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Estimates of the prevalence of thyroid disease vary considerably, particularlyacross populations. One review estimated that 27 million Americans havethyroid disease, with half going undiagnosed.1 There are a few key factors atthe root of the debate about prevalence: (1) symptoms can go unnoticed orbe attributed to a disorder other than thyroid disease,2 (2) testing can beunreliable,3 and (3) as many as 60% of people with thyroid disease areunaware that they have it.4 For those reasons, it’s essential that healthcareproviders look for the signs of thyroid disorders in their patients.

Blackwell J. Evaluation and treatment of hyperthyroidism and hypothyroidism. J Am Acad NursePract. 2004;16(10):422-425.

Gavin LA. The diagnostic dilemmas of hyperthyroxinemia and hypothyroxinemia. Adv Intern Med.1988;33:185-203.

National Academy of Hypothyroidism. How accurate is TSH testing?http://nahypothyroidism.org/how-accurate-is-tsh-testing/. Accessed September 24, 2013.

American Thyroid Association. Prevalence and impact of thyroid disease. Available at:http://www.thyroid.org/media-main/about-hypothyroidism/. Accessed September 24, 2013.

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The cause of hypothyroidism isn’t always known, but stress and anxiety arestrongly associated with diminished thyroid function. The reason for this is therelationship between the thyroid and adrenal glands, two key components ofthe endocrine system. The thyroid produces thyroid hormones thyroxine (T4 )and triiodothyronine (T3). These hormones control how quickly the bodyburns energy and produces proteins; they also aid in controlling how sensitivethe body is to other hormones.

The adrenal glands release epinephrine and cortisol in response to stress.Cortisol is a valuable part of the body’s reaction to stress, but ongoingsecretion of cortisol—as a result of chronic stress—can lead to thyroiddysfunction. Thyroid hormone and cortisol work in concert; when the amountof cortisol is correct, the thyroid functions optimally. However, an excess ofcortisol, particularly over time, triggers the thyroid to slow production,reducing levels of T3 and T4 and also increases the conversion of T4 to reverseT3, the inactive form of T3.

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Homeostasis is the idea that everything wants to come back into balance. Butwhen the body is faced with chronic and repetitive stress, it enters a state ofallostasis. It’s very important to address the stress connection. The problem ofhypothyroidism will not be fully corrected unless and until optimal adrenalresponsiveness is restored.

As practitioners, we need to stop and support. We need to improve sleep—byfar the best medicine—and to decrease stress. People need to rest, relax, andrepair. Right now most of us are in chronic fight or flight mode and are justsurviving. When we intervene in a holistic way and address thyroiddysfunction, especially with the inclusion of stress response modification, wecan make a significant difference in the wellness of our patients.

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Under normal circumstances, a decrease in T3 (active thyroid) results in an increase inTSH. That’s why TSH is considered the gold standard measure of thyroid performance.But the test fails to pick up on a large number of cases of hypothyroidism, and when itdoes pick up on them, the patient is often in dire straits. The American Association ofclinical endocrinologists has called for the upper limit of normal TSH to be changedfrom 5.0 to 3.04 mU/L—that change alone would quadruple the number of diagnoses.

One reason the TSH test is inadequate is that TSH, under negative feedback controlfrom T3, only indicates the pituitary level of T3—not its levels in other parts of thebody, making TSH an inaccurate measure of thyroid status throughout the body.5

Similar inconsistencies exist between TSH and T4 levels, as evidenced by the fact thattreatment with T4 does not necessarily return TSH levels to normal.5 A number ofstudies support this, showing that subclinical values of TSH are not consistent withother indicators of thyroid disorder, such as T4 and T3 levels, or with strong symptomsof hypothyroidism.6–8

National Academy of Hypothyroidism. How accurate is TSH testing? Available at:http://nahypothyroidism.org/how-accurate-is-tsh-testing/. Accessed September 23, 2013.

Bogner U, Arntz HR, Peters H, Schleusener H. Subclinical hypothyroidism and hyperlipoproteinaemia:indiscriminate L-thyroxine treatment not justified. Acta Endocrinol (Copenh). 1993;128(3):202-206.

Gavin LA. The diagnostic dilemmas of hyperthyroxinemia and hypothyroxinemia. Adv Intern Med.1988;33:185-203.

Canaris GJ, Manowitz NR, Mayor G, Ridgway C. The Colorado thyroid disease prevalence study. Arch InternMed. 2000;160:526-534.

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The TSH is intended only to be a screening tool. It can be especiallyunpredictable with age, stress, calorie restriction, and inflammation. That’swhy it’s essential that physicians be aware of the many clinical symptoms ofhypothyroidism. Unfortunately, these symptoms can be associated with otherconditions as well, and that can lead to difficulty in diagnosis. Nonetheless,the presence of hypothyroidism symptoms raises the index of concern for thepresence of hypothyroidism.

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When hypothyroidism is suspected based upon clinical symptoms, a completethyroid panel is indicated. This will help to identify the presence ofhypothyroidism as well as the nature of the condition. Decreased T4 and T3levels indicate primary hypothyroidism, possible secondary to prolongedexposure to cortisol. Elevated reverse T3 is another indication of prolongedhypercortisolemia as the cause of the hypothyroidism. Elevations inautoantibodies indicates the presences of Hashimoto’s thyroiditis andincrease the suspicion of underlying intestinal and immune dysfunction,which is further supported by vitamin D deficiency.

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Because of the unreliability of TSH and as an adjunct to other thyroid tests,other measures can uncover the presence of decreased thyroid function. Onemethod is basal body temperature. A study of 101 individuals withhypothyroidism found a statistically significant correlation between BMT andT3RU; a weaker correlation was found between BMT and T4.9 Basal bodytemperature is a good way to monitor changes over time.

Another clinical test for hypothyroidism is the Achilles reflex return, a methodthat has been used with some reliability since at least 1924. A number ofstudies have found some correlation between Achilles reflex time/durationand hypothyroidism. The majority conclude that although a correlation exists,Achilles reflex time alone is not an accurate indicator of hypothyroidism butcan be used in conjunction with other tests to support or confirm diagnosis.10

Sehnert KW, Croft AC.Basal metabolic temperature vs. laboratory assessment in "posttraumatichypothyroidism". J Manipulative Physiol Ther. 1996;19(1):6-12.

Robson AM, Hall R, Smart GA. A critical evaluation of the tendon reflex measurement as an index ofthyroid function. Postgrad Med J. 1965;41:518-525.

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Deficiency of certain vitamins may contribute to hypothyroidism. Theseinclude vitamins B, D, E, and A.11–14 Supplementation with iron, selenium, zinc,and iodine can also help to restore optimal thyroid function.15 In the case ofautoimmune thyroiditis, restoration of intestinal eubiosis and optimalpermeability is indicated. Omega-3 essential fatty acids and multi-strainprobiotics are two foundational strategies.

Jabbar A, Yawar A, Waseem S, et al. Vitamin B12 deficiency common in primary hypothyroidism. JPak Med Assoc. 2008;58(5):258-261.

Shomon M. Why is vitamin D so important to thyroid patients? Available at:http://thyroid.about.com/b/2010/09/30/vitamin-d-important-thyroid.htm. Accessed September25, 2013.

Sarandöl E, Taş S, Dirican M, Serdar Z. Oxidative stress and serum paraoxonase activity inexperimental hypothyroidism: effect of vitamin E supplementation. Cell Biochem Funct.2005;23(1):1-8.

Farhangi MA, Keshavarz SA, Eshraghian M, Ostadrahimi A, Saboor-Yaraghi AA. The effect of vitaminA supplementation on thyroid function in premenopausal women. J Am Coll Nutr. 2012;31(4):268-274.

Zimmermann MB, Köhrle J. The impact of iron and selenium deficiencies on iodine and thyroid

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metabolism: biochemistry and relevance to public health. Thyroid. 2002;12(10):867-878.

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One of the main strategies for restoring optimal thyroid function must be reducing stressand improving sleep in order to reduce elevated cortisol levels. A number naturalingredients reduce cortisol and stress levels and also improve sleep. One example isAshwagandha root (Withania somnifera), a plant whose species name is Latin for “sleep-inducing.” L-theanine, an amino acid that occurs naturally in the tea plant, has beenshown to enhance relaxation16 and reduce psychological and physiological stress.17

Magnolia officinalis has been shown to decrease cortisol and improve psychologicalmood state in moderately stressed subjects.18Additionally, research suggests thatphosphatidylserine, a dietary supplement made from sunflower or soy derivatives, maycounteract stress-induced activation of the hypothalamic-pituitary-adrenal axis.19

Similarly, a derivative from the plant extract Epimedium brevicornum possessesantidepressant-like activities that are at least in part mediated by improving theabnormalities in the functioning of the hypothalamic-pituitary-adrenal axis.20 NOTE: E.brevicornum and E. korneanum are interchangeable.

Vuong QV, Bowyer MC, Roach PD. L-Theanine: properties, synthesis and isolation from tea. J Sci Food Agric.2011;91(11):1931-1939.Kimura K, Ozeki M, Juneja LR, Ohira H. L-Theanine reduces psychological and physiological stress responses. BiolPsychol. 2007;74(1):39-45.Talbott SM, Talbott JA, Pugh M. Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisoland psychological mood state in moderately stressed subjects. J Int Soc Sports Nutr. 2013;10(1):37.Monteleone P, Maj M, Beinat L, Natale M, Kemali D. Blunting by chronic phosphatidylserine administration of thestress-induced activation of the hypothalamo-pituitary-adrenal axis in healthy men. Eur J Clin Pharmacol.1992;42(4):385-388.Pan Y, Kong LD, Li YC, Xia X, Kung HF, Jiang FX. Icariin from Epimedium brevicornum attenuates chronic mildstress-induced behavioral and neuroendocrinological alterations in male Wistar rats. Pharmacol Biochem Behav.

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2007;87(1):130-140.

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