Assessment and Treatment

(1)

Assessment and Treatment

of Thyroid Dysfunction

Dan Lukaczer, ND

Applying Functional Medicine in Clinical Practice

February 2011 February 2011

(2)

(3)

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Assessment and Treatment

of Thyroid Dysfunction

Dan Lukaczer, ND

Applying Functional Medicine in Clinical Practice

February 2011 February 2011

(5)

Assessment and Treatment of

Hypothyroid Dysfunction

yp

y

(6)

Clinical Objectives…in

Plain Speak

Plain Speak…

 What do we know that causes the thyroid to go awry?

 How do you recognize it clinically?  What do you test for?

(7)

(8)

Metabolic Effects of

Suboptimal Thyroid Function

Cardiovascular health:

 Decreased T3

production will raise LDL due to decreased metabolism of fats

 Decreased T3 lowers

the availability of cardioprotective

essential fatty acids

 Inadequate T3 lowers

oxygen consumption,

hi h t ib t t

which contributes to lipid peroxidation and free radical damage

(9)

Metabolic Effects of

 Worsens glucose tolerance  Increases insulin resistance

(10)

Summary of Metabolic Effects of

Suboptimal Thyroid Function

 Fatigue (mental and physical)g ( p y )  Weight gain

 Cardiovascular health

 Dyslipidemias  Atherogenesis

 Glucose intolerance/insulin resistance  Poor pregnancy outcome

Wartofsky L, Van Nostrand D, Burman KD.

Wartofsky L, Van Nostrand D, Burman KD. ObstetObstet GynecolGynecol SurvSurv. . 2006

(11)

Prevalence of Low Thyroid

Function in the United States

O

t f

One out of

every seven

y

adults

Canaris, GJ, et al. The Colorado thyroid disease y prevalence study. Arch Intern Med. 2000;160(4): 526-34.

(12)

Why so much Thyroid

Dysfunction?

 Stress  Infection/Inflammation  Dietary factors  Gluten  Goitrogens Lo calorie diet  Low-calorie diet  Nutritional insufficiencies Medications  Medications  Toxins

(13)

Another Way of Viewing

Antecedents, Triggers, and Mediators of

Thyroid Dysfunction

----PTSDE

PTSDE--

-- Production or synthesis of HPT axis hormones

 T4, T3, TSH, TRH

 Transport/distribution/metabolism of hormones

 Conversion to T3 and/or RT3

 Sensitivity at the cellular level of thyroid hormonesSensitivity at the cellular level of thyroid hormones

 Receptor sensitivity

 Detoxification/metabolism of thyroid hormones

 Excretion of thyroid hormones

(14)

(15)

Stress and Thyroid Function

Stress suppresses:

H h l i l f TRH

 Hypothalamic release of TRH  Pituitary release of TSH

 Thyroid gland production of thyroid

(16)

Stress and Thyroid Function

Increased urinary cortisol metabolites have been associated with reduction in

i h l th id h t b li d peripheral thyroid hormone metabolism and symptoms of functional hypothyroidism

Vantyghern

Vantyghern MC, et al. J MC, et al. J EndocrinolEndocrinol Invest. 1998;21(4):Invest. 1998;21(4): 219

(17)

Infection/Inflammation and

Thyroid Function

Cytokines block conversion of T4

to T3

(18)

Diet: Gluten, Celiac Disease,

and Thyroid Function

Study of 241 untreated celiac disease y patients vs. 212 controls confirmed that patients with celiac disease are at

increased risk for developing thyroid increased risk for developing thyroid disease with an overall threefold higher frequency than in controls (30% vs. 11%)

Sategna

Sategna--GuidettiGuidetti C, et al. Am JC, et al. Am J GastroenterolGastroenterol. 2001;96(3):. 2001;96(3): Sategna

Sategna GuidettiGuidetti C, et al. Am J C, et al. Am J GastroenterolGastroenterol. 2001;96(3): . 2001;96(3): 751

(19)

Celiac Disease and

Th

id D f

ti

Th

id D f

ti

Thyroid Dysfunction

Sategna

Sategna--GuidettiGuidetti C et al Am JC et al Am J GastroenterolGastroenterol 2001;96(3):2001;96(3): Sategna

Sategna--GuidettiGuidetti C, et al. Am J C, et al. Am J GastroenterolGastroenterol. 2001;96(3): . 2001;96(3): 751

(20)

After 1 year on a gluten-free diet:

y

g

 Subclinical hypothyroidism normalized in 10

of 14 (71%) patients with non-autoimmune disease

disease

 In three of five (60%) patients with

autoimmune thyroid disease (AIT), there was a hift t AIT ith th idi

shift to AIT with euthyroidism

 In four of five subjects with no improvement in

thyroid function, compliance with the diet was thyroid function, compliance with the diet was poor

Sategna

Sategna--GuidettiGuidetti C, et al. Am J C, et al. Am J GastroenterolGastroenterol. 2001;96(3): . 2001;96(3): 751

(21)

Diet:

Diet: Goitrogens

Goitrogens, Soy,

, Soy,

Animal studies show suppression But Animal studies show suppression…But…

Chang HC,

(22)

Diet: Humans, Soy,

 When initiating soy-formula feeding in

infants with congenital hypothyroidism the infants with congenital hypothyroidism, the L-thyroxine dose should be increased

because of significant reduction in intestinal absorption

absorption.

 Conversely, when soy feeding is

discontinued, the L-thyroxine dose should be decreased.

Jabbar

Jabbar MA, MA, LarreaLarrea J, Shaw RA.J, Shaw RA. J Am Coll J Am Coll NutrNutr. . 1997;16(3):280

1997;16(3):280--8282 1997;16(3):280

(23)

Diet: Humans, Soy,

 Case report of a 45-year-old woman who had

hypothyroidism after a near-total thyroidectomy and yp y y y radioactive iodine ablative therapy

 Required unusually high oral doses of levothyroxine to

achieve suppressive serum levels of free T4 and TSH

 She had routinely been taking a "soy cocktail" protein

supplement immediately after her levothyroxine

 Separation of the intake of the soy protein cocktail from

th l th i lt d i tt i t f i

the levothyroxine resulted in attainment of suppressive serum levels of free T4 and TSH with use of lower

doses of levothyroxine

Bell DS,

(24)

Three Human Studies with

No Clinical Effect

“Authors suggested were so minor as to not be of physiologic importance”

physiologic importance

“Intragroup differences were statistically indistinguishable at 6 months”

indistinguishable at 6 months ,

“Authors concluded that the changes were of such a

ll it d th t th lik l t b

small magnitude that they were unlikely to be clinically important”

(25)

Diet: Humans, Soy,

 Three soy powders containing different levels of

isoflavones (one powder containing virtually none a isoflavones (one powder containing virtually none, a second a modest level [1mg/kg] and a third with a high level [2mg/kg]) were consumed in a crossover design study by 18 postmenopausal women for 3 months each.

 Thyroid hormones assayed had only small changes

between the groups, which authors suggested were

i t t b f h i l i i t

so minor as to not be of physiologic importance.

Duncan AM, Underhill KE, Xu X, et al. J

Duncan AM, Underhill KE, Xu X, et al. J ClinClin EndocrinolEndocrinol Metab

(26)

Diet: Humans, Soy,

 Randomized, double-blind, placebo-controlled study

of the effect on thyroid function of a daily

supplement containing 90 mg of total isoflavones per day vs. placebo in 38 postmenopausal women

 TSH, T4, and T3 were measured at baseline and after

90 d 180 d

90 and 180 days

 Intragroup differences for all three measures were

statistically indistinguishable at 6 months, and levels ere similar bet een the isofla one s pplement and were similar between the isoflavone supplement and placebo groups at each measurement

Bruce B,

Bruce B, MessinaMessina M, M, SpillerSpiller GA.GA. J Med Food. 2003;6: J Med Food. 2003;6: 309

(27)

Diet: Humans, Soy,

 73 postmenopausal women randomly divided into three

groups and each given powders containing 40 g protein

g p g p g g p

 The protein contained: (group one) casein from nonfat

dry milk, (group two) isolated soy protein containing 56 mg isoflavones, (group three) isolated soy protein

t i i 90 i fl d f 6 th

containing 90 mg isoflavones; consumed for 6 months

 Soy protein groups had minimal effects on thyroid

function

Th th l d d th t th h f h

 The authors concluded that the changes were of such a

small magnitude that they were unlikely to be clinically important

Persky

(28)

Does this mean that soy would never

have a clinically significant effect on

thyroid function? My take….

 Concerns are based primarily on in vitro research

 Concerns are based primarily on in vitro research,

animal studies, and older reports of goiter in infants fed soy formula not fortified with iodine

 Some people are likely “thyroid sensitive” to soy  Some people are likely thyroid sensitive to soy

protein and/or its isoflavones

 It is reasonable to be cautious in people with a

history of thyroiditis or on a poor diet that may be history of thyroiditis or on a poor diet that may be marginally deficient in iodine

 For the broad majority of individuals, normal dietary

soy is unlikely to have any long-term negative y y y g g effects on thyroid function

(29)

Diet: Extremes in Caloric

Intake Affect Thyroid Function

 “During caloric restriction serum T3 concentrations

decrease as a consequence of its reduced production decrease as a consequence of its reduced production rate from peripheral deiodination of T4. Opposite,

serum RT3 concentrations markedly increase as a result of its decreased metabolic clearance rate.”

 “During caloric overfeeding serum T3 concentrations

increase whereas serum RT3 concentrations decrease. In this condition the production rate of T3 increases.

D i l i t i ti d f di T4

During caloric restriction and overfeeding serum T4 concentrations and its production and degradation are not modified.”

Roti

Roti EE MinelliMinelli R Salvi MR Salvi M IntInt JJ ObesObes RelatRelat MetabMetab DisordDisord Roti

Roti E, E, MinelliMinelli R, Salvi M. R, Salvi M. IntInt J J ObesObes RelatRelat MetabMetab DisordDisord. . 2000;24

(30)

Diet: Nutritional Insufficiencies

Factors that either produce vitamin A (retinol) insufficiency or prevent the

conversion of vitamin A to retinoic acid lt i d d th id l

may result in reduced thyroid nuclear signaling

Feart

Feart C, Pallet V, Boucheron C, et al. C, Pallet V, Boucheron C, et al. EurEur J J EndocrinolEndocrinol. . 2005;152:449

2005;152:449--458.458. 2005;152:449

(31)

Diet: Nutritional Insufficiencies

A study of older-aged individuals found that low T3-to-T4 ratio was related to impaired zinc and/or

to-T4 ratio was related to impaired zinc and/or

selenium status. Selenium and zinc both play a role in promoting proper thyroid function:

 Selenium through its deiodination and the activity  Selenium through its deiodination and the activity

of thyroid hormones

 Zinc by its role as a cofactor for the thyroid

t receptor

Nishiyama

Nishiyama S, S, FutagoishiFutagoishi--SuginoharaSuginohara Y, Y, MatsukuraMatsukura M, et al.M, et al. J Am Coll J Am Coll Nutr

Nutr 1994;13:621994;13:62--6767 Nutr

Nutr. 1994;13:62. 1994;13:62--67.67. Olivieri

Olivieri O, O, GirelliGirelli D, D, StanzialStanzial AM, et al. AM, et al. BiolBiol Trace Elem Res. Trace Elem Res. 1996;51:31

(32)

Diet: Nutritional Insufficiencies

Selenium supplements increased the circ lating seleni m le els

circulating selenium levels.

Supplementation was associated with modest changes in thyroid hormones, g y , with an earlier normalization of T4 and RT3 plasma levels.

Berger MM, Reymond

Berger MM, Reymond MJMJ, , ShenkinShenkin A, et al. Intensive A, et al. Intensive Care Med. 2001;27:91

(33)

Medications and Thyroid Function

Medications that block conversion of T4 to T3:

B t bl k

 Beta blockers

 Birth control pills

 Estrogen replacement  Lithium

 Phenytoin

 Theophylline  Chemotherapy

(34)

The T4-T3 conversion

Summary of 5’ deiodinase Summary of 5’-deiodinase inhibitors:  Medications  Selenium deficiencyy  Inadequate protein, excess carbohydrates  Chronic illness

(cytokines free radicals) (cytokines, free radicals)

 Compromised liver or kidney function  Cd, Hg, Pb, herbicides, , g, , , pesticides  Stress (emotional or physiological)  Excess cortisol  Excess cortisol, catecholamines  Excess estrogen

(35)

Thyroid

Gland

RT3 Factors involved in conversion

• Selenium • Zinc

T3 conversion inhibitors

• Stress

• Inflammation (cytokines, etc.)

Toxins RT3 conversion stimulators • Stress • Trauma • Toxins • Infections • Liver/kidney dysfunction • Medications • Low-calorie diet

(36)

Toxins: Mercury, Iodine,

 Exposed subjects with the lowest urinary iodine

(< 67.8 nmol mmol[-1] Cr) had higher serum

concentrations of RT3 and a higher free T4 free T3 ratio concentrations of RT3 and a higher free T4–free T3 ratio than the other subjects, suggesting that a low

concentration of iodine in urine may be a risk factor for increased serum concentrations of RT3 and the

free T4–free T3 ratio in subjects exposed occupationally to mercury vapor.

 The study could indicate a slight effect of low mercury

th f ti f th t I

vapor exposure on the function of the enzyme type I iodothyronine deiodinase, possibly modified by

comparatively low urinary iodine concentrations.

Ellingsen DG Efskind J Haug E et al J Appl Toxicol Ellingsen DG, Efskind J, Haug E, et al. J Appl Toxicol. 2000;20(6):483-9.

(37)

Summary: Antecedents, Triggers, and

Mediators of Thyroid Dysfunction

Thyroid

Gland

Factors involved in production • Nutrients: iodine, tyrosine, zinc, it i E B2

+

Production inhibitors • Stress

• Infection, trauma, radiation,

medications Fl id ( t i t t i di )

-Gland

vitamins E, B2, B3, B6, C • Antioxidants

• Fluoride (antagonist to iodine) • Toxins: pesticides, Hg, Cd, Pb • Autoimmune disease: celiac

RT3

+

-Factors involved in conversion

• Selenium • Zinc

+

T3 conversion inhibitors

• Stress

• Inflammation (cytokines, etc.)

Toxins RT3 conversion stimulators • Stress • Trauma

+

Factors involved in cellular sensitivity • Toxins • Infections • Liver/kidney dysfunction • Medications • Low-calorie diet Free T3 Inhibitors • Estrogen Cell cellular sensitivity • Vitamin A • Exercise • Zinc

+

(38)

Clinical Objectives…in

Plain Speak

Plain Speak…

 What do we know that causes thyroid to go awry?

(39)

Assessing Thyroid Function

 History

Ph i l i

 Physical exam signs  Symptoms

 Basal body temperature  Laboratory testing

(40)

Important Signs

of Low Thyroid Function

 Dry skin, elbow keratosis, brittle nails  Diffuse hair loss

 Puffy face, swollen eyelids; edema in

l f t h d legs, feet, hands

 Elevated cholesterol, generally seen as

LDL increases LDL increases

 Easy bruising

 Prolonged Achilles tendon reflex time  Prolonged Achilles tendon reflex time

(41)

Important Symptoms

 Fatigue, usually persistent, especially

ki l t d th i on waking; less toward the evening

 Cold intolerance, with cold extremities  Slow speech, movement, heart rate

 Morning stiffness, arthralgias, muscle

pain/cramps particularly in calves pain/cramps particularly in calves, thighs, and upper arms

(42)

Important Symptoms

(cont.)

 Memory and concentration problems  Diffuse headache migraines

 Diffuse headache, migraines  Depression; melancholia

 Constipation: hard bowel movements  Constipation: hard bowel movements

(43)

Assessing Metabolic Rate:

Basal Body Temperature

Procedure (in Tool Kit):

 Shake down a thermometer to below 95 degrees and

place it by the bed before going to sleep.

 Upon waking, place the thermometer under the

armpit for 10 minutes armpit for 10 minutes.

 Remain resting.

 Record the temperature for at least 3 consecutive

mornings preferably at the same time of day mornings, preferably at the same time of day.

 Note: Menstruating women should record where

they are in their cycle as BBT increases with ovulation

(44)

Laboratory Testing:

Is Blood the Best Medium?

Options: blood vs. urine vs. saliva Blood is easily available

 Blood is easily available

 Blood tests are covered by insurance  Blood is easier then 24-hour urine

 Blood is easier then 24 hour urine

 Blood has more documentation then saliva  Blood levels have been shown to be

consistent (though the brain can have different levels)

J

J ClinClin EndocrinolEndocrinol MetabMetab 2005 (Sept 20): E2005 (Sept 20): E publishedpublished J

(45)

Testing HPT Axis:

Testing the Ability of the

Pituitary to Respond to TRH

TRH stimulation test:

 Parenteral (IV or IM) TRH: 0.2–0.5 mg

 Oral 50 mg has been used

 Measure venous TSH at timed intervals

 Expect twofold (> 4.0 mIU/mL) increase in TSH and less than 30 mIU/mL rise

Laboratory Medicine Practice Guidelines,

Laboratory Medicine Practice Guidelines, NACBNACB,, Laboratory Medicine Practice Guidelines,

Laboratory Medicine Practice Guidelines, NACBNACB, , www.nacb.org/lmpg/main.stm, 2002:32.

(46)

Testing HPT Axis:

Thyroid

Thyroid Stimulating Hormone

Stimulating Hormone

Thyroid

Thyroid--Stimulating Hormone

Stimulating Hormone

TSH: Third-generation “highly sensitive” assay:

assay:

 Sensitivity to 0.02 mIU/mL

 Upper limit: went from ~10 to  Upper limit: went from 10 to

~4.5 mIU/mL in past 20 years  Cautions:

 Testing TSH indicates only pituitary

production

 Pituitary hormone levels alone are not  Pituitary hormone levels alone are not

sufficient to measure the function of the gland they regulate

(47)

TSH Assessment

What Is ‘Abnormal’?

What Is Abnormal ?

In 2002, the National Academy of Clinical

Biochemistry (NACB) issued new guidelines for th di i d it i f th id

the diagnosis and monitoring of thyroid disease.

 NACB reported that the current TSH p

reference range may be too wide, citing

newer research suggesting that these older ranges included individuals with borderline g thyroid disease

 When more sensitive screening was

performed 95% of the population tested performed, 95% of the population tested actually had a TSH level between 0.4 and 2.5 uIU/ml

(48)

TSH Assessment:

What Is ‘Abnormal’?

 Soon thereafter, The American College of Clinical Endocrinologists suggested that Clinical Endocrinologists suggested that a new reference range of 0.3–3.0 uIU/ml be adopted.

 However, many labs and clinicians have not adopted these new recommendations, and debate continues.

and debate continues.

American Association of Clinical Endocrinologists medical American Association of Clinical Endocrinologists medical

guidelines for clinical practice for the evaluation and treatment of guidelines for clinical practice for the evaluation and treatment of

g p

hyperthyroidism and hypothyroidism.

hyperthyroidism and hypothyroidism. EndocrEndocr PractPract, 2002. 8(6): p. , 2002. 8(6): p. 457

(49)

Is TSH the Ultimate

Diagnostic Criteria?

Beyond the deliberation of the TSH reference range is the

question: Should one use TSH as the sole diagnostic criteria for thyroid dysfunction?

There is debate on correlation bet een h poth roid s mptoms

 There is debate on correlation between hypothyroid symptoms

and TSH levels. There are limitations to the sensitivity of TSH:

 Can TSH reflect variations in target cell sensitivity or T4 or

T3 resistance, where cells fail to respond properly to these T3 resistance, where cells fail to respond properly to these hormones?

 Can TSH reflect peripheral T4 to T3 conversion

dysfunction?

 Can TSH reflect cellular transport problems where there is

faulty transport of T4 or T3 into mitochondria?

 Can TSH reflect displacement of thyroid hormones from

cellular receptors by RT3 antithyroid antibodies or other cellular receptors by RT3, antithyroid antibodies, or other substances?

(50)

Is TSH the Ultimate

Diagnostic Criteria?

“TSH reference ranges may in fact be but d t f d t ti di i a crude parameter for detecting disease in an individual patient and we should not be confusing a population reference range g p p g

with an individual’s ‘normal range’.”

Andersen S, Pedersen KM,

Andersen S, Pedersen KM, BruunBruun NH, NH, LaurbergLaurberg P. J P. J ClinClin Endocrinol

Endocrinol MetabMetab 2002;87(3):10682002;87(3):1068--7272 Endocrinol

(51)

Testing HPT Axis: T3, T4, RT3

Measuring total or free hormones?

 99% of thyroid hormones are bound to

t i d th f i ti

protein and are therefore inactive

 Only 1% of circulating thyroid is free to

work work

 The first tests of these hormones were

insensitive and measured both free se s t e a d easu ed bot ee and bound: “TOTAL”

 New assays are now sufficiently

sensitive to measure only “FREE” hormone.

(52)

Testing HPT Axis: T3, T4, RT3

 A small increase in binding proteins

makes:

ll h i “t t l” h

 a small change in “total” hormone

measures (99% is already bound, so little effect) but

 a large change in “free” hormone levels

(the small pool of 1% free is absorbed).

 Example: Most hypothyroid women on  Example: Most hypothyroid women on

becoming pregnant must increase their thyroid dose on average by 45%

(53)

Testing HPT Axis: T3, T4, RT3

The “radio-immuno-assay” (RIA):

 Immune globulins labeled with

di ti “t ” d t radioactive “tracer” are used to

accurately measure tiny amounts of material

material

 Accurately measure free T3 to only 2

pcg/mL (0.000 000 000 002 gm per 0.001 L).

 We can also measure blood levels of

T4 and RT3 with great accuracy T4 and RT3 with great accuracy

(54)

Testing HPT Axis:

Thyroid Antibodies

 AIT can be tested with about 90%

accuracy using RIA

 RIA is available for:

 TPO-Ab  Tg-Ab

TR Ab

(55)

Autoimmune Thyroid Disease

 Is the most common autoimmune

disease in the United States

I th t f

 Is the most common cause of

hypothyroidism in the United States

 Affects women four times more than  Affects women four times more than

men:

 Up to 20% of menopausal womenp p  Up to 24% of allergic women

(56)

Autoimmune Thyroid Disease

 Anti-TPO: attacks thyroid peroxidase,

which is important in the production of thyroid hormones

thyroid hormones

 TgAb: attacks thyroglobulin, which is

essential in the production of the T4 essential in the production of the T4 and T3 thyroid hormones

… remember to consider celiac disease in AIT

(57)

Other Testing: Iodine Sufficiency

 24-hour urine

 Epidemiology: overnight urine suffices

 WHO criteria: > 100 mcg/L is “replete”

 Mayo reference interval is different, based

on local residents many clearly low by on local residents, many clearly low by WHO standards

 Limitation: Results reflect only recent y

iodine intake, so used primarily as an epidemiological tool

(58)

Other Testing: Iodine Sufficiency

 Uptake scans: amount of radioiodine

dose taken up by the gland measured; expensive

expensive

 Oral Iodine loading test: Give known

iodine dose and measure amount lost iodine dose and measure amount lost in timed urine as estimate of body

sufficiency (similar method is used for testing magnesium)

testing magnesium)

(59)

Other Testing:

Selenium Sufficiency

 Serum: limited value, rapid flux

 Plasma/platelet GPx activity; Se levels

that saturate GPx activity insufficient to optimize immune/anticancer effects to optimize immune/anticancer effects of Se

 Whole blood or RBC levels; functional, o e b ood o C e e s; u ct o a , intracellular (longer-term status)

Raymond

(60)

Suggested Initial

Laboratory Workup

 TSH, free T4, free T3, RT3  Thyroid autoantibodies

 Iodine and selenium if clinically y

(61)

Plain Speak

Plain Speak…

 What do we know that causes the thyroid to go awry?

(62)

Treatment

 Nutrition: Review nutrient needs for

optimal function optimal function

 Production of T4 and T3  Conversion of T4 to T3  Conversion of T4 to T3

 Toxins: Eliminate or decrease toxins

and medications that affect thyroid function

(63)

Treatment

 Improve or minimize disease states

that affect thyroid function

A f li di

 Assess for celiac disease

 Assess for infections and/or inflammatory

conditions

 Lifestyle: Decrease chronic stress

 Regular sleep  Exercise

(64)

Treatment

 Thyroid replacement therapy:

 Levothyroxine  Liothyronine

 Armour® thyroid or similar medication  4 parts T4:1 part T3

 4 parts T4:1 part T3

 Compounded thyroid replacement  Various ratios of T4 to T3

(65)

Issues with TSH Suppression

Largest long term concern is bone mineral density

H t 2 t d f 6000

 Hunt 2 study of over 6000 women

 No differences were found in BMD with

TSH >/=0.50 mU/l TSH >/ 0.50 mU/l

 Tromsø study of almost 2000 men and

women

 Within the normal range of serum TSH

there was no association with BMD

ff Eur

Eur J J EndocrinolEndocrinol. 2009 Aug 11. [. 2009 Aug 11. [EpubEpub ahead of print] ahead of print] Thyroid. 2008

(66)

A General Treatment Strategy for

Hypothyroid Dysfunction

 Know the patterns that suggest hypothyroid

function (Pattern Recognition) function (Pattern Recognition)

 Know the Important Antecedents and

Triggersgg of hypothyroid dysfunctionyp y y

 Recognize the Mediators of hypothyroid

dyfunction

 Appropriately order tests (and retests) as

(67)

A General Treatment Strategy for

Hormonal Dysfunction

Know where and what points of leverage you may need to address in thyroid imbalances

Hormonal Dysfunction

y

 Production/synthesis and secretion of hormones

 Supply hormone precursors as needed

 Transport/conversion/distribution/interaction with other  Transport/conversion/distribution/interaction with other

hormones

 Cellular sensitivity to the hormone signal

 Thyroid receptor insensitivity

 Metabolism/detoxification of the hormone

 Increase conversion to T3 instead of RT3

(68)

A General Treatment Strategy for

Finally

gy

Adrenal Dysfunction

Finally,

Supply hormone replacement as

indicated and needed.

(69)

48

48--year

year--old Female

old Female

with Fatigue and Weight Gain

 Chief Complaints:

Si ifi f i f

 Significant fatigue for past year

 Weight issues: gained 20-25 lbs. gradually over past 3 5 years after having been at same weight past 3.5 years after having been at same weight during much of adult life

 Past Medical History:ast ed ca sto y

 Started on Armour Thyroid. Switched to Synthroid with new MD in view of ongoing

symptoms. Dose increase led to feeling “manic” -so dose was reduced again

(70)

 Past Medical History (contd.):

 Severe intolerance to cold for years

 Poor memory and concentration past 2 years  Hair thinning for past 3-4 years

 Body temperature 97 7º never over 98º  Body temperature 97.7º, never over 98º  Occasional constipation, dry skin

 Variable menstrual cycle past year; sometimes skips a

period

 Occasional hot flushes and night sweats  Family History:

 Family History:  Unremarkable  Diet History:

(71)

 Physical Exam:

H i ht 60 i h W i ht 142 lb BP 118/80

 Height: 60 inches; Weight: 142 lbs. BP: 118/80

 Exam: unremarkable  Objective/Laboratory:  Objective/Laboratory:  TSH: 4.3 (0.4-4.7 IU/mL)  Free T4: 6.8 (4.8-13.20 ng/dL) F ee T3 3 6 (3 7 10 4 l/L)  Free T3: 3.6 (3.7-10.4 pmol/L)  Anti TPO Ab: 1100 (0-35 IU/mL)

(72)

 Assessment:

 Borderline hypothyroidism and thyroiditis

 Skipped periods suggest perimenopause

 Plan:

N t iti l l t ith

 Nutritional supplement with:

 Selenium 300 mcg, iodine 150 mcg, zinc 10 mg, and

vitamin A, E, D, B2, B3

C f S

 Continue current dose of Synthroid

 Continue supplements

 No dietary changes

(73)

2

2--week followweek follow--upup

 Feels warmer, especially hands  Noted energy level has picked up  Skin is not as dry

 Constipation improved.

4

4--week followweek follow--upup

F l ti

 Feels more energetic

 Hands and feet are warm

Fatigue 60 70% improved

(74)

3

3--month follow

month follow--up

up

 Subjective:j

 Feels “really good”; “energy has been so improved”

 Tolerates working in an air-conditioned building without feeling cold

N l l i h i i tti th

 No longer losing hair, is getting new growth  Concentration is definitely improved - doesn't

seem to have lapses of memory as frequently seem to have lapses of memory as frequently  Body temperature averaged 98.8 orally over

(75)

 Subjective (contd.):

N bl ith i i ll f l t d

 No problems with insomnia - generally feels rested on

awakening

 BMs are regular - no constipation  Skin is no longer dry

 Increased evenness of emotions, energy and

concentration concentration

 Continued hot flushes

 Objective/Laboratory:j / y

 TSH: 2.75 (0.4-4.7 IU/mL)  Free T4: 9.95 (4.8-13.20 ng/dL)  Free T3: 6.21 (3.7-10.4 pmol/L)  Free T3: 6.21 (3.7 10.4 pmol/L)  Anti TPO Ab: 623 (0-35 IU/mL)

(76)

Each person takes the

limits of their own field of

vision for those of the world

Arthur Schopenhauer

(77)

Post AFMCP Webinar Series

Tom Sult, MD and Patrick Hanaway, MD

Tuesday, March 8, 4 pm PST Tuesday, March 15, 4 pm PST Tuesday, March 22, 4 pm PST Robert Hedaya, MD Tuesday, April 5, 4 pm PST Tuesday, April 12, 4 pm PST Tuesday, April 26, 4 pm PST

Invitations will be sent to you via WebEx for each of these Webinars.