The thyroid is a butterfly-shaped endocrine gland in the neck responsible for producing and releasing thyroid hormones into the bloodstream. Thyroid hormones thyroxine (T4) and triiodothyronine (T3) are responsible for regulating many metabolic and essential bodily functions, including cardiovascular function, body temperature, body weight, nervous system function, digestion, growth and development, menstruation, muscle contractions, breathing, and waste elimination. (1)
Hashimoto's thyroiditis is an autoimmune condition that can affect thyroid function. In developed countries, it is a common cause of hypothyroidism and is estimated to affect 5% of Americans. Women are 4-10 times more likely to develop Hashimoto's disease than men, especially between the ages of 30-50. (2)
Hypothyroidism is most commonly identified when a screening serum thyroid stimulating hormone (TSH) comes back elevated. However, an annual screening of TSH is estimated to miss 7% of hypothyroid cases. Additionally, thyroid autoantibodies are detectable in patients up to years before clinical signs and symptoms appear. Advanced screening methods and integrative approaches may help healthcare providers to intervene in the early stages of Hashimoto's thyroiditis and address factors contributing to autoimmunity to support better health outcomes.
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What is Hashimoto's Disease?
Hashimoto's disease (also called chronic lymphocytic thyroiditis and autoimmune thyroiditis) is an autoimmune form of hypothyroidism that accounts for 90% of adult hypothyroidism. Autoimmunity occurs when the body's immune system produces autoantibodies to self-tissues, which may lead to tissue inflammation and changes in tissue function. In Hashimoto's thyroiditis, antibodies formed against thyroglobulin (TG) and thyroid peroxidase (TPO) can affect the thyroid's ability to produce hormones and may lead to changes in thyroid function over time.
Hashimoto's Disease Symptoms
The initial stages of Hashimoto's can affect thyroid cells and lead to an increased release of thyroid hormone into the bloodstream, presenting as hyperthyroidism with symptoms like increased appetite, sweating, heart palpitations, diarrhea, insomnia, and anxiety.
However, after this period, due to changes in thyroid capacity, signs and symptoms of hypothyroidism may appear, potentially affecting many organ systems in the body, including (3):
- Dry, thinning hair and skin
- Brittle nails
- Loss of the outer third of eyebrows
- Puffy face
- Enlarged thyroid
- Slow heartbeat
- Muscle and joint pain
- Weight gain
- Constipation
- Cold intolerance
- Depression
- Fatigue
- Forgetfulness
- Menstrual disorders
- Infertility
If not managed, hypothyroidism can be associated with chronic health issues like heart disease, heart failure, hypertension, and high cholesterol. Myxedema is a serious condition related to long-term unmanaged hypothyroidism that occurs when the body's vital processes slow down, presenting as profound lethargy and unconsciousness. (3)
What Causes Hashimoto's Disease?
All autoimmune diseases are known to be multifactorial, arising from the interplay of environmental factors in genetically predisposed individuals, which may lead to immune changes, loss of self-tolerance, and the production of autoantibodies.
Specific factors that may play a role in the development of Hashimoto's include selenium and vitamin D levels, iodine intake, infections, certain medications, stress, intestinal permeability, and environmental exposures. (3-5)
The presence of acute and chronic infections may influence autoimmunity through molecular mimicry. This occurs when similarities between foreign and self-proteins may lead to the activation of immune cells that react to self-tissues. Infectious agents that have been studied in relation to Hashimoto's include Helicobacter pylori, Yersinia enterocolitica, Candida albicans, Epstein-Barr virus (EBV), and Borrelia burgdorferi. (4, 6)
Exposure to heavy metals and certain chemicals, such as those in plastics and pesticides, may contribute to changes in intestinal health, inflammation, and thyroid autoimmunity by affecting normal detoxification and endocrine pathways. (4)
Functional Medicine Labs to Test for Root Cause of Hashimoto's Disease
Ordering and interpreting a comprehensive panel of specialty tests, and comparing a patient's results to optimal reference ranges, may support the early identification of autoimmune thyroid conditions and the factors contributing to thyroid changes.
Thyroid Panel
A complete thyroid panel, including TSH, free T3 and T4, total T3 and T4, reverse T3, and thyroid antibodies (anti-TPO and anti-TG), is important in assessing autoimmune thyroid conditions. Ordering the above thyroid biomarkers ensures a comprehensive evaluation of thyroid hormone synthesis, conversion, and autoimmunity to identify early thyroid changes and understand the underlying mechanisms. Elevated TSH, low T4 and T3 values, and elevated anti-TPO and/or anti-TG are often associated with Hashimoto's thyroiditis.
Standard reference ranges help detect overt thyroid conditions; however, as discussed above, thyroid autoimmunity can occur in the background for years before overt Hashimoto's thyroiditis is seen on standard labs. In addition, many patients may experience hypothyroidism symptoms despite their labs returning as "normal" based on standard reference ranges. Evaluating the thyroid panel using optimal/functional reference ranges may help in the detection of thyroid changes so that early interventions can be considered to support thyroid health. (7)
Food Sensitivities
Unidentified food sensitivities may contribute to increased intestinal permeability, systemic inflammation, and the formation of autoimmune responses. Food sensitivities often cause vague and delayed reactions and, because of this, can be challenging to identify without specialty testing. Food sensitivity testing can help pinpoint specific food-related factors associated with an individual's Hashimoto's disease so that dietary modifications can be personalized to their needs.
Gluten is often discussed in relation to thyroid autoimmunity because of its similar appearance to an enzyme called transglutaminase in the thyroid gland. Some evidence suggests a connection between gluten intolerance and thyroid autoimmunity. A blood panel can help screen for celiac disease and gluten sensitivity, which may contribute to thyroid health.
Infections
The Pathogen-Associated Immune Reactivity Screen (Array 12) by Cryex Laboratories is a broad all-in-one infectious screening to help identify active, chronic, and latent infections that may influence autoimmune conditions.
Environmental Toxins
Combining urinary tests to screen for heavy metals and chemicals can help identify toxin exposure when the patient's history does not obviously identify the causative agent. These panels may help identify toxic agents contributing to health changes and provide a picture of how well the patient's detoxification pathways are functioning.
Functional Medicine Labs to Test That Can Help Individualize Support for Hashimoto's Disease
Functional medicine labs can help practitioners personalize support options for their patients. Below are some of the most common labs considered for patients experiencing Hashimoto's thyroiditis.
Cardiometabolic Assessment
Hypothyroidism can be associated with high cholesterol, changes in blood sugar levels, and liver function. A comprehensive metabolic panel (CMP) and lipid panel can be used to assess cardiovascular and liver health in relation to thyroid levels that may further influence thyroid autoimmunity.
Comprehensive Stool Test
The gut-thyroid axis refers to the communication between the intestinal microbiome and the thyroid through the metabolic actions of beneficial gut microbes. A comprehensive stool analysis assesses digestive function, intestinal inflammation, and the intestinal microbiome to screen for infection, dysbiosis, and other gastrointestinal factors that may impact the gut-thyroid axis.
Comprehensive Hormone Panel
Acute and chronic stress may cause changes in cortisol secretion, which can influence the thyroid axis, potentially affecting thyroid hormone synthesis, secretion, and conversion. Stress and hypothyroidism, together and independently, can cause menstrual cycle irregularities and other hormonal symptoms. A comprehensive hormone panel measures cortisol and sex hormone metabolites for a holistic evaluation of the endocrine system.
Micronutrient Panel
Nutrient imbalances may influence thyroid function, inflammation, and immune regulation. A nutritional assessment measures intra- and extracellular levels of essential vitamins, minerals, antioxidants, amino acids, and fatty acids. These results can be used to target therapies to meet specific nutritional and clinical goals.
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Conventional Approaches for Hashimoto's Disease
The conventional approach for managing Hashimoto's disease often involves levothyroxine, a replacement for T4, to help bring TSH back into the normal reference range. Other thyroid replacement medications, such as liothyronine (replacement T3) and desiccated thyroid preparations, are not emphasized in conventional medical approaches.
Functional Medicine Approaches for Hashimoto's Disease
A functional medicine approach to Hashimoto's disease may differ from its conventional counterpart by focusing on addressing autoimmunity as a factor in hypothyroidism. While thyroid replacement is often considered for patients to support thyroid hormone levels and provide symptomatic relief, an integrative medicine plan may also incorporate natural modalities to support the patient holistically and improve overall well-being.
Diet and Nutrition Considerations for Hashimoto's Disease
A nutrient-dense anti-inflammatory diet, such as the autoimmune protocol (AIP) diet, may be tailored to the patient's dietary preferences and sensitivities. A referral to a functional nutritionist may be indicated because making nutritional modifications while meeting sufficient caloric and nutrient needs can be challenging.
Those with concurrent celiac disease or gluten sensitivity may consider removing gluten from the diet; studies have explored the association between a gluten-free diet and changes in thyroid autoantibodies.
Research has explored the correlation between iodine intake and thyroid antibody levels. Some studies suggest that daily iodine restriction to less than 100 mcg may support thyroid function. Processed foods with iodized salt, seaweed, dairy, and dietary supplements are typical sources of iodine intake. (8-10)
Supplement Considerations for Hashimoto's Disease
Dietary supplements may complement dietary interventions, lifestyle modifications, and other complementary and integrative medicinal modalities to support factors associated with autoimmunity and thyroid health.
Myo-Inositol
Myo-inositol is a naturally occurring sugar the body makes that is important in hormonal signaling. It may support iodine oxidation needed to produce thyroid hormones and help manage oxidative stress and inflammation to support thyroid cells. Supplementation of Myo-inositol has been studied for its potential effects on TSH, thyroid antibodies, and thyroid size (16, 17).
Dose: 600 mg daily
Duration: at least six months
Selenium
Selenium is an antioxidative trace mineral that plays a role in supporting metabolism, the immune system, and thyroid function. Selenium supplementation in patients with Hashimoto's has been studied for its potential effects on TPO antibodies, thyroid hormones, and hypothyroid symptoms. (11-13)
Dose: 200 mcg daily
Duration: at least three months
Glutathione
Glutathione is often referred to as the body's master antioxidant. Glutathione levels are a characteristic of oxidative stress and the development of immunological production of thyroid antibodies leading to Hashimoto's disease. Glutathione can be taken orally or applied topically to the thyroid.
Dose: Apply one pump topically to the thyroid three times daily
Duration: at least one month
Vitamin D
Vitamin D levels are often discussed in relation to inflammatory reactions and thyroid autoimmune conditions like Hashimoto's. One study found that a significant percentage of Hashimoto's patients were deficient in vitamin D and that supplementation restored vitamin D status and affected anti-TPO levels. Numerous studies have explored the relationship between vitamin D and self-tolerance and inflammation, as shown by the inverse relationship between 25-hydroxyvitamin D levels and thyroid antibody levels. (14, 15)
Dose: 2,000 IU daily
Duration: at least six months
When to Retest Labs
It is suggested that, at minimum, TSH be remeasured 6-8 weeks after changing a patient's medications and/or supplements to assess thyroid status accurately. Note that changes to thyroid antibodies may take up to three months to measure on labs. Once the patient reaches a balanced thyroid state, lab monitoring frequency can be reduced to every 6-12 months.
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Summary
Given the thyroid's far-reaching effects on the body, managing Hashimoto's hypothyroidism can quickly become complex. A functional medicine approach to Hashimoto's disease appreciates the "Hashimoto's Web" - the notion that autoimmunity and underactive thyroid are not limited to the thyroid and, instead, may affect the whole body. The impacts of hypothyroidism on every body system may influence autoimmunity, creating a cycle of systemic inflammation and dysregulation. The functional medicine doctor's role is to address this web delicately; and, in doing so with an integrative approach, may help restore balance, health, and well-being to the Hashimoto's patient.
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