di Huang 15g
Dang Gui 7g
Chuan Xiong 7g
Bai Shao 7g
Ban Xia 6g
Fu Ling 9g
Mai Men Dong 10g
Chai Hu 6g
Chen Pi 6g
Shi Hu 1g5
Dong Chong Xia Cao Jun Si 1000mg tablet BID
Acumoxibustion Choose from Pi Shu (Bl 20), Shen Shu (Bl 23),
Guan Yuan (CV 4), Qi Hai (CV 6), Zu San Li (St
36), Feng Long (St 40), Gong Sun (Sp 4), San Yin
Jiao (Sp 6), Yin Ling Quan (Sp 9), Tai Xi (Ki 3).
For spleen qi xu, add Tai Bai (Sp 3). Moxa is
applicable.
5 Shi Hu is now a rare and endangered medicinal, and many substitutes and varying qualities are offered on the
market. This dosage is for true, excellent quality Huo Shan (Huo Mountain in Anhui Province, China) Shi Hu. One
should ask for “fēng dǒu (枫斗)” when buying Shi Hu for use in treating thyroid disease.
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
14
Table 9: Xu Cold Complicated with Heat: Spleen and Kidney Qi and Yang Xu and Liver
and Kidney Yin Xu Fire and/or with Damp and Phlegm Heat Stagnation Suggested
Formulas to be modified
Yi Guan Jian:
Sheng Di Huang 15g
Bei Sha Shen 9g
Mai Men Dong 9g
Dang Gui 9g
Gou Qi Zi 9g
Chuan Lian Zi 6g
Jing Shui Liu Jun Jian Six Gentlemen of Metal and Water Decoction
Ban Xia 6g
Chen Pi 5g
Fu Ling 6g
Zhi Gan Cao 3g
Dang Gui 6g
Sheng Di Huang 15g
Dr. Li’s Personal Formula: A combination and modification of Huang Lian Jie Du Tang, Yi Guan Jian,
and Xi Jiao Di Huang Tang, (with added yang supplements):
Huang Lian 10g
Xuan Shen 15g
Ban Lan Gen 10g
Lian Qiao 9g
Jin Yin Hua 15g
Mu Dan Pi 9g
Dan Shen 7g
Chi Shao 6g
Bai Shao 6g
Sheng Di 15g
Shu Di Huang 10g
Da Huang 4g
Ban Xia 6g
Fu Ling 9g
Mai Men Dong 10g
Lu Rong 0.1g/ powdered, once every morning
Dong Chong Xia Cao Jun Si 1000mg tablet BID
Acumoxibustion: Choose from the point listed in the previous differentiations plus those that
clear heat and nourish yin such as Du 14, LI 11, L1 4, UB 40, LV 3, Ki 3, Ht 6, etc.
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Formulas in Case 5 Commentary
Qing Ying Tang:
Xi Jiao 9g
Xuan Shen 9g
Sheng Di 15g
Mai Men Dong 9g
Jin Yin Hua 9g
Lian Qiao 6g
Huang Lian 4.5g
Dan Zhu Ye 3g
Dan Shen 6g
Mai Men Dong Tang:
Mai Men Dong 15g
Ren Shen 6g
Geng Mi 9g
Da Zao 5 pieces
Gan Cao 3g
Ban Xia 9g
Table 10: Menopausal Women with Hypothyroidism Representative Formula
A modification and combination of Jin Shui Liu Jun Jian and Liu Wei Di Huang Wan or Xi Jiao Di
Huang Tang minus Xi Jiao:
Ban Xia 9g
Chen Pi 6g
Fu Ling 6g
Zhi Gan Cao 3g
Dang Gui 6g
Shu Di Huang 20-30g
Shan Zhu Yu 12g
Shan Yao 12g
Ze Xie 9g
Mu Dan Pi 9g
Huang Lian 9g
Xuan Shen 20g
Dong Chong Xia Cao Jun Si 1000mg tablet BID
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Table 11: Clinical Research Formulas
Deng Shi Jia Fang (Mr. Deng’s A Formula) consists of:
Huang Qi 30g
Dang Shen 18g
Bai Zhu 24g
Dang Gui 12g
Zhi Gan Cao 6g
Chai Hu 6g
Sheng Ma 6g
Ba Ji Tian 9g
Gou Qi Zi 9g
Chen Pi 3g
Deng Shi Yi Fang (Mr. Deng’s B Formula) consists of:
Huang Qi 18g
Fu Ling 30g
Bai Zhu 24g
He Shou Wu 24g
Ze Xie 9g
Gui Zhi 9g
Shan Yao 9g
Yin Yang Huo 9g
Tu Si Zi 12g
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Supplemental material
I. A Historical Account of Thyroid Diseases
Chinese medicine has provided effective treatment for thyroid diseases from ancient times to the present.
A selection of the historical records that discuss and suggest treatments for “瘿 yǐng,” as goiter and other
thyroid diseases have historically been known in China.
A. Pre-Han Dynasties
Although only completed in the Han, the Shān Hǎi Jīng (Classic of Mountains and Seas) existed in the
Fourth Century BCE.6 In it “goiter and pestilence” are mentioned.
7
Goiter is mentioned a few times in Zhuāng Zǐ’s writings, thought to be of the Fourth Century BCE. For
example “Dé Chōng Fú” (“The Seal of Virtue Complete”) has the following line: “[A man] who had a
large goiter like an earthenware jar addressed his counsels to Duke Huan of Qi, who was so pleased with
him that he looked on a perfectly formed man as having a neck lean and small in comparison with him.”8
Again, in the Third or Fourth Century BCE, Lü Shì Chūn Qiū (Lü’s Spring and Autumn) states that, “In
regions where the water is ‘light’9 water the people frequently are bald and have goiters on the neck (輕水
所多禿与與人…).”10
Wiseman notes that this “indicates that a connection between goiter, environmental
factors, and baldness had been observed.”11
Furthermore, medicinals to treat goiter are mentioned in the Shén Nóng Bĕn Căo Jīng. Under “Middle
Class Medicinals,” Hai Zao is suggested for the treatment of goiters.12
B. Western Han (206 BCE –9 CE)
6 Leo Bagrow, R. and A. Skelton, History of Cartography, Transaction Publishers, Piscataway, NJ, 2009, p. 204
7 Wang Zhen-guo and Ping Chen History and Development of Traditional Chinese Medicine, Xing Xiao-chen,
editor, Science Press, Beijing, 1999, p. 17
8 http://ctext.org/zhuangzi/seal-of-virtue-complete
9 “輕 qīng” is literally “light.” Knoblock and Riege (see below) translate “輕 qīng” as “brackish,” but it usually
indicates pure, clear water, perhaps without minerals. In fact, the next line in this sequence, “重水所多尰與躄人,”
speaks of “heavy” water, which usually indicates water with dissolved minerals in it.
10 Lǚ Bù-wéi, The Annals of Lü Buwei, trans. Knoblock, John and Riege, Jeffrey K., Stanford University Press,
Stanford, CA 2000, p. 100
11 Wiseman, Nigel and Fang, Ye, A Practical Dictionary of Chinese Medicine, Paradigm Publications, Brookline
MA 02146, 1965, p. 243
12 Shen Nong Ben Cao Jing (The Divine Farmer’s Materia Medica), trans. Yang Shou-zhong, Blue Poppy Press,
Boulder CO, 1998, p. 65
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While the Huáng Dì Nèi Jīng Sù Wèn Líng Shū, Chapter 10, on channels and collaterals, does mention
“yǐng,” the discussion that follows implies that in this context “瘿 yǐng” refers to lymph swelling or
scrofula. However, one can make a case that in a rather disperse and complicated discussion of mania and
withdrawal (癫 狂 diān kuáng), thyroid disease symptoms are described. (Early in Chinese history a
connection was made between goiter and emotional disturbance.) Again in same chapter, it is said that
“the stomach foot yangming vessel…rules the diseases that are born of blood such as mania…swollen
neck, throat obstruction…”
C. Eastern Han (25-220 CE)
In what has come to be known as the Jīn Kuì Yào Lüè Fāng Lùn, Chapter 11, Zhāng Zhòng-jǐng says:
Accumulations are diseases of the solid organs, they are immovable throughout. Conglomerations affect the
hollow organs; they bring on regular seizures of migrating pain and are curable… The rule for diagnosing
all accumulations is to look for a thin and submerged pulse that is palpable only when the fingers press
heavily and touch the radial bone. Such a pulse detected on the cun locates the accumulation in the chest; a
little ahead of the cun locates the accumulation in the throat…
In the next chapter, Zhāng Jī discusses phlegm-rheum in detail. This pathological substance is involved in
almost all goiters. Zhāng Jī established certain treatment strategies for phlegm-rheum that are still viable,
and several of his formulas from the Shāng Hán Lùn as well as the Jīn Kuì Yào Lüè Fāng Lùn are still
used to treat various types of thyroid diseases. Examples include Jin Kui Shen Qi Wan, Si Ni San, Si Ni
Tang, Li Zhong Wan, and Ban Xia Xia Xin Tang.
D. Jin Dynasty (265-420 CE)
In the Eastern Jin Dynasty, Gé Hóng used Hai Zao in the first medicinal treatment protocol for “goiter
syndrome” (瘿证 yǐng zhèng) as presented in his book Zhǒu Hòu Bèi Jí Fāng (Emergency Formulas to
Keep up One’s Sleeve).13
Also in the Jin, ChēnYán-zhī, in the 10th scroll of his Xiǎo Pǐn Fāng (The Concise Formulary),
14 “Zhì
Yǐng Bìng Zhū Fāng” (“Formulas for Treating Various Goiters”), states the following.
Goiters: in the beginning they resemble a [fruit] pit. Goiters hang under the neck. In the central states, the
Chinese contract goiter through indignation causing binds, but here the goiter is heavy and without a pit.
The Chang An and Xiang Yang barbarians drink sandy water, producing goiter with a pit...without a root,
and suspended in the skin. When local women contract this disease, [it causes] kidney qi shi. The [water's]
“sandiness” homes to the kidneys, thus causing the kidney shi. This disease results in goiter. Northern
13
Anti-Angiogenic Functional And Medicinal Foods, edited by Losso, Jack N., Shahidi, Fereidoon, and
Bagchi Debasis, 2007, CRC Press, Taylor and Francis Group, Boca Raton, FL, p. 101
14 Xiǎo Pǐn Fāng (The Concise Formulary) was required reading for all Chinese medicine scholars/doctors during
the Tang Dynasty. It disappeared after the Song Dynasty. In 1985, it was “rediscovered” in Japan.
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women who drink sandy water produce milk only with difficulty, if one does not use acupuncture the milk
will not flow. Home remedies are of no use, but Zhi Ying Fang is efficacious.15
Zhi Ying Fang contains wine-treated Fu Xiao Mai as well as Hai Zao. One can see that this formula treats
the emotions as well as transforming phlegm and softening hardness. (In Western terms, seaweeds supply
iodine.) The diet is also addressed as there is a proscription against salt, raw fish, raw vegetables, and
pork.16
E. Tang Dynasty (618-907 CE)
In the early Tang Dynasty, Wáng Tāo made an exhaustive study and collection of every branch of
medicine from ancient sources up to his own time and published this collection in Wài Tái Mì Yào Fāng
(Medical Secrets of an Official). In scroll 23 on goiter formulas, Wang states,
Goiter springs from various sources, worry, grief, anger, depression, but also sandy water. The sand
following the channels and arrives under the neck...and gradually becomes a goiter.”17
A few examples of his formulas for goiter follow.18
1. One of Wáng’s collected formulas for goiter caused by worry and stress, as well as drinking sandy
water leading to qi constraint and damp stagnation contains Kun Bu 6 fen, Hai Zao 7 fen, Song Luo 4 fen,
Gan Jiang 4 fen, Gui Xin 4 fen, Tong Cao 5 fen.
2. For qi goiter Wáng suggests mixing Su Zi, Gui Xin, Da Huang, Dang Gui, Gan Jiang, Ju Pi, Shu Jiao,
all @3 fen with 1 sheng of pork lard to make pills.
3. For all types of goiter Wáng lists a recommendation of burning moxa on Qu Chi (LI 11) three times,
(for men 18 times on the left, 17 times on the right and for woman 18 times on the right, 17 times on the
left), burning 30 cones of moxa on Da Zhui (GV 14) and a point 1/ ½ cun out from Da Zhui (GV 14), as
well as burning 100 cones of moxa on Fei Shu (Bl 13).
Note Wáng Tāo’s strong correlation between emotional caused “qi constraint” and goiter.
In this same work, Wáng mentions Cuī Zhī-tī, a contemporary of Sūn Sī‐miǎo, who wrote the Gǔ Zhēng
Bìng Jiǔ Fāng (Formulas for Steaming Bone Syndrome). To some scholars, Cuī made a distinction
between tumors and goiters. Wang writes, “Cui said that soft or movable goiters can be cured, but stone-
like tumors cannot be cured...”19
15
http://www.zysj.com.cn/lilunshuji/xiaopinfang/758-14-24.html
16 Ibid.
17 http://www.zysj.com.cn/lilunshuji/waitaimiyao/121-30-1.html#m0-0
18 Wáng Tāo, Wài Tái Mì Yào Fāng (Medical Secrets of an Official), 752 (Tang), Hua Xia, Beijing 1997, Volume 23,
p. 433-439
19The oft-cited conclusion of Temple’s, (Temple, Robert, The Genius of China: 3,000 Years of Science, Discovery,
and Invention, with a forward by Joseph Needham. Simon and Schuster, Inc., New York, 1986, p 134), that Cuī Zhī-
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Sūn Sī‐miǎo himself, in his Qiān Jīn Yào Fāng (Important Formulas worth a Thousand Gold Pieces), has
dozens of formulas for goiter. These formulas often use Hai Zao, Kun Bu, and the prepared thyroids of
sheep and deer.20
F. Song Dynasty (960-1279 CE)
In his book Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn (A Treatise on the Three Categories of Pathogenic
Factors of Disease), Chén Yán classified goiter into five types: stone, flesh, sinew, blood, and qi goiters.21
G. Yuan Dynasty (1279-1368 CE)
Zhū Dān-xī wrote a short chapter on “Goiter Qi” in his Dān Xī Zhì Fǎ Xīn Yào (The Heart and Essence of
Dan-xi’s Methods of Treatment).
(In order to treat this,) it is first necessary to abstain from thick flavored (food). Powder 1.2 liang [Hai Zao]
and 1 liang of [Huang Lian], put a small amount in the palm, lap from time to time, and swallow with
saliva. When (the goiter) reduces to 2/3 its size, it is necessary to stop administration (of these
medicinals).22
Notable is Zhū’s emphasis on diet and his use of Huang Lian, both of which I hope to discuss at length in
this book. We present another of Zhu’s formulas, this one for accumulations and conglomerations, in
Chapter 5.
H. Ming Dynasty (1368-1644 CE)
An expanded account of the treatment of goiter is to be found in Xú Chūn-fǔ’s Ming dynasty work Gǔ Jīn
Yī Tǒng Dà Quán (Complete Compendium of Ancient and Modern Medicine) Volume 67.23
Some ancient acupuncture prescriptions are presented in Table 1.
I. Present Times
tī made a distinction between a tumor and goiter may be misleading. “瘿 yǐng” can mean “tumor” or “goiter.” The
actual passage, obtained from http://www.theqi.com/cmed/oldbook/book84/b84_23.html , is “崔: 崔氏云凡水"癭氣
癭可瘥,石癭不可治療氣癭方。” It does not end with, “cannot be cured” but with “cannot be cured by qi goiter
formulas.” For a discussion of the types of “瘿 yǐng” or goiters, see Chapter 5.
20 http://www.zysj.com.cn/lilunshuji/beijiqianjinyaofang549/index.html
21 http://www.zysj.com.cn/lilunshuji/sanyinjiyibingzhengfanglun/index.html
22 Zhū Dān-xī, Dān Xī Zhì Fǎ Xīn Yào (The Heart and Essence of Dan-xi’s Methods of Treatment), trans. Yang
Shou-zhong, Blue Poppy Press, Boulder, CO, 1993, p. 311
23 Xú Chūn-fǔ, Gǔ Jīn Yī Tǒng Dà Quán (Complete Compendium of Ancient and Modern Medicine), Book 2,
Peoples Health Publishing Co., Beijing, 1991
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In one recent study, a general effectiveness rate of 95.74% was achieved using Chinese medicine for
hyperthyroidism.24
Table: Ancient Acupuncture Prescriptions for Goiter25
Author Book Date Prescription
Huáng Fǔ-mì
皇甫 谧
Zhēn Jiǔ Jiǎ Yǐ Jīng
针灸甲乙经
(The ABCs of Acumoxibustion)
259 Tian Rong (SI 17)
Sūn Sī-miǎo
孙思邈
Qiān Jīn Yào Fāng
千金要方
(Priceless Prescriptions)
652 Nao Hui (TB 13), Tian Fu (Lu 3),
Qi She (St 11)
Wáng Zhí-
zhōng
王執中
Zhēn Jiǔ Zī Shēng Jīng
针灸资生经
(Fundamentals of Acumoxibustion)
1220 Fu Bai (GB 10), Qi She (St 11)
Xú Fèng
徐凤
Zhēn Jiǔ Dà Quán
针灸大全
(The Complete Collection of
Acumoxibustion)
1439 Lie Que (Lu 7), Fu Tu (LI 18), Tian Tu
(CV 22), Tian Ding (LI 17), Que Pen
(St 12), Shu Fu (Ki 27), Ying Shu (?),
Shan Zhong (CV 17), He Gu (LI 4),
Shi Xuan (M-UE -1) (bleeding)
24
Zhang Bai-meng, “Observation of Symptoms and Signs in Hyperthyroidism Treated by Acupuncture and
Medication.” Shanghai Journal of Traditional Chinese Medicine, Wang Hong, editor, 1999 Volume 4, p 26. A
clinical trial was undertaken to treat hyperthyroidism with Chinese medicine. 47 individuals with hyperthyroidism
were treated. These individuals were between the ages of 21-61 years with an average age of 37.07. Individuals had
had a history of hyperthyroid disease from between one month to 34 years, with an average of 4.41 years. 32 cases
had had strong side effects from anti-thyroid medicine, or had a recurrence when they stopped the medicine. One
case had recurrent hyperthyroidism after surgery. 14 cases had not been treated before the trial. All patients stopped
their Western pharmaceutical regiment for two weeks during the trial. There was also a control group of 35
individuals.
25 http://www.pacificcollege.edu/pcom_static/alumni/newsletters/winter2008/Goiter.html
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22
Examples of Five Phases Etiology and Pathology Using Three Important
Causes of Thyroid Disease:
Three major causes of thyroid diseases are a unhealthy or “toxic” diet, exposure to toxic chemicals (these
are considered external toxins or heat and toxins by the Warm Disease School and include pesticides,
heavy metals, and petroleum products, to name a few), and emotional stress. Each of these may cause a
pathological progression in the body that follows the various five phases cycles.
A. A Toxic Diet
A toxic diet is one of the fundamental causes of disease. Inappropriate foods first affect the digestive
system, here under the rubric of the stomach/spleen. The American diet contains large quantities of fat,
salt, sugar, alcohol, caffeine, dairy, gluten-containing foods along with those that are charred, raw, or
cold. Additionally, many food products contain toxins from pesticides, residues of antibiotics, and
disease-causing microorganisms. These damage the stomach/spleen or digestive system causing
inflammatory Western diseases such as gastritis, reflux disease, irritable bowel syndrome, colitis, etc. In
the five phases cycle Earth is restrained by Wood, i.e., the spleen is physiologically restrained by the
liver. When the spleen becomes pathological it can “insult” the liver organ and its channel, or allow the
liver to become shi resulting in Western diseases such as fatty liver, liver tumors and cancers, cirrhosis,
etc.
The liver stores the blood in the chong mai and uterus, and the liver channel winds around the genitals.
When the liver and its liver channel are shi or xu, this can result in dysmenorrhea, pre-menstrual
syndrome (PMS), uterine fibroids, ovarian cysts, etc. The liver channel goes up the throat, and shi in that
channel can lead to thyroid disease.
Earth’s mother is Fire. A weak digestion or inflammation in the digestive and/or in the hepatic systems
can affect the heart causing various heart diseases including angina, enlarged heart, heart attacks and
stroke.
Earth restrains Water, inflammation or toxins in the digestive system may damage the kidneys leading to
infections, stones, and fibrosis. Water, in turn, “communicates” with, or restrains Fire, and shi or xu
Water can exacerbate any heart problems.
Of course, once any of the phase-elements or organs is compromised, their relationships with all the other
organs are compromised.
B. Exposure to Toxins
In the above example, we started with a toxic diet affecting the digestive system. We could also have
started with the inhalation of toxins such as pesticides, preservatives, solvents, viruses, radioactive
materials, etc. which damage the lung. Of course chemical exposure can damage any organ through direct
contamination. However, any primary organ affected may cause organ imbalances in any other organ
through the five phases cycles. For example, the lung’s mother in the generating cycle is the heart, and a
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weakened lung can draw qi from and weaken the heart. The lung is the upper source of water, water that
ultimately descends to the kidney and bladder. Chemicals inhaled through the lung will eventually
concentrate in the kidney and bladder causing toxic heat in these organs. This can be seen as a shi mother
phase causing shi in her son phase. The lung restrains the liver, but once the lung is shi it can
“overwhelm” the liver causing liver disharmony. In Western terms, toxins inhaled through the lung will
eventually reach the liver, the major detoxifying organ, and damage it. The lung also communicates with
the throat and toxins inhaled through the lung can infiltrated the thyroid.
C. Emotional Stress
Emotional stress refers to the eliciting of inappropriate, negative, or excessive emotions or the
sublimation of normal emotional responses. Each organ is associated with an emotion or emotions that if
inappropriate or excessive can upset the harmonious functioning of that organ. For example, constant
frustration and repressed anger can damage the liver’s function. Through the five phases cycle, once the
liver’s function is compromised, any other organ, but especially the spleen’s functions, can be affected.
That is, the liver restrains the spleen, but if this restraint becomes excessive the liver can overwhelm the
spleen causing spleen xu. Spleen xu can lead to its mother the heart being overtaxed, and the kidney not
being restrained properly. As the sequelae of the liver’s compromised function works their way through
other organs, each of these organs becomes weakened and more susceptible to environmental insults such
as a poor or toxic diet, air pollution, chemical exposure, micro-organism infections, etc. Thus stress can
be thought of as an indirect cause of auto-immune diseases: it weakens the ability of the organs to respond
appropriately to adverse environmental factors, either depriving the organs of the ability to respond, or
causing an over-response that becomes auto-immune disease.
I. Western Medical Designations and Treatment
A. Nosology
The most common types of hypothyroidism are Hashimoto’s thyroiditis, lymphocytic thyroiditis, thyroid
destruction, pituitary or hypothalamic disease, pituitary injury, and severe iodine deficiency. Here I will
discuss hypothyroidism from any cause except iodine deficiency since this type of hypothyroidism has
practically been eliminated in the USA with the advent of iodized salt, and for which treatment is self-
evident.
B. Epidemiology
In iodine-replete communities, the prevalence of spontaneous hypothyroidism is between 1% and 2%. It
is more common in older women and much more common in women than in men.26
C. Definition
26
Vanderpump MPJ. The Epidemiology of Thyroid Diseases. In: Braverman LE, Utiger RD, eds. Werner and
Ingbar's The Thyroid: A Fundamental and Clinical Text, JB Lippincott-Raven, Philadelphia, 2005, 9th
edition, p.
398-406
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Hypothyroidism is a condition in which the thyroid gland’s production of triiodothyronine (T3) and/or
thyroxine (T4) is compromised. As a result of lowered levels of these hormones in the bloodstream, the
anterior pituitary gland secretes increasing amounts of thyroid-stimulating hormone (also known
as TSH or thyrotropin). See the following Table for “normal” ranges of thyroid hormones.
Table: Blood Levels of T3, T4, and TSH in Hypothyroidism27
T3 and T4 TSH
Low [T3<80; T4 <4.5] High [>3.0-5.0 mIU/L]
D. Etiology and Pathophysiology
Hypothyroidism is usually caused by thyroiditis, that is, inflammation of the thyroid gland that damages
the thyroid gland cells. This inflammation can be autoimmune in nature, as is the case in Hashimoto’s
Thyroiditis, or can be due to a secondary infection after an upper respiratory infection. “Postpartum
thyroiditis” is inflammation resulting from pregnancy. Certain drugs such as Lithium and Amiodarone
may also cause thyroiditis. Other causes include birth defects, radiation treatments, especially to the neck
or brain, and Sheehan syndrome. Finally, hypothyroidism can be caused by the destruction of thyroid
tissue by radioactive iodine used to treat hyperthyroidism, or surgical removal of parts or of the entire
thyroid gland.
E. Risk Factors
Besides the risk factors suggested above, i.e., infections, pregnancy, certain drugs, irradiation or surgery,
the risk factors are as follows. Sex: women are two to eight times more likely to develop hypothyroidism
depending on the age group. Family history: personal or family history of thyroid or other endocrine
gland diseases increases the risk. Age: hypothyroidism risk increases with age, especially after 50 years of
age. Race: whites are most likely, and blacks least likely to develop hypothyroidism. Obesity: Overweight
individuals are more likely to develop hypothyroidism.
F. Symptomatology
Symptoms of hypothyroidism may be divided into early-onset symptoms and later-onset symptoms (if the
disease is not treated). Early onset symptoms include fatigue, weakness, increased sensitivity to cold or
feeling cold, hard stools or constipation, heavier menstrual periods, weight gain, joint or muscle pain, pale
or dry skin with thin brittle hair or fingernails, and depression or melancholy. Later-onset symptoms
include hoarseness and/or slow speech, a decreased sense or taste and smell, a slow pulse, goiter,
puffiness of the face, hands, and feet, numbness of the fingers or hands, thickening of the skin, thinning of
the eyebrows, confusion, and depression or dementia. In addition, in children there is slowed growth,
delayed teething, and slow mental development.
G. Differential Diagnosis 27
The standard for “normal” ranges of hormones is controversial. Different laboratories have different standards.
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25
One must differentiate hypothyroidism from the following diseases: Addison Disease, Anovulation,
Apnea [and other Sleep Disorders], Autoimmune Thyroid Disease and Pregnancy, Cardiac Tamponade,
Chronic Fatigue Syndrome, Constipation, Craniopharyngiomas, DeQuervain’s Thyroiditis, Depression,
Dysmenorrhea, Eosinophilia, Eosinophilia-Myalgia Syndrome, Erectile Dysfunction, Euthyroid Sick
Syndrome, Fibromyalgia, Goiter, Goiter, Lithium-Induced, Goiter, Nontoxic, Hypercholesterolemia,
Familial, Hypercholesterolemia, Polygenic, Hypoalbuminemia, Hypochondriasis, Hypopituitarism
(Panhypopituitarism), Hypothermia, Ileus, Infectious Mononucleosis, Infertility, Infertility, Male, Iodine
Deficiency, Lithium Nephropathy, Lymphomas, Endocrine, Mesenchymal, and Other Rare Tumors of the
Mediastinum, Megacolon, Chronic, Menopause, Myxedema Coma or Crisis, Obesity, Ovarian
Insufficiency, Pericardial Effusion, Pituitary Macroadenomas, Polyglandular Autoimmune Syndrome,
Type I, Polyglandular Autoimmune Syndrome, Type II, Polyglandular Autoimmune Syndrome, Type III,
Prolactin Deficiency, Riedel Thyroiditis, Sleep Disorder, Geriatric Sleep Disorders, Syndrome of
Inappropriate Secretion of Antidiuretic Hormone, Thyroid Lymphoma, Thyroiditis, Subacute, Thyroxine-
Binding Globulin Deficiency.28
H. Diagnosis
Diagnosis includes palpation of the thyroid gland (which may be smaller than normal) and blood tests for
TSH and T4 and T3. Some doctors use total T4 and T3 results, others will require separate tests for free T4
and T3. Other blood tests may include those for cholesterol, complete blood count, liver enzymes,
prolactin, and sodium.
I. Standard Western Medical Treatment and Management
Treatment is directed at replacing thyroid hormone. The most commonly used medication is
Levothyroxine.
J. Prognosis and Complications
Western hormone replacement therapy is expected to be continued throughout the patient’s life. Hormone
levels must be checked with the risk of too high or low dosing. As with all chronic illnesses dependent on
drug therapy, there may be gastroenterological, urinary, emotional, or other side effects. Other
complications include heart disease, increased risk of infection, infertility and miscarriage.
In individuals with untreated hypothyroidism there is a rare risk of myxedema coma. Infection, illness,
exposure to cold, or certain medications may elicit this coma. Symptoms include low body temperature,
shallow breathing, low blood pressure, low blood sugar, and unresponsiveness. Couples with untreated
hypothyroidism are at an increased risk of having offspring with birth defects.
28
http://emedicine.medscape.com/article/122393-differential
© David Frierman & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715 Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
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