When someone with Graves’ Disease or Hashimoto’s Thyroiditis takes a natural treatment approach, the ultimate goal is to achieve a state of remission.  But one of the questions I commonly get asked is “how can someone tell if they are in remission?”  In this blog post I am going to discuss what someone should expect when they reach this state.  I’ll also discuss what you can do to maintain a state of wellness once remission has been achieved.

Before I talk about this, I’ll admit that I don’t like the word remission.  I like the word “cure” much better, as it of course sounds better to say “my autoimmune thyroid condition has been cured”, rather than say that “my autoimmune thyroid condition is in remission”.  While I have been guilty of using the word “cure” in the past, since genetics plays a role in the development of autoimmune thyroid conditions, the word remission is more appropriate.  However, I like to aim for a “permanent” remission, which is the next best thing to a cure.

The Difference Between Cancer And Thyroid Autoimmunity

If you visit www.cancer.gov they explain the difference between cure and remission with regards to cancer.  They mention that a “cure” means that there are no traces of cancer after treatment and the cancer will never come back.  On the other hand, they label “partial” remission as meaning the signs and symptoms of cancer have been reduced, whereas in complete remission the signs and symptoms of cancer have completely disappeared.  And when it has been completely gone for at least five years this is frequently labeled as being a cure.

But then they go on to say that even after five years there is a chance that the cancer can come back.  And when cancer returns after five years then a so-called cure was essentially a prolonged remission.  And I’d say that there are similarities between cancer and thyroid autoimmunity, as someone like myself who has been in remission for over five years is less likely to relapse than someone who has been in remission for less than five years.  But I’ve also worked with people who have been in remission for over five years and relapsed, which is why I can’t honestly say there is a permanent “cure” for thyroid autoimmunity.  On the other hand, there is a chance to achieve remission and stay there without relapsing, which is why I prefer to use the term permanent remission.

3 Signs That You Have Achieved A State Of Remission

So how do you know when you have achieved a state of remission?

1. Your symptoms have completely resolved.  One of the main goals is to get complete resolution of your symptoms.  For example, when I was dealing with Graves’ Disease I had an elevated resting heart rate, palpitations, tremors, weight loss, an increased appetite, and a few other symptoms.  All of these symptoms eventually resolved upon taking a natural treatment approach, and the same thing occurs with most of my Graves’ Disease patients.  And of course the same goal applies to my patients with hypothyroidism and Hashimoto’s Thyroiditis.

While most people who take responsibility for their health receive great results, unfortunately not everyone who follows a natural treatment protocol will get complete resolution of their symptoms.  Why is this the case?  When someone doesn’t get into remission, in most cases it’s because the underlying cause of their condition hasn’t been addressed.  Thyroid autoimmunity can be challenging, and finding the autoimmune trigger isn’t always easy.

But symptom resolution doesn’t always come down to finding and removing triggers, as sometimes certain imbalances can’t be completely resolved.  For example, if someone with Graves’ Disease or Hashimoto’s Thyroiditis has small intestinal bacterial overgrowth (SIBO) due to damage to the migrating motor complex, which in turn is caused by an autoimmune process, not everyone will have complete resolution of their symptoms.  This doesn’t mean that tremendous improvement isn’t possible, but a person in this situation might still have some mild symptoms after treating SIBO, and in order to prevent SIBO from coming back they might need to take prokinetics on a continuous basis after treatment.

2. Your thyroid panel and other blood tests are normal.  Of course we want the thyroid panel to normalize, and this includes the thyroid antibodies.  But other markers that were out of range initially should normalize as well.  For example, if someone had low or depressed vitamin D levels upon starting the natural treatment protocol, then upon restoring their health this should be within a healthy reference range.  If someone has elevated liver enzymes, which is common with hyperthyroidism, then these should normalize upon remission.

It’s important to understand that certain markers on a blood test might be important to normalize, but at the same time don’t directly relate to your condition.  And if this is the case, then these markers might remain out of range, even if someone is in a state of remission.  For example, some people will have an elevated homocysteine, but this doesn’t always directly relate to one’s thyroid or autoimmune thyroid condition.  This doesn’t mean that we don’t want to do things to lower the person’s homocysteine, but my point is that it’s possible to be in remission even with elevated homocysteine levels.  However, one wouldn’t be in an optimal state of health in this situation.

By the way, I’m not suggesting that having a high homocysteine level isn’t significant, but only that it might not be directly related to one’s thyroid or autoimmune thyroid condition.  However, an elevated homocysteine level indicates problems with methylation, which can be a factor.  I spoke about homocysteine and methylation in an article entitled “Methylation, MTHFR, and Thyroid Health”.

3. Other tests have normalized.  When I was dealing with Graves’ Disease I obtained an adrenal saliva panel, and the initial test results revealed depressed cortisol levels, a depressed DHEA, and a depressed secretory IgA.  All of these markers eventually normalized, and I expect the same with my patients who have compromised adrenals.  If someone tests positive for a gut infection in the blood or stool, such as H. Pylori or Blastocystis Hominis, then of course you want them to test negative for this in the future.

Does this mean all tests need to be perfect before someone achieves a state of remission?  Just as is the case with the high homocysteine example I gave above, some markers are more significant than others.  Let’s look at a different example that relates to testing the sex hormones.  If someone has low levels of progesterone and testosterone, even though these low levels are causes of concern, it still is possible to get into a state of remission.  However, a person with low or depressed hormone levels isn’t in an optimal state of health, and if chronic stress is the cause of the low sex hormones then this can prevent the person from maintaining a state of wellness.

How Can You Maintain A State of Remission?

So once you have achieved a state of remission, how can you maintain your health?  I admit that maintaining a state of wellness can be a challenge, especially initially.  But even after being in remission for many years there still is always a chance of a relapse.  However, doing the following will greatly increase the chances of maintaining a state of wellness:

1. Continue to eat well most of the time.  What do I mean by “most of the time”?  In other words, does the 80/20 rule apply here where someone can eat healthy 80% of the time, and indulge 20% of the time?  The truth is that it depends on the person, as some people are able to get away with eating “bad foods” more than others, while others need to eat more strictly in order to maintain a state of wellness.  But since you won’t know what you can get away with when you’re in remission I wouldn’t indulge too much…at least not initially.  I definitely don’t eat a perfect diet, but I do try to eat healthy most of the time.

In addition, over the last couple of years I’ve been following a 21-day liver detoxification program three or four times per year.  And while eliminating toxins is important, during the 21 days I also follow a very strict diet.  And so essentially I’m following a gut repair diet for 21 days.  As a result, even if I get into a bad eating spell, which I admit does happen every now and then, I can count on giving my body a 21-day break every three or four months.  Once again, this doesn’t mean I eat poorly for 3 or 4 months and then go on a 21-day liver detoxification, as I do try to eat well most of the time in between.

2. Always work on stress handling.  Stress was a big factor in the development of my Graves’ Disease condition, and it’s a factor with many of the people I work with.  In fact, when someone relapses it frequently is due to chronic stress.  This might be a concern to some people reading this, mainly because stress is a factor with just about everyone.  This is true, and this is why managing your stress is important.

However, just as is the case with diet, this doesn’t mean that you need to be perfect in the stress department.  And while completely getting rid of your stressors isn’t feasible, improving your stress handling skills is something you can do.  I’m not suggesting that it’s easy to do, but just like anything else you need to block out the time to do it and get into a routine.  If necessary I’d start by blocking out five minutes per day, and make sure you choose some type of mind body medicine that you enjoy doing.  Then once you’re in the routine of blocking out five minutes per day for stress management you can work on increasing the duration.

3. Minimize your exposure to other autoimmune triggers.  Sometimes this is easier said than done.  For example, in addition to food allergens and stress, two other potential autoimmune triggers include environmental toxins and infections.  While avoiding certain foods and improving your stress handling skills can be challenging, it’s impossible to avoid all of the environmental toxins you’re regularly exposed to.  And it’s not always possible to prevent an infection such as H. Pylori, Blastocystis hominis, Lyme disease, etc.  In the case of environmental toxins you obviously won’t be able to avoid exposure to every chemical out there, but you can do a lot of things to change your home environment, which can help a great deal.  And you can also do regular detoxifications like I do.

Just keep in mind that your body is always detoxifying, and so while every three or four months I personally follow a 21-day program to further support my detoxification pathways, you don’t necessarily have to take this approach.  Eating healthy foods on a daily basis, especially plenty of vegetables, will help to support your detoxification pathways.  If you have access to an infrared sauna then this can also help with the elimination of toxins.  And so in no way am I suggesting that most people need to follow three or four 21-day liver detoxifications per year.

With regards to preventing infections, the best way to do this is to improve the health of your immune system.  And of course this is the main goal for anyone who has Graves’ Disease or Hashimoto’s Thyroiditis, although even if you have a thyroid condition that doesn’t have an autoimmune component you still want to have a healthy immune system.  As for how to achieve a healthy immune system, I talk about this in other articles and blog posts, but I will say that following some of the advice given in this post will greatly help.

4. Get sufficient sleep.  Once you achieve a state of remission, in order to maintain a state of wellness you also want to get sufficient sleep on a consistent basis.  This doesn’t mean that staying up late once in awhile will cause you to relapse, but most people need to get at least a minimum of six or seven hours sleep each night, and many people do better getting seven or eight hours of sleep each night.  And “catching up” on sleep doesn’t work.  For example, if you only get four hours sleep Monday through Friday, and then sleep 10 to 12 hours on Saturday and Sunday, the extra sleep on the weekend isn’t going to compensate for the sleep deprivation during the week.

In summary, the primary goal of following a natural treatment protocol should be to achieve a state of permanent remission.  Three signs that you have achieved remission include 1) complete resolution of your symptoms, 2) normalization of your thyroid panel and other blood tests, and 3) normalization of other tests.  As for how to maintain a state of remission, you of course want to eat well most of the time, you should always work on improving your stress handling skills, minimize your exposure to other autoimmune triggers, and you also need to get sufficient sleep on a regular basis.

Recently I attended an autoimmune conference via livestream, and one of the presenters was talking about the different herbs that can be beneficial in people with autoimmune conditions.  One of the herbs he spoke about highly was ashwagandha, which is an herb I absolutely love.  However, ashwagandha is also a member of the nightshade family, and those with autoimmune conditions are supposed to avoid nightshades.  And so the question I plan on answering in this blog post is whether or not those with autoimmune thyroid conditions should avoid taking ashwagandha.

But before I answer this question, I first want to answer this question: why would someone with an autoimmune thyroid condition want to take ashwagandha in the first place?  Ashwagandha, which is also known as Withania somnifera, is an adaptogenic herb.  It helps to support both the hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-thyroid (HPT) axes.  As a result, it can help people who have HPA axis dysregulation as a result of chronic stress, and by supporting the HPT axis it can also help to support thyroid function.

However, we need to remember that Graves’ Disease and Hashimoto’s Thyroiditis aren’t thyroid conditions, but are autoimmune conditions.  And so we also need to consider the effects of ashwagandha on the gut and immune system.  In the opening paragraph I mentioned how ashwagandha is part of the nightshade (Solanaceae) family, and how nightshades are excluded from an autoimmune Paleo diet.  But while it might make sense to avoid nightshade vegetables since they have compounds which can cause inflammation, does it make sense to avoid an herb like ashwagandha that has anti-inflammatory properties?  I’ll answer this question later on in this post.

What Are Some of The Health Benefits Of Ashwagandha?

If you’re wondering why ashwagandha is commonly recommended by healthcare professionals, it’s because this herb has many different health benefits.  Here are just a few of the benefits of ashwagandha:

Helps With Stress and Anxiety.  This is probably the main reason why many natural healthcare professionals recommend ashwagandha.  Without question this is one of the primary reasons why I sometimes recommend ashwagandha to my patients, as besides seeing some wonderful benefits of ashwagandha in some of my patients, the research shows that ashwagandha can help people to better adapt to stress and anxiety (1) (2).  Of course taking ashwagandha isn’t meant to be a replacement for eating well and incorporating mind body medicine techniques, but it can help to provide additional support in those who are dealing with high levels of stress and anxiety.

Modulates the Immune System and Reduces Inflammation.  This is one of the main arguments for using ashwagandha in those with autoimmune conditions.  Even though this herb is part of the nightshade family, and while nightshades can cause inflammation in some people, there is a lot of research which shows that ashwagandha has anti-inflammatory properties (3) (4) (5).  And some of these studies even involve autoimmune conditions, such as rheumatoid arthritis (6) (7).  One of these studies showed how ashwagandha significantly suppressed lipopolysaccharide (LPS) induced production of proinflammatory cytokines TNF-alpha, IL-1beta, and IL-12p40 in both normal individuals and patients with rheumatoid arthritis (7).  Another study showed that ashwagandha can help with chronic renal dysfunction by reducing inflammation (8).

Helps With Insomnia.  Ashwagandha also can help some people who are dealing with insomnia.  One way it does this is by lowering cortisol levels, although one study showed that this herb might help with insomnia by increasing levels of the neurotransmitter GABA (9).  However, a recent study from 2017 shows that triethylene glycol, which is an active component of ashwagandha, might be a sleep-inducing component of this herb (10).  However, the study mentioned that this component is in the leaves of ashwagandha, and usually the root is used in most ashwagandha supplements.

Improves Sexual Function and Fertility.  One study I came across showed that ashwagandha can help to improve sexual function in women (11).  I’m sure some of this is due to the effect of ashwagandha on the HPA axis, as in order to have healthy sex hormones you need to have healthy adrenals, and for more information on this I would read a blog post I wrote entitled “The Negative Impact of The Pregnenolone Steal“.  There is also evidence that ashwagandha can help males with a low sperm count (12).

Cognition.  A few studies show that ashwagandha can help to improve cognition and might even be helpful with certain neurodegenerative diseases, including Alzheimer’s disease (13) (14) (15).

Muscle strength and recovery.  One study I came across showed that taking an ashwagandha supplement is associated with significant increases in muscle mass and strength (16).

A Few Things To Know Before Purchasing An Ashwagandha Supplement

There are a few things you should know before you purchase an ashwagandha supplement.  First of all, you want to make sure you are purchasing a supplement that uses ashwagandha root.  Although most manufacturers of ashwagandha supplements do use the root, there are some that solely use ashwagandha leaves.  And while I did mention the study earlier that spoke about how triethylene glycol is found in the leaves, most of the studies demonstrating the beneficial effects of ashwagandha have used the root.  Of course if you can find a formulation that has both the leaves and the root then this is an option to consider, although using a product that just has the root should be fine in most cases.  In addition, typically the higher the concentration of withanolides the better, and this should be listed on the product label.

Why Are Nightshades Excluded From An Autoimmune Paleo Diet?

For more detailed information on nightshades you can read an article I wrote entitled “Nightshades and Thyroid Health”.  The main problem with nightshades is that they have compounds which can cause problems  in those with autoimmune conditions.  These compounds include lectins, alkaloids, and glycoalkaloids.  And the reason why these are problematic is because they can cause inflammation, and in some cases can even lead to an increase in intestinal permeability.  In other words, consuming nightshades might cause or contribute to a leaky gut, which is theorized to be a factor in all autoimmune conditions.

Based on this information it makes sense to look at some of the compounds found in ashwagandha.  According to the research, the roots of ashwagandha contain several alkaloids, withanolides, a few flavanoids and reducing sugars (17) (18) (19).  The active compounds reported in ashwagandha include the following (19):

• Sitoindosides VII–X
• 5-dehydroxywithanolide-R
• Withasomniferin-A, 1-oxo-5β
• 6β-epoxy-witha-2-ene-27-ethoxy-olide
• 4-(1-hydroxy-2,2-dimethylcyclpropanone)-2,3-dihydrowithaferin A
• 2,3-dihydrowithaferin A
• 24,25-dihydro-27-desoxywithaferin A
• Physagulin D (1→6)-β-d-glucopyranosyl-(1→4)-β-d-glucopyranoside
• 27-O-β-d-glucopyranosylphysagulin D
• Physagulin D, withanoside I–VII
• 27-O-β-d-glucopyranosylviscosalactone B
• 4,16-dihydroxy-5β
• 6β-epoxyphysagulin D
• Viscosalactone B
• Diacetylwithaferin A

Although I did do some research on these compounds, I admit that I need to do more.  I didn’t realize how many active compounds are in ashwagandha.  From the research I have done so far, most of these compounds should be beneficial in people with Graves’ Disease and Hashimoto’s Thyroiditis.  After all, the compounds in ashwagandha can help those dealing with stress and anxiety, which describes many people with these conditions.  And of course ashwagandha can have a positive effect on immune system health by decreasing inflammation, which is also a factor in thyroid autoimmunity, as well as other autoimmune conditions.

However, even though these compounds have beneficial effects, this doesn’t mean that everyone with an autoimmune thyroid condition can safely take ashwagandha.  If you do some searching on your own you’ll no doubt find some people with autoimmune conditions who had negative symptoms when taking ashwagandha.  On the other hand, you’ll also come across people with Graves’ Disease and Hashimoto’s Thyroiditis who have benefited from taking ashwagandha.  And this pretty much describes most of my patients, as while I don’t give ashwagandha to everyone, most of my patients who have taken ashwagandha haven’t had any negative side effects.  On the other hand, over the years I’ve had a few patients who didn’t do well when taking ashwagandha.

What’s interesting is that some people who don’t do well when eating nightshades such as tomatoes, eggplant, and peppers have no problems taking an ashwagandha supplement.  Is it possible that ashwagandha is causing inflammation in these people, but just not causing any overt symptoms?  Of course this is a possibility to consider, but I will add that it seems that most people who don’t do well when eating the nightshades experience overt symptoms, and I find this to be the case with those who don’t do well when taking ashwagandha supplements as well.

Should YOU Avoid Ashwagandha?

Sarah Ballantyne, author of the Paleo Approach, does a lot of research with regards to the autoimmune Paleo diet, and she excludes ashwagandha from the AIP diet.  However, in one of her posts she did mention (under the comments section) that many people who can’t tolerate nightshades seem to do okay with ashwagandha, and I also find this to be the case with many of my patients.  Over the years I have had many patients with autoimmune thyroid conditions do fine with ashwagandha.

Does this mean that taking ashwagandha is completely safe for those with Graves’ Disease and Hashimoto’s Thyroiditis?  I wouldn’t necessarily say this, as while many people with autoimmune thyroid conditions do fine with this herb, there are some people who do have a negative reaction.  As a result, when following a strict AIP diet it probably is a good idea to avoid ashwagandha during this time.  But of course everything comes down to risks vs. benefits, and there are times when I’ll recommend ashwagandha to a patient with thyroid autoimmunity.  Most of the time this won’t cause any problems, but of course if the person does experience a negative reaction, or if they don’t seem to be progressing when taking ashwagandha, then they obviously should stop taking it.

In summary, although those with autoimmune conditions such as Graves’ Disease and Hashimoto’s Thyroiditis are supposed to avoid nightshades, many people do fine when taking ashwagandha.  This herb has numerous health benefits, such as helping people to better adapt to stress and anxiety, reduces inflammation, helps with insomnia, cognition, muscle strength and recovery, and can even improve sexual function and fertility.  However, there are some people that don’t do well when supplementing with ashwagandha, and if this describes you then of course it is best to avoid it.

When it comes to trying to find out the cause of one’s thyroid or autoimmune thyroid condition, testing can play a very important role.  This is why I recommend testing to just about all of my patients with Graves’ Disease and Hashimoto’s Thyroiditis.  However, one shouldn’t underestimate the importance of a comprehensive health history.  While many times doing a thorough health history alone won’t identify the autoimmune trigger, it can still provide some important clues.

What I plan on doing in this blog post is to discuss some of the more important components of a health history.  While I hope that most people reading this are working with a natural healthcare professional who will conduct a thorough health history, if this isn’t the case I would go through each of these components on your own.  In fact, regardless of whether or not you are working with an expert I think it’s a good idea to read through this information, as doing so might help to identify certain triggers.  Another benefit of a thorough health history is that it can help determine which tests are required to find certain imbalances which are either directly or indirectly responsible for your condition.

It’s also important to understand that completing a thorough health history might require you to fill out multiple forms.   It depends on the healthcare professional you’re working with, as some doctors will have all of the information on a single form, while others will require multiple forms to be completed.  Some offices will allow you to fill out all of the patient information electronically, while this won’t be the case for others.

Components of A Comprehensive Health History                   

Lifestyle factors.  This is one of the main reasons that more and more people are developing autoimmune thyroid conditions.  Some of the more common lifestyle factors which can either directly trigger autoimmunity, or make someone more susceptible to autoimmunity, include the following:

• High stress levels
• Low stress handling skills
• Drinking alcohol on a regular basis
• Consuming a lot of sugar
• Overtraining
• Excess caffeine consumption
• Insufficient sleep

Medications and supplements.  Certain medications such as antibiotics, NSAIDs, and acid-blockers can make someone more susceptible to developing an autoimmune condition by having a negative effect on the health of the gut.  While most nutritional supplements and herbs won’t trigger or exacerbate an autoimmune thyroid condition such as Graves’ Disease or Hashimoto’s Thyroiditis, there are possible exceptions.  For example, some natural healthcare professionals recommend for people with Hashimoto’s to avoid Echinacea and chlorella out of fear that these will further enhance the immune system response, thus exacerbating, or possibly even causing an autoimmune condition.  However, this is controversial, and I spoke about this more in past blog post entitled “Echinacea: Harmful for Hashimoto’s, Beneficial For Graves’ Disease?”

Past procedures and surgeries.  While most medical procedures and surgeries won’t trigger thyroid autoimmunity, certain procedures may make someone more susceptible to developing autoimmunity.  For example, while there is a concern over estrogen dominance, estrogen also has a protective effect with regards to immune system health.  And while I didn’t find any evidence of a correlation between getting a hysterectomy and developing Graves’ Disease or Hashimoto’s Thyroiditis, there is evidence that a hysterectomy can be a factor in other autoimmune conditions, such as systemic lupus erythematosus (1).  Other surgical procedures might also increase the risk of autoimmunity, such as bariatric surgery (2).  Keep in mind that I’m not suggesting that women should never get a hysterectomy, as there definitely is a time and place for these and other surgical procedures.  And I think it’s safe to say that most of the time these and other medical procedures won’t trigger thyroid autoimmunity, but it’s still a factor we need to consider when gathering information.

Infections (current and past).  Certain infections can play a role in the development of autoimmune thyroid conditions.  As a result, it’s good to know if someone with Graves’ Disease or Hashimoto’s Thyroiditis had a previous infection.  Of course just because someone had a previous infection prior to developing an autoimmune thyroid condition doesn’t mean that the infection was the trigger.  But it still can be beneficial to know if someone had an infection.

For example, there is a correlation between H. Pylori and thyroid autoimmunity, especially with regards to Graves’ Disease.  As a result, if someone with Graves’ Disease tested positive for H. Pylori a few months or years prior to being diagnosed with Graves’ Disease, this doesn’t confirm that this was the trigger.  However, it is possible that this infection was a trigger, and even if the person had received treatment to eradicate this infection, it probably would be a good idea to do an updated test for H. Pylori.

Family history.  Although genetics isn’t the most important factor in the development of an autoimmune thyroid condition, it is a factor.  And while you can’t change your genes, I still think it is beneficial to find out if there is a family history of a thyroid or autoimmune thyroid condition in someone who has Graves’ Disease or Hashimoto’s Thyroiditis.  Although the natural treatment approach might not differ much for someone who does have a strong family history of thyroid autoimmunity, if a person with Graves’ Disease or Hashimoto’s Thyroiditis has multiple family members with an autoimmune thyroid condition then they might want to be a little more strict with the diet and other lifestyle factors not only while restoring their health, but while trying to maintain a state of wellness.

Symptoms.  While you usually can’t rely on symptoms for detecting the autoimmune trigger, this doesn’t mean that one’s symptoms should be ignored.  For example, many people with Hashimoto’s Thyroiditis are overweight, but some people with Hashimoto’s Thyroiditis have the opposite problem.  In other words, some people with Hashimoto’s have difficulty gaining weight.  And if this is the case then one possible cause is a malabsorption problem, which in turn can be due to a pathogenic infection, or a condition such as small intestinal bacterial overgrowth.  Speaking of infections, if someone has extreme fatigue, along with migrating muscle and joint pain, then Lyme disease might be the culprit.

Of course certain symptoms can have multiple causes.  For example, if someone with Hashimoto’s Thyroiditis has extreme fatigue, then this can be due to low thyroid hormone levels, adrenal fatigue, one or more nutrient deficiencies, a pathogenic infection, or even blood sugar imbalances.  And while testing might be necessary to determine the cause of the fatigue, asking the right questions can also help.  Below are some of the signs and symptoms people with Hashimoto’s Thyroiditis commonly have:

• Trouble concentrating/memory difficulties/brain fog
• Fatigue
• Cold hands and feet
• Weight gain
• Bloating/belching/gas
• Constipation
• Hair loss
• Lowered libido
• Hot flashes and/or night sweats

And these are some of the signs and symptoms people with hyperthyroidism and Graves’ Disease commonly have:

• Increased resting heart rate
• Heart palpitations
• Weight loss
• Increased appetite
• Tremors
• Loose stools or diarrhea
• Hair loss

These are other signs and symptoms some people with both hypothyroid and hyperthyroid conditions can experience:

• Sweet cravings
• Caffeine cravings
• Headaches/migraines
• Muscle pain/joint aches
• Bloating/belching/gas
• Stomach burning
• Dry eyes and/or dry skin
• Increased frequency to food reactions
• Intolerance to smells
• Multiple smell and chemical sensitivities
• Indigestion and fullness last 2-4 hours after eating
• Sense of fullness during and after meals
• Coated tongue
• Dizziness when standing up quickly

Exposure to Environmental Toxins.  We live in a toxic world, and most people are exposed to hundreds, if not thousands of different chemicals on a regular basis.  Because of this, if an environmental toxin is the trigger, then many times it can be challenging to find out what the triggering chemical is.  While you can spend money to test for certain environmental toxins, including heavy metals, as well as other chemicals, you can’t test for all of the chemicals you’re exposed to.  And so rather than spend a lot of money testing for environmental toxins, sometimes the best approach is to 1) minimize your exposure to environmental toxins, and 2) do things to eliminate chemicals from your body.

With that being said, sometimes you can find out some valuable information about environmental toxins during a thorough health history.  For example, mercury is a potential trigger of thyroid autoimmunity.  As a result, a natural healthcare professional who conducts a health history should find out if their patients with autoimmune thyroid conditions has mercury amalgams.  The presence of these amalgams doesn’t mean that this is the autoimmune trigger, although there of course is a possibility that this is the case.

Recently I had a patient who had very high cadmium levels on a hair mineral analysis.  Upon further investigation the patient told me that his work environment involves exposure to certain chemicals, and cadmium was one of them.  And while there isn’t a correlation in the literature between cadmium and thyroid autoimmunity, this doesn’t mean that high cadmium levels can’t be a factor.  For example, even if a certain environmental toxin isn’t a direct trigger of thyroid autoimmunity, this doesn’t mean that it can’t indirectly cause autoimmunity by compromising the immune system.

The truth is that we don’t know everything about environmental toxins and autoimmunity.  As a result, when conducting a health history, it’s foolish to just focus on the environmental toxins that have been proven to trigger autoimmune thyroid conditions.  Keep in mind that being exposed to one or more environmental toxins can result in a loss of self tolerance, which in turn can make someone more susceptible to developing an autoimmune thyroid condition.  I spoke about this in an article I wrote entitled “Thyroid Autoimmunity and Loss of Self Tolerance”.

When conducting a health history I recommend asking the patient (or you can ask yourself if you are conducting your own health history) the following questions with regards to environmental toxins:

• Do you consume conventionally grown fruits and vegetables on a regular basis?
• Do you consume conventionally raised animal products on a regular basis?
• Do you consume fish or seafood on a frequent basis?
• Do you consume foods with artificial colors, flavors, and/or preservatives on a regular basis?
• Do you frequently use conventional cleaning chemicals, hand sanitizers, air fresheners, and other scented products?
• Do you smoke or are you often exposed to second-hand smoke?
• Do you have mercury amalgams, root canals, crowns, dental implants, etc.?
• Do you have a history of heavy alcohol use?
• Do you have a history of heavy use of recreational or prescription drugs?
• Have you been exposed to new construction materials or furniture?
• Are you frequently exposed to adhesives, paints, solvents, and other air-borne chemicals?
• Do you live near a cell phone tower or high-voltage power lines?
• Have you been frequently exposed to herbicides, pesticides, and/or fungicides?
• Do you jog or ride your bike along busy streets?

Sex hormones/Reproductive health history.  Sex hormone imbalances can be a factor in thyroid and autoimmune thyroid conditions, and here is some of the information I ask for on my health history forms:

• Do you currently take, or have you taken oral contraceptives or bioidentical hormones?
• Do you currently take, or have you had an intrauterine device (IUD)?  If yes, was it a copper or hormonal IUD?
• How many live births have you had?
• Were they natural births or Cesarean sections?
• Is there a history of ovarian cysts?
• Is there a history of uterine fibroids?
• Is there a history of endometriosis?
• Is there a history of fibrocystic breasts?

Estrogen dominance can be an autoimmune trigger, and estrogen dominance is also a common factor with ovarian cysts, uterine fibroids, endometriosis, and fibrocystic breasts.  As a result, if someone checks off one of these then I will suspect problems with estrogen metabolism.  This is also one way to determine if testing of the sex hormones is necessary.  For example, if a cycling woman has irregular menstrual cycles, moderate to severe cramping, and a history of ovarian cysts, uterine fibroids, and/or endometriosis, then one can argue that testing the sex hormones might be necessary in this situation.

Completing A Food Diary Can Be Very Valuable

In addition to completing a health history, I find that having the patient put together a food diary can be valuable.  After all, certain foods can act as triggers, or can make someone more susceptible to autoimmunity by increasing the permeability of the gut.  I would recommend putting together at least a one-week food diary.  And the reason for this is because a person’s eating habits can vary depending on the day of the week.

So hopefully you understand the importance of conducting a thorough health history.  While doing tests can help to detect the underlying cause of your condition, doing a comprehensive health history can provide a lot of value as well.  First of all, a good health history can help to determine what tests are necessary to obtain, as well as what diet the person should follow, supplements they should take, etc.  And there are times when a thorough health history can help to detect the thyroid or autoimmune thyroid trigger.  If you choose not to work with a healthcare professional I would recommend to conduct your own health history.

Recently I wrote an updated article on selenium.  In the article I mentioned how many people take selenium supplements, and if this describes you I’d like to know what your experience with selenium has been.  I realize that it’s not always easy to know if a specific supplement is helping, especially when most people are taking more than one supplement at the same time, which frequently is the case.  But if you noticed some positive changes when taking selenium I’d like to know.

So if you noticed an improvement in any of your symptoms while taking selenium please share it below in the comments section.  This can include an improvement in hypothyroid symptoms such as fatigue, brain fog, cold hands and feet, or other symptoms.  And of course if you have hyperthyroidism or Graves’ Disease and experienced an improvement when taking selenium please let me know!  If you didn’t experience an improvement in symptoms but noticed a decrease in your thyroid antibodies after adding selenium please let me know!  If you happened to experience any negative symptoms when taking a selenium supplement please let me know!  If you don’t take a selenium supplement but are instead relying on food sources of selenium you of course can also comment below if you’d like.  Thank you so much for sharing your experience with everyone.

Many people reading this are familiar with small intestinal bacterial overgrowth, which is also known as SIBO.  This involves an overgrowth of bacteria in the small intestine, and can lead to symptoms such as bloating, gas, and abdominal pain, along with diarrhea and/or constipation.  Although SIBO is more common in people with Hashimoto’s Thyroiditis, I have also seen it in patients with Graves’ Disease as well.  But can SIBO trigger an autoimmune thyroid condition?

Numerous pathogens have been associated with thyroid autoimmunity.  This includes H. Pylori, Yersinia enterocolitica, Lyme disease, Epstein barr, and parasites such as Blastocystis Hominis.  However, it’s important to understand that SIBO isn’t a pathogenic infection.  This condition involves having good bacteria in the wrong place, as most of the bacteria should be located in the large intestine, and only a small amount should be located in the small intestine.  But for numerous reasons that I’ll discuss in this blog post, there can be an overgrowth of bacteria in the small intestine.

As a result, small intestinal bacterial overgrowth itself doesn’t seem to be an autoimmune trigger.  However, there are a few things to keep in mind.  Some cases of SIBO are due to an autoimmune process, which I’ll describe below, and having one autoimmune condition can make someone more susceptible to having another autoimmune condition.  So perhaps having SIBO can lead to another autoimmune condition such as Graves’ Disease and Hashimoto’s Thyroiditis, but the correlation hasn’t been made yet.  But even if this isn’t the case, SIBO can cause an increase in intestinal permeability (a leaky gut), and this in turn can set the stage for the development of an autoimmune thyroid condition.

What Causes SIBO?

There are numerous factors which can cause someone to develop SIBO, and so let’s take a look at some of these:

1. Dysfunction of the migrating motor complex (MMC).  This is the main reason why people develop SIBO.  The MMC is a small wave that cleanses the small intestine of debris.  And so if the MMC isn’t working properly then bacteria and other debris are no longer swept through the lumen of the small intestine.  Food poisoning is the most common cause of a dysfunctional MMC, but other causes include hypothyroidism, diabetes, or an infection such as C. difficile, giardia, or Lyme disease.  Certain drugs such as opiates and antibiotics can also affect the MMC.

2. Altered anatomy.  This can interfere with the clearance of bacteria.  For example, adhesions due to surgery or endometriosis are potential causes of SIBO.  Other anatomical anomalies include a narrowing of the small intestine, fistulas, and diverticuli.

3. Hypochlorhydria (low stomach acid).  Millions of people take acid blockers, and this is a big problem.  Besides being necessary to break down nutrients, stomach acid also can help to eradicate harmful pathogens, and prevent the overgrowth of bacteria.  However, you don’t need to take acid blockers to have low stomach acid, as having a hypothyroid condition alone can result in the decreased production of stomach acid.  Stress can also decrease the production of stomach acid.

4. Absent or inefficient Ileocecal valve.  The ileocecal valve is the barrier that separates the small intestine from the large intestine.  It prevents backflow from the large intestine into the small intestine.  If this is absent or dysfunctional then it can cause the bacteria from the large intestine to migrate into the small intestine, thus leading to SIBO.

What Is The Relationship Between IBS and SIBO?

Infectious gastroenteritis, more commonly known as food poisoning, can result in the production of toxins by bacteria that can damage the nerves which play an important role in gut motility.  The specific name of the toxin is cytolethal distending toxin (CDT).  What happens is the immune system forms antibodies to this toxin (called anti-CDTb antibodies), but anti-vinculin antibodies are also produced.  Vinculin is a protein that helps connect the interstitial cells of Cajal (ICC) so that they can communicate properly to help the MMC .  When someone has the CDT-b toxins these harm the ICC, and in a case of mistaken identity the immune system attacks vinculin, which has a negative effect on gut motility.

So to summarize, food poisoning is the most common cause of irritable bowel syndrome with diarrhea (IBS-D).  This in turn has a negative effect on gut motility, and the problem with gut motility is what leads to small intestinal bacterial overgrowth.  There is a blood test called IBSchek by Commonwealth Laboratories that can determine if someone has IBS-D associated with anti-CDTb and anti-vinculin antibodies.

How Is SIBO Diagnosed?

Although one’s symptoms can provide a lot of valuable information, if SIBO is suspected then it is a good idea to test.  And the way it is detected is through a breath test.  With the breath test the patient fasts overnight, and then in the morning they will start with a baseline breath test, followed by the consumption of a substrate (i.e. lactulose or glucose).  After the baseline breath test they will measure a breath sample approximately every 20 minutes, and what the lab is looking for is bacterial fermentation, and it measures this fermentation by measuring the levels of hydrogen and methane. In other words, if someone has SIBO, there will be more fermentation, which will lead to higher levels of hydrogen, methane, or both gases. Let’s take a look at the two main breath tests used:

Lactulose breath test.  Lactulose can’t be absorbed by humans, but can be broken down by bacteria.  As bacteria consume lactulose they produce hydrogen and/or methane gases, which are measured with the breath test.  This is most commonly used because it can diagnose SIBO in the distal end of the small intestine.

Glucose breath test.  The glucose breath test seems to be more accurate, but the reason this test isn’t as commonly used is because glucose is absorbed in the beginning of the small intestine.  As a result, if someone has SIBO that is occurring in the distal small intestine then it is less likely to be detected.  However, some bacteria don’t ferment lactulose, and as a result, if SIBO is suspected yet the lactulose test comes back negative then you should consider doing a glucose breath test.  Another option is to do both the lactulose and glucose tests initially, although many labs don’t offer both types of testing.

Can A Stool Panel Detect SIBO?

Hydrogen and methane are produced by bacteria, and this is what’s being measured on the breath tests.  Methanobrevibacter smithii is a bacteria that accounts for most of the methane production in the body.  Some comprehensive stool panels test for this “methanogenic” bacteria, and if this is high then this might suggest that someone has SIBO.  However, this isn’t conclusive, and the breath test remains the gold standard for determining if someone has SIBO.

What Health Conditions Are Associated With SIBO?

Below I have listed some of the other health conditions associated with SIBO.  This doesn’t mean that SIBO is always responsible for the development of these conditions, but if you have any of the following conditions then SIBO is a possible cause.

• Acne Rosacea
• Chronic fatigue syndrome
• Fibromyalgia
• Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)
• Interstitial Cystitis
• Restless legs syndrome
• Rheumatoid arthritis

What’s The Ideal Diet For Those With SIBO?

Although I like my patients with Graves’ Disease and Hashimoto’s to start on an autoimmune paleo diet, in the past I have written blog posts which discuss how there is no diet that fits everyone perfectly.  And the same concept applies with SIBO.  While all cases of SIBO involve the overgrowth of bacteria into the small intestine, the bacteria will differ from person to person.  As a result, one person with SIBO might be able to tolerate foods that someone else with SIBO can’t tolerate, and vice versa.  In addition, some people might be able to eat small quantities of a certain food, but if they eat larger quantities they experience bloating and gas.  With that being said, there are certain diets that people with SIBO should consider following, although there will be some modifications depending on the person.

Below I’m going to discuss the different diets that are recommended for patients with SIBO.  The primary goal of each of these diets is to feed the person while starving the bacteria.

Low FODMAP diet.  This probably is the most well known diet when it comes to SIBO, and because of this, many healthcare professionals will put their patients with SIBO on this type of diet.  FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols.  Examples of high FODMAP foods include fermented foods (i.e. sauerkraut), starch (grains, beans, starchy vegetables), soluble fiber (grains, beans, fruits, vegetables), sugar (fruit, agave), and resistant starch (legumes, whole grains).

This doesn’t mean that everyone with SIBO needs to avoid all of these foods.  For example, some people with SIBO are able to tolerate sauerkraut, while others can’t eat any fermented foods without experiencing gas, bloating, and other symptoms.  Some people are able to eat small amounts of these foods, while others are unable to tolerate certain foods altogether.  And so you need to listen to your body.

Specific Carbohydrate Diet.  The Specific Carbohydrate Diet (SCD) is similar to a Paleo diet in that it allows meat, fish, eggs, nuts, seeds, vegetables, and fruit.  However, it differs in that it does allow some lactose-free dairy and certain beans.  The dairy products that are allowed include yogurt, aged cow and goat cheeses, butter, ghee, and cottage cheese.  The allowed beans include white beans, navy beans, lentils, split peas, lima beans, kidney beans and black beans.  In order to make the beans easier to digest you want to soak them overnight.  For more information I would read the book “Breaking The Vicious Cycle”, or you can visit the website www.scdlifestyle.com.

GAPS diet.  GAPS stands for Gut and Psychology Syndrome, and the diet was developed by Dr. Natasha Campbell-McBride.  The diet is very similar to the Specific Carbohydrate Diet, and involves minimal supplementation.  The only legumes allowed on the GAPS diet include lentils, split peas and white navy beans, and they need to be soaked first.  Dairy is initially eliminated, but then the person is allowed to slowly reintroduce ghee, followed by butter, yogurt, sour cream, kefir, hard cheese, and cream.  One of the main differences between the GAPS diet and the Specific Carbohydrate Diet is that the GAPS diet involves going through a 6-stage introduction diet before moving onto the “full” GAPS protocol, which is usually followed for one or two years.

SIBO Specific Diet.  This is a diet created by Dr. Allison Siebecker, and is a combination of the Specific Carbohydrate Diet and the low FODMAP diet.  While it’s a great diet for those who have SIBO, it’s important to understand that this a very restrictive diet, and as a result, Dr. Siebecker first recommends to try one or more of the other diets listed above first, and if you don’t do well with the other diets then you might want to consider giving this diet a try.   For more information I would visit www.siboinfo.com/diet.

Elemental diet.  The elemental diet can be the most effective diet when it comes to alleviating the symptoms of SIBO.  However, it is arguably the most challenging diet to follow.  It’s considered an antimicrobial approach because the goal is to starve the bacteria, but supply the person with sufficient nutrients in an easily absorbed form.  It essentially consists of protein, fat, carbohydrates, amino acids, vitamins, minerals, and either glucose or maltodextrin.  You can get a premade formula from a company such as Integrative Therapeutics, or if you visit www.siboinfo.com and visit the resources page you can get a recipe to make your own.  The elemental diet can help to lower both methane and hydrogen levels and typically you want to follow it for 2 or 3 weeks, and then do another breath test immediately upon completion of it.

Should Someone With Graves’ Disease or Hashimoto’s Also Follow An AIP Diet?

Many people with Graves’ Disease and Hashimoto’s Thyroiditis follow an AIP diet, and they might want to know if they should continue following an AIP diet when trying to address SIBO.  So for example, should they follow an AIP diet and a low FODMAP diet?  Doing this is extremely difficult, and what you usually want to do is prioritize the eradication of SIBO.  In other words, it’s usually okay to stray from the AIP diet while trying to address SIBO, and this falls into the “Remove” category of the 5-R protocol I mentioned in a previous blog post.  Then once the bacterial overgrowth has been “removed” you can focus more on gut healing by following the AIP diet, along with eating gut-healing foods (i.e. bone broth) and taking certain nutrients (i.e. L-glutamine).

Eradicating SIBO Through Drugs and Herbs

In order to eradicate SIBO there are two main methods used: prescription antibiotics and natural antimicrobials.  Let’s look at the pros and cons of each.

Prescription antibiotics.  Rifaximin is the antibiotic most commonly recommended for SIBO.  While I’m not a big fan of antibiotics, Rifaximin is different than most other antibiotics.  First of all, it stays in the small intestine, which means that it doesn’t harm the beneficial bacteria in the large intestine like most other antibiotics do.  In fact, there is evidence that Rifaximin can actually increase good bacteria (i.e. bifidobacteria) in the large intestine.  In addition, bacterial resistance isn’t too common when using Rifaximin.  With that being said, not everyone with SIBO will respond to Rifaximin.

Herbal antimicrobials.  I personally prefer to use herbal antimicrobials when dealing with SIBO.  Some of the natural agents which can help to eradicate SIBO include berberine, oregano oil, neem, and allicin.  Keep in mind that while garlic is a high FODMAP food, most people with SIBO can tolerate an allicin supplement, although not everyone.  Although I personally haven’t used pomegranate as of writing this blog post, Dr. Nirala Jacobi has a lot of experience with SIBO and has been experimenting with pomegranate as an antimicrobial.  As for whether the herbs are as effective as Rifaximin, there actually was a study that showed that herbal therapy is equivalent to Rifaximin for treating SIBO (1).  However, just as is the case with Rifaximin, not everyone with SIBO will respond to the herbal antimicrobials.

What To Do When Rifaximin or The Natural Antimicrobials Don’t Work

So what should be done if someone takes either Rifaximin or the natural agents and doesn’t improve?  Well, it is important to do another SIBO breath test after completing a round of treatment.  On the retest, if the gas levels have decreased a good amount but are still high then it makes sense to do another round of the Rifaximin or natural antimicrobials, regardless if the person’s symptoms have improved or not.  On the other hand, if the gas levels haven’t improved then it probably is wise to try a different treatment approach.  If the gas levels have normalized and the person is still symptomatic then this is usually an indication that there is something else going on besides SIBO, and additional testing might be indicated.

The Role of Prokinetics In Preventing a Relapse

Prokinetics help to stimulate the MMC, and since most cases of SIBO are caused by a dysfunctional MMC, taking prokinetics can be important to prevent a relapse after receiving treatment for SIBO.  It’s also important to understand that the MMC works in a fasting state, and so while I commonly recommend for patients to eat regularly throughout the day to help stabilize the blood sugar levels, those with SIBO probably shouldn’t snack in between meals, and should go at least 12 hours overnight without eating.

As for what prokinetics you should take, I used to recommend an herbal formulation called Iberogast, but it seems as this is being discontinued.  Ginger can be a good prokinetic, and 5-HTP also can be helpful.  Many reading this are familiar with low dose naltrexone, and this can also act as a prokinetic.  For those who aren’t familiar with LDN you can read the article I wrote entitled “Low Dose Naltrexone and Thyroid Autoimmunity“.  Erythromycin is commonly used as an antibiotic, but in very low doses it can also help to stimulate the MMC (2).

How long should someone take a prokinetic for after SIBO has been eradicated?  It depends on the person, as most will need to take it for at least 3 to 6 months.  And if someone has autoimmunity to vinculin then they might have to take prokinetics on a permanent basis.  I mentioned earlier how if someone has the CDT-b toxins these harm the ICC, and in a case of mistaken identity the immune system attacks vinculin.  And until we figure out how to stop the autoimmune process then the person will most likely have to continuously take prokinetics.

Can Someone With Graves’ Disease or Hashimoto’s Get Into Remission By Eradicating SIBO?

As I mentioned earlier in this post, SIBO doesn’t seem to be a direct trigger of thyroid autoimmunity.  However, SIBO can cause an increase in intestinal permeability, which is a factor in autoimmune conditions such as Graves’ Disease and Hashimoto’s Thyroiditis.  Because of this, one can argue that if someone has SIBO and a leaky gut, then in order to heal the gut it is necessary to eradicate SIBO, and if the trigger is also removed then this can put the person into remission.  And so while eradicating SIBO might be necessary for healing a leaky gut, in order to get someone with an autoimmune thyroid condition into remission it is still necessary to find and remove the trigger.

In summary, small intestinal bacterial overgrowth can be present in people with Hashimoto’s Thyroiditis and Graves’ Disease.  The most common cause of SIBO is dysfunction of the migrating motor complex.  SIBO is usually diagnosed with either the lactulose or glucose breath test, although false negatives are possible with either test.  Some of the common diets recommended for those with SIBO include the low FODMAP diet, the Specific Carbohydrate Diet, the GAPS diet, the SIBO Specific Diet, and the Elemental diet.  Although antibiotics such as Rifaximin are commonly given to people with SIBO, herbal antimicrobials can be equally effective in many people.  And taking prokinetics can be important to prevent a relapse from occurring after receiving treatment for SIBO.