So what exactly is hyperthyroidism?

Your thyroid gland produces a hormone (thyroxin) that sensitives all your cells to the metabolism stimulating effects of adrenal hormones. You can think of thyroid hormone as your body’s metabolic cruise control system. It sets the speed of your metabolism, from how warm you are to how fast your heart beats. While adrenalin comes and goes in spurts, thyroid hormone sets the long-term tempo. Normally, your thyroid gland produces just the right amount of hormone. Hyperthyroidism is an over-production of thyroid hormone, causing an increase in temperature, heart rate, muscle contraction and nerve firing. Too much thyroid hormone therefor causes rapid, irregular pulse rate, low grade fever, muscle trembling, anxiety or panic, irritability and fits of rage. Imagine drinking a whole pot of espresso. It’s not fun. Furthermore, it puts a stress on your heart.  Hyperthyroidism is classified into several types: 

Grave’s disease, 

Hyperfunctioning thyroid nodules (Toxic Thyroid Adenoma and Toxic Multinodular Goiter) and 

Thyroiditis (Hashimoto’s, post-partum and subacute or DeQuervain’s). 

All of these conditions are forms of thyroid autoimmune disease, meaning that your immune system has attacked your own thyroid.  Taken together, thyroid autoimmune diseases affect 7-8% of the population, totaling up to 24 million people in the United States, up to 10% of women and 3% of men.  In other words, hyperthyroidism is a relatively common condition, particularly in women. I also suspect it is under diagnosed for reasons you will read later.

Grave’s disease

At 70 to 80% of all cases of hyperthyroidism, Grave’s disease is the most common form of the disease.  It occurs most frequently in women over the age of 20, occurring in about 2% of this demographic.  

Grave’s disease is an autoimmune disorder.  More than 85% of all autoimmune patients are female.  As part of a broader trend, the incidence of autoimmune disease in general is estimated to be between 14.7 and 23.5% of the population and that incidence is rising.   This increasing incidence is very likely to be due to environmental toxins.

What are the symptoms of Grave’s disease?

Fever, heat intolerance, nervousness, anxiety, insomnia, fits of rage, sweating, tremor, heart palpitations, rapid heart rate and profound fatigue.  In women, menses are scant and infrequent.

Objective signs include fever and an elevated resting heart rate.  I have measured a heart rate of over 120 beats per minute in a patient who was resting in bed.  This went on for a few weeks accompanied by a fever of 99 to 100 degrees.  Even to stand up is exhausting when the body is working that hard to raise metabolism.  As opposed to fever caused by infection where the patient wants to get under the covers and stay warm, in Grave’s disease, the patient has heat intolerance and throws off the sheets.  Sweating occurs to dissipate heat.  In some cases, the patient may also exhibit protruding eyes (exophthalmos).  Swelling of the thyroid gland (goiter) is common in Graves disease. The lack of these signs does not rule out thyroid disease.

Hyper-functioning thyroid nodules (Also known as Toxic Thyroid Adenoma and Toxic Multinodular Goiter)

There are several kinds of thyroid nodules.  They differentiated by whether or not they are actively producing hormones and also by their composition.  Some nodules are mere fluid filled cysts.  Others are filled with a colloid.  The nodules that produce symptoms are doing so because they are producing extra thyroid hormones.  These hyper-functioning thyroid nodules produce symptoms of hyperthyroidism as discussed above.

How are nodules detected?  In a physical exam, the doctor stands behind you and feels the thyroid with his or her fingertips.  The thyroid gland is wrapped around the trachea (windpipe), in the hollow just above the sternum. In a normal person, the thyroid is barely detectable and feels equal when comparing right and left sides.  A nodular thyroid feels lumpy or asymmetrical.  Nodules are generally non-tender, the exception being de Quervain’s thyroiditis. 

Rule out thyroid cancer

While the incidence of thyroid cancer is low, the consequence of failing to detect it early is high.  Only about 5% of palpable thyroid nodules are cancerous.  The warning sign in palpation is that the lump feels hard and attached to deeper tissues.   Your doctor will order other tests if a lump feels suspicious.

Hashimoto’s thyroiditis

Hashimoto’s is a chronic, sub-acute autoimmune destruction of the thyroid gland.  

Hashimoto’s is harder to diagnose because symptoms of Hashimoto’s thyroiditis are symptoms of low thyroid function, namely fatigue, weight gain, low temperature/intolerance to cold, dry skin and hair, frequent heavy menstrual periods, hoarseness and lack of mental clarity. Many doctors do not check for the autoimmune component and just treat it as hypothyroidism.

Goiter is the usual clinical finding in Hashimoto’s, with the thyroid commonly though not always, being 2-3 times it’s normal size.  

Post-partum Thyroiditis

The stresses of pregnancy, childbirth, nursing and early childcare can induce thyroiditis in susceptible women.  Typically, an episode of hyperthyroidism occurs 2-6 months post-partum and resolves without treatment within a year.  About a quarter of these women develop hypothyroidism four or more years later.

Regarding pregnancy, sub-clinical hypothyroidism does not reduce rates of conception but does increase the rate of spontaneous abortion.

Sub-Acute or DeQuervain’s thyroiditis

The etiology of de Quervain’s is thought to be a viral infection.  Being an acute inflammatory condition, the thyroid nodules are tender to palpation.  The thyroid is generally asymmetrically enlarged and firm.  

Symptoms of de Quervain’s are hyperthyroid symptoms while the infection is raging, followed by symptoms of hypothyroidism when the autoimmune damage is done.   Fever can range from 100 to 101 degrees F.  Symptoms may include neck, jaw, throat and ear pain.  It is often confused with upper respiratory or dental infection in the early stages and in fact is often a sequel to an upper respiratory infection.  There may be pain with swallowing or turning the head.   Patients with de Quervain’s are more likely to be profoundly fatigued and confined to bed than those with other forms of thyroid disease.

De Quervain’s is self-limiting, generally resolving within a few months, though chronic hypothyroidism (Hashimoto’s) is a common sequel.  

Lab testing in the acute stage shows elevated T4 and T3 with decreased TSH and elevated ESR (Erythrocyte Sedimentation Rate is a general measure of inflammation).

Differential Diagnosis

If you experience recent onset of extreme fatigue, malaise, heart palpitations, insomnia, emotional instability and tremors, you should ask your doctor to test you for hyperthyroidism. While waiting to see your doctor, start taking and recording your temperature and your pulse rate. A thermometer and pulse oximeter are both readily available at your local drug store. Measure yourself and write down the date and time of your measurements in a notebook or by other means.  Hyperthyroidism causes rapid heart rate and mild fever. Keeping a log of your temperature and pulse will help track the severity of your disease and the progress of your treatment. 

Unless you recently gave birth or are recovering from an infection, you likely have Grave’s disease. Your doctor will palpate your thyroid to check for swelling and also order blood tests to make a differential diagnosis. Most doctors will only order a TSH (Thyroid Stimulating Hormone) to determine whether or not you have hyperthyroidism. They do not typically order tests that quantify the autoimmune component. This is because the treatment for hyperthyroidism is to suppress thyroid hormone production with a bromide based drug or radioactive Iodine, not to try and modify the immune response.  A TSH below 0.3 is indicative of hyperthyroidism. I have listed other tests below that can be helpful in determining what is happening with the immune system and make a more informed differential diagnosis. I order these in addition to TSH, plus T4, T3 and reverse T3 (see prior article on hypothyroidism).

If you have hyperthyroid signs and symptoms following an acute infection, you would expect the diagnosis to be de Quervain’s hyperthyroidism.  If the onset followed the birth of a child, expect post-partum thyroiditis to be the diagnosis.  Neither de Quervain’s, nor post-partum thyroiditis are known for producing palpable swelling of the thyroid gland.  In lab testing, de Quervain’s patients can also expect an elevated ESR.  In both cases, elevated T3 and T4 with decreased TSH can be expected.

Hashimoto’s is more difficult to diagnose because it develops slowly.  It is an autoimmune thyroiditis but results in more destruction of tissue and therefore the clinical presentation is hypothyroidism.  The patient is cold, tired, has dry skin and thinning hair with a loss of the lateral third of the eyebrows (see article on hypothyroidism).  In her or his case, the thyroid gland is likely to be palpably enlarged and nodular.  Lab tests include elevated anti-microsomal and antithyroglobulin antibodies with decreased peroxidase antibodies.  Because of the possibility of thyroid cancer, I always refer out to her or his primary care physician or a specialist for evaluation in patient’s with thyroid nodules.

Etiology

So how does a patient get autoimmune thyroiditis?  The usual risk factors are genetics, prolonged high stress, female gender, environmental toxins, infections and low Selenium.  Let’s take these one at a time.

Genetics

There is a genetic predisposition to Grave’s disease that can be determined through HLA testing (The association is between HLA B8 and DW3 in Caucasians and DW35 in persons of Japanese descent), however it appears to be triggered by infection, stress and/or environmental toxins. Hashimoto’s also has a genetic pre-disposition.  In Caucasians, the HLA-B8, DR3 haplotype is associated with atrophic autoimmune thyroiditis.  HLA-DR5 is associated with goitrous autoimmune thyroiditis.  There is a high prevalence of autoimmune thyroiditis in Down’s syndrome, Turner’s syndrome and familial Alzheimer’s  further suggesting a genetic susceptibility.

High stress/ Low adrenal function

Stress provokes an increase in metabolic rate so that the person has the energy to deal with the crisis.  To raise metabolism, our bodies produce thyroid hormone, which sensitizes cells to adrenal medullary hormones, epinephrine and norepinephrine.  These are the hormones that increase metabolic rate.  The adrenal cortex produces hormones that balance water, salt, blood sugar, reduce inflammation, etc.  They are cooling, nourishing hormones.  High stress and insufficient adrenal cortical hormones to help the body cope with that stress may allow the development of autoimmune thyroiditis. 

Female Gender

Women are over three times more likely to have autoimmune thyroid disease than men.  The stress of childbirth is also a cause of autoimmune thyroiditis.  Post-partum thyroiditis is an example of the effect of physical stress leading to this condition and is of course, a form of the disease that is limited to women.  

Environmental toxins

The common lab tests for Grave’s and Hashimoto’s disease are antiperoxidase antibodies and anti thyroglobulin antibodies.  Several studies have demonstrated an association between exposure to PCB’s (polychlorinated biphenyls), dioxins, BPA (bisphenol A), perchlorate, DDE, hexachloroenzene and other toxins with elevated levels of these antibodies. 

How big a problem is this?  According to the National Health and Nutrition Examination Survey III, 13% of the total U.S. population is positive for both of these antibodies.  Thirteen percent is over thirty-nine million people!  That’s thirty-nine million Americans, whose immune systems are gunning for their thyroids.  Not all of those people have overt thyroid disease but individuals with both antibodies were 23 times more likely to be clinically hypothyroid and 12 times more likely to have sub-clinical hypothyroidism.  Individuals with both antibodies and a TSH over 2.5 were forty times more likely than the general population to have clinical hypothyroidism.  Remember, a TSH of 2.5 is ideal. In other words, your immune system could be attacking your thyroid and your lab test for thyroid disease could still be normal.

Infections

The last straw (in a patient already burdened with stress and toxins) can be an acute infection.  This would be diagnosed as de Quervain’s hypothyroidism but as you can imagine, the stresses that lead to de Quervain’s are likely to have been present for some time. 

Low Selenium

A little known nutritional factor in autoimmune thyroid disease is Selenium deficiency.  Selenium is a trace mineral.  To understand why Selenium is important, you must first understand that the thyroid gland converts Iodide to Iodine and then attaches Iodine to Tyrosine to make the hormone thyroxine (T4) using hydrogen peroxide, a potent oxidant at both steps.  If you have ever put hydrogen peroxide on a cut, you know that it fizzes as it tears cells apart.  That’s what makes it an effective antibacterial.  To protect your healthy cells, the thyroid produces glutathione peroxidase, a Selenium dependent enzyme.  Glutathione peroxidase neutralizes hydrogen peroxide.  If you are deficient in Selenium, you cannot produce adequate glutathione peroxidase and the resulting excess hydrogen peroxide damages your cells.  In response to this damage, the immune system begins to regard the thyroid gland as a source of trouble and starts coding antibodies against the thyroid.  If you recall, one of those enzymes discussed above is antithyroiperoxidase or anti-TPO.  Is this making sense?

Selenium is so important that the thyroid gland has higher concentrations of Selenium than the liver.  Furthermore, deficiency of Selenium is associated with cancer of the thyroid.  Exposure to chemicals that disrupt the thyroid’s ability to make glutathione peroxidase such as DDT, increase the risk of thyroid cancer.  Prolonged stimulation by high levels of TSH increases cellular differentiation in the thyroid and increases the risk of neoplasia.  High TSH is often a response to low levels of Iodine (see below) and high levels of exposure to toxic chemicals.  Add high TSH to prolonged exposure to thyroid disruptor chemicals and you have a recipe for thyroid cancer.  The rate of thyroid cancer in the United States has more than doubled over the last 30 years.

Clinically, if a hyperthyroid patient takes Iodine without first ensuring adequate levels of Selenium, symptoms are likely to worsen.  Of course, Selenium can be given as a nutritional supplement but the therapeutic range is very small.  The RDA is 400 mcg’s per day and toxicity can occur with as little as 1000 mcg’s per day.  Blood, urine or hair analysis can be performed to determine if the patient has adequate selenium.  The lab I use to test levels of minerals and heavy metals is Doctors Data in Chicago.  

A more traditional East Asian method of supplementing Selenium is to use Huang Chi or Radix Astragalus as this herb contains a concentration of Selenium.  This herb is used in many tonic formulas, notably Ginseng and Astragalus Formula or Bu Zhong Yi Chi Tang.  This is often the best formula for the adrenal deficient patient who is pre-clinical for a thyroid disorder or the patient with Hashimoto’s thyroiditis.  Furthermore, Astragalus Membranous is not only known to raise serum Selenium levels, it also boosts immunity to viral infection by raising levels cytokine and T cell immunity.  By helping to protect the body against infection, it reduces the risk of de Quervain’s thyroiditis.  

Acupuncture and Chinese Medicine

According to the oldest Chinese medicine text, “A superior physician prevents disease.  An inferior physician treats disease”.  Of course, patients don’t usually come in until they are sick but whenever possible, in our office we focus on prevention.  In the pre-clinical stage, we often see patients who are anxious and run down.  They are not yet sick but their lifestyle is spreading their energy too thin.  To these patients, I sometimes relay an old Chinese saying, “If we don’t change direction, we will end up where we are headed”.  Using acupuncture and tonic herbs to relax and strengthen the patient may get their attention so they will be more open to following our advice.  A program of Tai Chi, Chi Gung, yoga or other relaxation techniques and breathing exercises can really help.  We counsel patients to set priorities, accept limits and let go of trying to be and do everything.

Acupuncture can modulate immune response and reduce inflammation in the acute stage of the disease.  In the post-acute hypothyroid stage (Hashimoto’s), acupuncture and tonic herbs can help to modify the immune response and raise metabolism.  Nutritional therapy is also very helpful.

L-Carnitine

During the acute stage of hyperthyroidism, the amino acid L-Carnitine can be used to prevent or minimize the symptoms and physiologic changes associated with elevated levels of T3 and T4.  The dosage required is 2 – 4 grams per day of oral L-Carnitine, given in a divided dose.   

L – Carnitine is a normal amino acid found most abundantly in meats.  The supplemental form is made by bacteria and is easily absorbed and utilized as it is in a free, single amino acid form as opposed to complexes with other amino acids as it is normally found in food.  The mechanism of action for L-Carnitine is that it blocks the uptake of T3 and T4 at the cell nucleus.  Thyroid hormone works by causing transcription of DNA in the cell nucleus that increases receptor sites for catacholamines in the cell membrane.  Without access to the nucleus, T3 and T4 cannot raise metabolism and cause hyperthyroidism.  

Iodine

Since T3 and T4 are made from Iodine, it would be natural to assume that taking Iodine would worsen hyperthyroidism because the body would be able to make more of the hormones.  This is true in the acute stage, particularly if there is a lack of Selenium.  But in the post-acute stage, taking Iodine can actually decrease the levels of antithyroglobulin antibodies and antiperoxidase antibodies found in Hashimoto’s disease.

What to do?

First of all, make an appointment with your doctor. In this office, we are not medical doctors, let alone endocrinologists. We do not prescribe drugs. We offer nutritional support, lifestyle recommendations and supportive care. While it is true that we have helped many patients with thyroid disorders improve their health and it is also true that we provide treatment for aspects of thyroid disease often ignored by medical doctors, there are some cautions to bear in mind. First of all, if your heart rate is above 100 at rest, you may need to take medications to reduce the amount of thyroid hormone produced and reduce its effects on your heart. Secondly, if you have nodules on your thyroid gland, those should be checked for cancer.

The next thing to do is start measure and recording your resting pulse rate and temperature. Make a chart with these headings: Date, Time, Pulse Rate, Temperature, Symptoms. You are the only person who is with you all the time. We doctors are not. By taking an active role in your health, you will notice what helps you and what hurts you. There may be foods that make you better or worse, sleep patterns, stressors, etc. Be an expert in what makes you feel good.

Last, strive to maintain a relaxed, happy mood. Fear and anxiety hurt you. Anger hurts you. These emotional states trigger a flood of hormones that arouse your immune system and cause more destruction. A friend once said, “You can’t afford the luxury of a negative thought.” Sure your spouse may deserve a good tongue lashing but the person who will suffer is you. I have one patient who put her Grave’s disease in remission largely by walking away from everything stressful in life. She won’t even read the news or watch a suspenseful movie. It’s not worth it to her. She is happy gardening, cooking and reading, so that’s where she puts her focus. Does life still bring crisis that must be managed? Of course. We all have major life events that require us to get into high gear. We just don’t have to be in that heightened state all the time. It may be a habit. We may have built our roles and personalities around unsustainable demands.  Many of us are attracted to high stress activities, whether it is completing a big project at work, skiing down a steep hill or engaging in emotional dramas. Adrenaline makes us feel more alive. It may not seem possible to disengage from these high stress activities – that we “have to” do (fill in the blank), but many of them are optional. If you can turn a diagnosis of hyperthyroidism into a change towards a happier, less stressful life, the suffering will at least have meaning and possibly be worthwhile. Let the crisis be an opportunity to create a healthier, happier life.

Wishing you the best of health,

David Wells, D.C., L.Ac., MS (Nutrition).

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