Most people reading this probably have heard of a leaky gut.  But many people don’t truly understand what causes a leaky gut, how to determine if they have it, and how to heal their gut.  Many people just assume they have a leaky gut, and then will attempt to repair their gut by drinking bone broth and/or taking gut repair supplements.  In the past I have written numerous articles and blog posts on leaky gut syndrome, but since a leaky gut is something that impacts those with Graves’ disease and Hashimoto’s I’ve decided to put together an updated blog post that focuses on five things you should know about a leaky gut.

1. According to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s has a leaky gut.  The triad of autoimmunity involves a genetic predisposition, an environmental trigger, and an increase in intestinal permeability, which is also known as a leaky gut.  It’s common to work with an autoimmune thyroid patient who wonders if they have a leaky gut, although according to this theory, EVERYONE with any type of autoimmune condition has a leaky gut, at least initially.  In other words, according to this theory a leaky gut is one of the three factors necessary for autoimmunity to develop, but this doesn’t mean that a leaky gut can’t be healed.  In fact, in order to reverse the autoimmune component it is necessary to find and remove the environmental trigger and heal the gut.

2. Gluten causes a leaky gut in everyone.  Speaking of environmental triggers, recent evidence shows that gluten causes a leaky gut in everyone.  This is a very good argument for everyone with Graves’ disease and Hashimoto’s to avoid gluten while restoring their health, and to also try to your best to avoid it after you have achieved a state of remission.  I was diagnosed with Graves’ disease in the fall of 2008, and I achieved a state of remission in 2009.  And while I avoid gluten most of the time, I can’t say that I’ve been 100% gluten free since restoring my health.  So if gluten causes a leaky gut in everyone, why haven’t I relapsed?

There are a few potential reasons for this.  First of all, I do minimize my exposure to gluten.  Second, I’m pretty sure that I don’t have Celiac disease or a non-gluten sensitivity.  So while gluten causes a leaky gut in everyone, in my case it wasn’t the direct trigger of my Graves’ disease condition.  A third reason is luck, as if I were to overindulge in foods with gluten for a prolonged period of time, and at  the same time I was exposed to a certain environmental trigger, then there is a very good chance I would relapse.  So every time I’m exposed to gluten I’m playing with fire.  And to be honest, there is a risk even with a single exposure to gluten.  So in no way am I encouraging anyone to consume gluten after getting into remission.

By the way, I think another reason why I haven’t relapsed is because I do a lot of other things to maintain a healthy state.  Even though I’m not perfect with the diet, I eat well most of the time.  And just like most people, I deal with a lot of stressors, but I’m confident that I do a good job of dealing with them, as I block out time for stress management each day, and I also make sure to get sufficient sleep each night.  In addition, I’m always doing things to reduce my toxic load, including doing a 21-day liver detox a few times per year, as well as infrared sauna therapy a few days per week.  Don’t get me wrong, as there is always room for improvement, but it’s also important to understand that perfection isn’t necessary to maintain a state of wellness after achieving a state of remission.  If this were the case then everyone would eventually relapse.

3. Leaky gut testing is available.  Some people aren’t aware that there is testing available to find out if you have a leaky gut.  One option is the lactulose-mannitol test, which is a urine test that requires someone to swallow a sugary solution of lactulose-mannitol.  Lactulose is a larger molecule, and therefore it’s poorly absorbed in someone who has a healthy gut.  As a result, if someone who does this test has high levels of lactulose in the urine then this usually indicates that they have an increase in intestinal permeability.

Cyrex Labs also has a leaky gut test.  The name of the test is the Intestinal Antigenic Permeability Screen, also known as their Array #2.  This tests for a few different antigens associated with a leaky gut, including actomyosin, occludin/zonulin, and lipopolysaccharides.

I used to recommend leaky gut testing frequently, most commonly the Array #2 from Cyrex Labs.  And there are times when I still recommend this test to my patients, but in most cases I assume that the person has a leaky gut.  And there are a few reasons why I take this approach.  First of all, according to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s has a leaky gut.  Second, when I used to recommend the Array #2 more frequently I found that most people did test positive.  And when someone tested negative I would wonder if the results were accurate since everyone with an autoimmune condition has a leaky gut, at least according to the triad of autoimmunity I mentioned earlier.

Of course there is always the possibility that someone initially had a leaky gut but then took the necessary steps to heal it.  So for example, in some people gluten is the sole leaky gut trigger, and if someone has eliminated gluten from their diet, yet hasn’t found and removed the “direct” autoimmune trigger, then conceivably this can cause someone to have a normal leaky gut test, even in the presence of positive autoantibodies.  Stated differently, it’s possible to remove the “leaky gut” trigger and heal the gut, yet still have elevated thyroid antibodies if the “direct” environmental trigger hasn’t been removed.

4. A leaky gut can lead to multiple food sensitivities.  I’m not a big fan of food sensitivity testing, but there are times when I have had patients order a food sensitivity panel.  And it’s common for those who have a leaky gut to have many different food sensitivities.  The good news is that healing the gut usually will help to resolve most, if not all of the food sensitivities.

5. In order to heal your gut you need to follow the 5-R protocol.  The five components of the 5-R protocol include 1) remove, 2) replace, 3) reinoculate, 4) repair, and 5) rebalance.  It is imperative to remove the leaky gut trigger, and while this may sound like common sense, I commonly see people focusing on replacing, reinoculating, and repairing before they find and remove the factor that caused the leaky gut.  Admittedly it can be challenging at times to find the leaky gut trigger, and while you can incorporate the different “Rs” of the protocol simultaneously, you won’t heal a leaky gut if you don’t remove the factor that is causing it.

So how can you find the leaky gut trigger?  I talk about this in great detail in my book Hashimoto’s Triggers, and the same process of finding and removing triggers also applies to those with Graves’ disease.  While many times testing is necessary to find your leaky gut trigger, this isn’t always the case.  For example, if gluten is someone’s sole leaky gut trigger, then simply eliminating gluten can allow someone’s gut to heal.  If taking a course of antibiotics were the leaky gut trigger, then of course you removed the trigger as soon as you stopped taking the antibiotics.

Sometimes it’s not so simple, and testing may be necessary to find your leaky gut trigger.  And even if testing isn’t necessary to detect your “leaky gut trigger”, it very well might be necessary to find your “direct trigger”.  If this is confusing to you then I’d recommend reading my blog post on the triad of autoimmunity.  It’s also important to keep in mind that someone can have multiple leaky gut triggers.  So for example, if someone is eating gluten and has a gut infection, both of these can cause a leaky gut, and thus both of these “leaky gut triggers” would need to be removed in order for the gut to heal.

So let’s summarize this blog post.  According to the triad of autoimmunity, everyone with an autoimmune condition has a leaky gut, which of course would include those with Graves’ disease and Hashimoto’s.  Although gluten isn’t a “direct” environmental trigger in everyone, it does cause a leaky gut in everyone.  A leaky gut can also cause multiple food sensitivities, and while leaky gut testing is available, it’s not something that I commonly recommend to my patients.  Finally, in order to heal your gut you need to remove the leaky gut trigger, which is the first “R” of the 5-R protocol.

Methimazole (brand name Tapazole), is commonly prescribed to those who have hyperthyroidism and Graves’ disease.  In most cases it is effective in reducing thyroid hormone levels, and while it’s not doing anything for the cause of the problem, it can help to prevent someone from receiving radioactive iodine (RAI) or thyroid surgery while the underlying cause of the condition is being addressed.  However, not everyone is able to tolerate Methimazole, and if someone has a negative reaction to Methimazole, there is a good chance the endocrinologist will recommend RAI or thyroid surgery.

Methimazole, along with other thionamide-derived antithyroid drugs, have been used for over half a century.  A common starting dosage is 20 mg per day, although if someone has a more severe case of hyperthyroidism then larger doses might be prescribed (i.e. 40 mg/day).  Most endocrinologists will recommend Methimazole for 12 to 18 months, assuming the person isn’t experiencing any severe side effects, or other problems, including elevation of the liver enzymes.

As for how Methimazole works, it inhibits an enzyme called thyroperoxidase, which is important in the synthesis of thyroid hormone.  It specifically inhibits the metabolism of iodide and the iodination of tyrosine residues, which in turn prevents the synthesis of both T4 and T3 (1).

Potential Side Effects of Methimazole

Here are some of the side effects people can experience when taking Methimazole (2) (3):

• Changes in taste
• Dizziness
• Hair loss
• Headaches
• Hives
• Itching
• Joint pain and swelling
• Nausea
• Rashes
• Vomiting

More serious side effects include the following (3):

• Blood in your urine or stools
• Clay-colored stools
• Dark urine
• Fever
• Jaundice (yellowing of the skin or eyes)
• Loss of appetite
• Severe blistering, peeling, and red skin rash

Two Additional Complications Associated With Methimazole

Agranulocytosis.  This is a term used to describe a severe reduction in the production of white blood cells. This is more likely to affect those who take high doses of Methimazole.  Some patients with agranulocytosis will present with signs and symptoms of an infection, including a high fever and a sore throat (4).

Elevated liver enzymes.  This is more commonly associated with Propylthiouracil (PTU), but over the years I’ve had numerous patients with hyperthyroidism whose liver enzymes were elevated when taking Methimazole or Carbimazole.  You might want to check out an article I wrote entitled “How To Decrease Elevated Liver Enzymes In Hyperthyroidism and Graves’ Disease“.  In the article I discuss when you should be concerned about elevated liver enzymes, and some strategies to decrease them.

What Alternatives Are There To Methimazole?

As I mentioned in the opening paragraph, if someone is unable to take Methimazole, it’s common for their endocrinologist to recommend radioactive iodine or thyroid surgery.  However, there are three treatment options you should consider before getting your thyroid gland ablated or surgically removed:

Option #1: Try to get a prescription for Propylthiouracil (PTU).  The downside of PTU is that it can be harsher on the liver than Methimazole, and approximately 50% of those who are unable to tolerate Methimazole will also be unable to tolerate PTU.  That being said, it still might be worth giving PTU a try, as while it might produce similar side effects as Methimazole, there is also a chance that you might be fine taking it, and at the very least it can buy you some time while you are trying to address the underlying cause of your condition.

Option #2: Consider natural antithyroid agents.  Many reading this know that when I was diagnosed with Graves’ disease I didn’t take antithyroid medication.  Instead, I took an antithyroid herb called bugleweed to manage my hyperthyroid symptoms.  Although bugleweed isn’t always potent enough to lower the thyroid hormone levels, it’s definitely worth a try before resorting to extreme treatment methods such as RAI and thyroid surgery.  It’s also important to mention that the quality of the herb is important, and you should consider taking a stronger extract ratio.  For more information on bugleweed and other herbs that can help manage the hyperthyroid symptoms, I would read a blog post entitled “Which Are The Best Herbs For Managing The Symptoms Of Hyperthyroidism & Graves’ Disease?”.

Option #3: Low dose naltrexone (LDN).  This option should be considered for those people with Graves’ disease, and not other types of hyperthyroid conditions (i.e. toxic multinodular goiter, subacute thyroiditis, etc.).  Naltrexone is an FDA-approved medication, and it was discovered that low dose naltrexone (LDN) has immune-modulating effects that can benefit many people with autoimmune conditions.  While there are no studies I’m aware of that specifically show that LDN can help people with Graves’ Disease, over the years I have had some people with Graves’ disease successfully use LDN to manage their symptoms while addressing the underlying cause of their condition.

If LDN can modulate the immune system and effectively manage the hyperthyroid symptoms, then why don’t I recommend it more frequently to my patients with Graves’ disease?  There are a few reasons for this.  The main reason is because while it’s not harsh on the body like Methimazole, it’s also not as effective in managing the hyperthyroid symptoms.  I also find bugleweed to be more effective than LDN.  And if someone has an elevated resting heart rate due to high thyroid hormone levels, then it’s important to get the thyroid hormone levels down as soon as possible.

Another reason why I don’t commonly recommend LDN to my patients is because it can be challenging to get a prescription.  Unfortunately most endocrinologists aren’t open to prescribing LDN, and many aren’t even aware of the benefits regarding its immune-modulating effects.  However, recently I’ve had a few patients get a prescription remotely by working with a medical doctor online at www.ldndoctor.com.  The way this works is that you schedule a consultation with a medical doctor, and they will write a 6-month prescription for LDN.  I must warn you that I don’t personally know any of the LDN-prescribing doctors, although so far the feedback from my patients have been positive.

Another website to check out is www.ldnscience.org, where you can find a local doctor who prescribes LDN.  The upside is that you not only can search for a doctor who prescribes LDN in the United States, but in other countries too.  The downside is that there are some locations that don’t have an LDN-prescribing doctor.  For example, I live right outside of Charlotte NC, but as of writing this blog post, the closest doctor who prescribes LDN practices approximately 2 hours away.  However, if I was facing either radioactive iodine or thyroid surgery I would gladly drive a few hours to get a prescription for LDN, although I also would consider scheduling a consultation with someone through www.ldndoctor.com.

Which Option Should YOU Choose?

If you had a negative reaction to Methimazole and are currently facing a situation where your endocrinologist is pressuring you to receive radioactive iodine or thyroid surgery, you might be wondering which of these three alternatives to consider.  It’s not an easy decision to make, as while I listed PTU first, this doesn’t mean that you can’t try a natural approach such as bugleweed.  And even though I gave a few reasons why I don’t initially recommend LDN to my patients with Graves’ disease, you might decide to start with this option.

One of the benefits of LDN is that unlike antithyroid medication and herbs, LDN actually modulates the immune system.  However, even if LDN effectively modulates your immune system, keep in mind that it’s not addressing the underlying cause of the problem.  Of course neither is antithyroid medication or bugleweed, and so regardless of which of these three options you choose, you would still want to address the cause of your condition.  If someone has a non-autoimmune hyperthyroid condition, such as toxic multinodular goiter, then they will want to consider the first two options I mentioned.

In summary, many people with hyperthyroid conditions take Methimazole to manage the hyperthyroid symptoms.  However, not everyone with hyperthyroidism can take Methimazole, as some people experience side effects.  When this is the case you might want to look into other options, including PTU, bugleweed, and low dose naltrexone.

The last month or two I have been talking a lot about my new book “Hashimoto’s Triggers”, which was released a few days ago.  During this time I’ve had a few people with Graves’ disease ask about “Graves’ Disease Triggers”.  The truth is that while managing the symptoms of Graves’ disease is dramatically different when compared to Hashimoto’s, the process of finding and detecting the autoimmune triggers is the same with both conditions.  And many of the same triggers that are found in Hashimoto’s are also found in Graves’ disease, although some triggers are more common in Graves’ disease, and vice versa.

For example, although I discuss H. Pylori in my book as a potential trigger of Hashimoto’s, this is a more common trigger in those with Graves’ disease.  Similarly, the research shows a higher correlation between stress and the development of Graves’ disease.  On the other hand, the parasite Blastocystis hominis seems to be a more common trigger in those with Hashimoto’s.

Some people with Graves’ disease have asked if they should read my Hashimoto’s Triggers book, or if it’s best to read the book I wrote on hyperthyroidism and Graves’ disease?  The honest answer is “both”, and here is the reason.  The book on hyperthyroidism and Graves’ disease focuses on hyperthyroid conditions, and so it of course makes sense for anyone with Graves’ disease or a non-autoimmune hyperthyroid condition to read this book.  However, there is a lot of updated information in my Hashimoto’s Triggers book that isn’t in my other book.  And while some of the information is specific to Hashimoto’s thyroiditis, a lot of the information will be useful for those with Graves’ disease, as well as those with other autoimmune conditions.

For those wondering when I plan on releasing a new book on Graves’ disease, all I can say is that this is something that will happen in the near future.  It almost definitely won’t be this year since I haven’t started writing it, but I wouldn’t rule out a new Graves’ disease book in 2019.  Of course originally I was hoping to release my book on Hashimoto’s a few years ago, and so I’m sure you can understand that I can’t put a firm date on the book at this point.  But in the meantime I would not only check out my book on hyperthyroidism and Graves’ disease, but I would also seriously consider reading my new book on Hashimoto’s Triggers…especially since the electronic version is steeply discounted and I’m also offering 3 special bonus gifts.  You can check out this special offer by clicking here.

Whether you have Graves’ disease or Hashimoto’s thyroiditis, the primary key to getting into remission is to find and remove your specific autoimmune triggers.  This can be very challenging to do, which is why it took so long to write my new book “Hashimoto’s Triggers” (which is now available on Amazon).  Speaking of which, even though the title of the book may imply that it’s specifically for those who have Hashimoto’s, the truth is that the process of detecting and removing triggers is similar regardless of whether someone has Hashimoto’s, Graves’ disease, or a different autoimmune condition (i.e. rheumatoid arthritis, multiple sclerosis, lupus, etc.).  So the truth is that this book can benefit those people with other autoimmune conditions, although some of the information is specific to Hashimoto’s.

But why can it be so challenging to find your autoimmune triggers?  While there are only 4 main categories of autoimmune triggers (food, stress, microbes, and chemicals), there are numerous triggers within each of these categories.  And while I mentioned in the opening paragraph that the process of detecting and removing triggers is similar regardless of the autoimmune condition someone has, different people will have different triggers.  In addition, it’s common to have multiple triggers.

Dealing With Multiple Autoimmune Triggers

For example, one person with an autoimmune condition might have gluten and an infection as triggers.  In this situation, removing gluten alone won’t always result in a significant improvement in the person’s symptoms and/or a reduction in their autoantibodies.  As a result, the person might end up eliminating gluten and not notice any improvement in their symptoms, and on top of this their autoantibodies remain elevated, and so they conclude that the problem isn’t with gluten.  Perhaps this person even had a negative celiac panel, and they don’t realize that it’s possible to have a gluten sensitivity, even in the absence of celiac disease (called a non-celiac gluten sensitivity).

This example shows why you can’t always rely on symptoms to detect your triggers.  Sure, there are some people who have experienced complete resolution of their symptoms and a normalization of their antibodies upon removing gluten, or upon following an autoimmune Paleo (AIP) diet.  But I don’t find these situations to be common in my patients.  Of course one reason for this is because many people make these dietary changes on their own, and some are able to find their food triggers without working with a natural healthcare professional.  On the other hand, other people aren’t able to successfully find and remove their autoimmune triggers.

In any case, the reason why I brought up this example is because if someone has multiple autoimmune triggers, then the obvious goal should be to remove all of them.  But sometimes not all of these triggers are detected initially, which is why you can’t conclude that food isn’t a trigger just because you don’t feel better upon eliminating it.  In the example I just gave, the person very well might have to eliminate gluten AND eradicate the infection before they see a significant improvement in their symptoms and/or a lowering of their thyroid antibodies.  On the other hand, others might experience significant symptomatic improvement just by eliminating gluten alone, even in the presence of one or more additional triggers.

How Much Testing Do You Need To Find Your Triggers?

In my book on Hashimoto’s Triggers, I talk about conservative vs. comprehensive testing.  Conservative testing involves doing some basic testing, and for many people this is sufficient to find their triggers.  On the other hand, some people need more comprehensive testing.  How can you determine if you need conservative or comprehensive testing?  Some people make this decision based on the costs of the tests, and while I can understand not wanting to spend a lot of money on testing, at the same time you also want to do what is necessary to find your triggers.

Does this mean that I’m in favor of comprehensive testing?  Not necessarily, as I actually prefer to take a conservative approach whenever possible, but if after conducting a thorough health history I feel that more comprehensive testing is necessary, then I’ll make this recommendation to the patient.  Of course regardless of whether a healthcare practitioner recommends conservative or comprehensive testing, it is ultimately up to you.  In other words, all a healthcare practitioner will do is give his or her recommendations, and then it’s up to you to decide how much testing you want to do.

I’ll also add that there are risks of doing either conservative or comprehensive testing.  For example, when I was diagnosed with Graves’ disease I personally didn’t do a lot of testing.  So I fell under the “conservative testing” category.  The risk with conservative testing is that you might not detect all of your triggers, and additional testing might be necessary in the future.  While some people are fine taking this approach, other people don’t want to take the chance.  In other words, some don’t want to rely on conservative testing, risk not finding all of their triggers, and then have to do additional testing a few months later.

Of course the “risk” with comprehensive testing is that you might end up spending money on testing that you don’t need.  For example, there are some healthcare professionals who recommend in excess of $1,000 worth of testing to all of their patients.  I’m not saying this is right or wrong, as everyone takes a different approach.  And while it can be beneficial to rule out certain triggers (i.e. infections), some people are on a very tight budget, and are therefore unable to spend a lot of money on testing.

Don’t Forget To Heal Your Gut!

Although the main focus of this blog post was to discuss triggers, it’s important to remember that while finding and removing your triggers is necessary to reverse the autoimmune component, you need a healthy gut in order to have a healthy immune system.  And according to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s (and every other autoimmune condition) has a leaky gut.  And while in some cases finding and removing your triggers will be sufficient for gut healing, this isn’t always the case.

In my book I discuss the difference between “direct” triggers and “leaky” gut triggers, and while I won’t get into detail here about this, I will say that sometimes the direct trigger and the leaky gut trigger are the same, but at other times they can be different.  For example, the research shows that gluten can cause a leaky gut in everyone, and so gluten is a leaky gut trigger.  And while it can also be a direct trigger of autoimmunity, this isn’t the case with everyone.  Don’t get me wrong, as ideally everyone with an autoimmune condition should avoid gluten since it can cause a leaky gut, and according to the triad of autoimmunity, a leaky gut is a necessary component of autoimmunity.

Now I’d like to hear from you, as I’d like to know what you have specifically done to find your autoimmune triggers.  Please leave a comment below and let me know!

Note: by the way, for a limited time the electronic version of my book is available on Amazon for 99 cents.  In addition, for anyone who purchases either the electronic version or paperback version of my book I’m also offering 3 free bonus gifts.  For more information click here.

Last Friday I was on Facebook Live doing a presentation on testing the adrenals, but for those who prefer reading the information I’m giving a summary in this blog post.  I’ll be focusing on 3 different types of adrenal testing.  Although in the upcoming weeks a lot of the material will focus on Hashimoto’s thyroiditis to celebrate the release of my new book “Hashimoto’s Triggers”, which will be released on March 5^th, this information on adrenal testing will benefit those with hyperthyroidism and Graves’ Disease as well.

Why Should You Test The Adrenals?

When I was diagnosed with Graves’ Disease, I didn’t think stress was a factor.  I always considered myself to have good stress-handling skills, and so you can imagine how surprised I was when an adrenal saliva panel revealed that I had depressed cortisol levels and a depressed DHEA.  This was my first lesson on how you can’t go by symptoms when determining the state of your adrenals.  The pattern I had is referred to by many as an “adrenal fatigue” pattern, and while I can’t say that I felt awesome while I had Graves’ Disease, I can say that fatigue wasn’t one of my primary symptoms.

Some healthcare professionals don’t recommend adrenal testing because they assume that all people have adrenal imbalances.  I argue that this is a reason why everyone should do adrenal testing.  It would be one thing if everyone with an adrenal imbalance had the same pattern, but this isn’t the case.  As I mentioned earlier, when I was dealing with Graves’ Disease both my cortisol levels and DHEA were depressed.  However, many others will have elevated cortisol levels.  And while there is some overlap between treating someone with elevated cortisol levels when compared to depressed cortisol levels, the treatment isn’t exactly the same.

Healthy Adrenals Are Necessary For Healthy Sex Hormones

In the past I wrote a blog post entitled “The Negative Impact of the Pregnenolone Steal”.  The pregnenolone steal is also known as the cortisol steal, and what this means is that the body prioritizes the production of cortisol at the expense of the sex hormones.  As a result, someone who is dealing with prolonged chronic stress not only is likely to have an adrenal imbalance, but there is a very good chance that some or all of their sex hormones (i.e. progesterone, estrogen, testosterone) will be deficient.

In this scenario, many doctors who dispense bioidentical hormones would recommend these to the patient.  However, the real problem isn’t with the sex hormones, but instead is with the adrenals.  I’m not suggesting that all sex hormone deficiencies are due to adrenal imbalances, but the truth is that the majority of sex hormone imbalances can be corrected by improving the health of the adrenals.

Can You Take Adrenal Supplements Without Doing Any Testing?

Even though I’m discussing the importance of adrenal testing in this blog post, the truth is that many people take adrenal support supplements without doing any testing.  For example, I commonly see people randomly taking adaptogenic herbs such as ashwagandha, rhodiola, and eleuthero.  Others will take nutrients such as vitamin C and the B vitamins to support the adrenals.  And while taking these without testing might not do you any harm, you want to be cautious about taking other supplements without knowing what type of adrenal imbalance you have.

For example, if you have elevated cortisol levels then you wouldn’t want to take licorice root or an adrenal glandular, as these are best taken when someone has depressed cortisol levels.  Similarly, phosphatidylserine is best taken if someone has elevated cortisol levels.  And while I don’t commonly recommend DHEA to my patients, when I do recommend it I’ll make sure that the person has low DHEA levels.  This might sound like common sense to some people reading this, but you’d be surprised how many people I’ve seen over the years who were taking supplements and/or hormones that didn’t fit their adrenal pattern.

While I’d be cautious about taking adrenal supplements without any testing, anyone can of course incorporate lifestyle changes to help improve their adrenal health.  In fact, in order to have optimal adrenal health it is necessary to eat well, do a good job of managing stress, and to get sufficient sleep.  These are factors that everyone can and should work on.  In fact, working on these diet and lifestyle factors is even more important than taking supplements.

3 Types of Adrenal Testing

What I’d like to do next is discuss three different ways to test for the adrenals:

1. Blood Testing.  Many medical doctors, including just about all endocrinologists, never do any adrenal testing.  The exception is if they suspect that someone has adrenal insufficiency in the form of Addison’s disease or Cushing’s syndrome.  Those medical doctors who do test the adrenals usually utilize blood testing.  In most cases they will order a morning cortisol, and perhaps test the DHEA.

Adrenocorticotropic hormone (ACTH) is a pituitary hormone that can also be tested for in the blood.  It stimulates cortisol production, and if someone has a condition such as Addison’s disease they will usually see depressed cortisol and increased ACTH, while with Cushing’s syndrome, both cortisol and ACTH will usually be increased.  An adrenal tumor frequently presents with increased cortisol levels and a decreased ACTH.

While blood testing isn’t completely useless, there are a few reasons why you shouldn’t rely on this type of testing for determining the health of the adrenals.  First of all, blood testing doesn’t look at the circadian rhythm of cortisol, and the reason for this is because this almost always involves a single blood sample.  As I’ve discussed in past blog posts and articles, cortisol follows a circadian rhythm, as it should be at the highest level in the morning, and gradually decrease throughout the day.  While someone can conceivably visit a lab multiple times in a single day to see what cortisol looks like at different times, this a major inconvenience, which is one of the main reasons why it usually isn’t done.

In addition, false elevations of cortisol are common in the blood.  One of the main reasons for this is because it’s common for people to get stressed out when getting a blood draw.  And cortisol increases when someone is in a stressed out state.

One advantage of blood testing is that you can test for anti-adrenal antibodies.  An example is 21-hydroxylase antibodies.  I can’t say that I have most people test for this, and even though I once had depressed cortisol levels I personally didn’t test for these antibodies.  But if someone has low cortisol levels that remain depressed over a prolonged period of time, then in this situation it would be a good idea to test these antibodies, as this might be suggestive of Addison’s disease.

2. Adrenal Saliva Testing.  I’ve been recommending adrenal saliva testing to my patients for many years.  The main reason I started using saliva testing in my practice is because of the success I personally had with saliva testing when I was diagnosed with Graves’ Disease.  And over the years I have also seen many of my patients benefit from saliva testing.  There are a few reasons why saliva testing is a good option for evaluating the adrenals.  Let’s take a look at three of these reasons:

• Saliva testing looks at the circadian rhythm of cortisol
• Saliva testing is less invasive than blood testing
• Saliva testing is just as accurate as blood testing

Just as is the case with blood testing, false elevations of salivary cortisol are possible.  Cortisol responds to stress, and so for example, if someone is in a stressed out state prior to collecting the saliva sample, then there is a good chance this will cause an elevation of cortisol.  Based on what I just said, you might assume that it’s best to do cortisol testing in a relaxed state.  And many of my patients do collect their saliva samples on an off-day from work due to this reason.  However, one can argue that it might be best to test your adrenals under “normal” conditions, which means that if you are stressed out Monday through Friday due to work, but are relaxed on the weekend, then perhaps it’s best to try to test the adrenals during the week.  So for example, you can collect a saliva sample upon waking up, another sample during your lunch break at work, another one when you come home for dinner, and then one right before going to bed.

I realize that for some people this isn’t practical, and truth to be told, even for those who collect the saliva samples on a more relaxed day it can still provide some valuable information.  And as I mentioned earlier, it’s very common for my patients to collect their saliva samples on their off days from work.  Either way, you definitely don’t want to collect the saliva samples under abnormally stressful conditions, as this is likely to result in false elevations of cortisol.

It’s also worth mentioning that many saliva panels test for more than the cortisol and DHEA.  The Adrenal Stress Index test from the lab I use also tests for 17-OH progesterone and secretory IgA.  You can also test for the sex hormones through the saliva, and cycling women can choose to do a cycling hormone panel.  This involves collecting a saliva sample every few days of one’s cycle, which not surprisingly gives more information than a single blood test taken in the second half of the cycle.

3. Dried Urine Testing.  In 2017 I started “experimenting” with dried urine testing.  A lot of well known healthcare professionals (i.e. Dr. Joseph Mercola) recommend this type of testing.  I used myself as a guinea pig initially, and I was impressed with what I saw, which is why I started recommending it to some of my patients.  This test involves urinating on test strips throughout the day, which like the saliva, allows you to look at the circadian rhythm of cortisol.  It also tests the sex hormones, but unlike saliva testing, dried urine testing can also look at the “hormone metabolites”, which in some cases can be helpful.

While there can be some value in looking at cortisol metabolism through dried urine testing, perhaps the most important metabolites to evaluate are the estrogen metabolites.  These include 2-hydroxyestrone (2-OH), 4-hydroxyestrone (4-OH), and 16α-hydroxyestrone (16α -OH).  The reason why looking at these metabolites can be important is because having higher levels of 4-OH metabolites can potentially be a risk factor for developing certain types of cancer, while having higher levels of 2-OH metabolites can be protective.

Which Type of Testing Should You Do?

Now that you are familiar with the different ways to test for the adrenals, you might be wondering what the best test is for you.  As of now I still recommend adrenal saliva testing to most of my patients.  However, if someone wants to test for both the adrenals and sex hormones then either saliva testing or dried urine testing can be a good option.  Dried urine testing is more comprehensive in that it also tests for the hormone metabolites. For cycling women, both saliva testing and dried urine testing offer cycling hormone panels.

In summary, I recommend adrenal testing to just about all of my patients, and the reason for this is because most people have adrenal imbalances, and people will present with different adrenal patterns.  I have primarily used saliva testing in my practice over the years, although recently I started using dried urine testing on some of my patients.  If someone is just interested in evaluating the adrenals then I think it’s fine to use saliva testing, and while I have also used saliva testing to evaluate the sex hormones in the past, dried urine testing has the advantage of looking at the hormone metabolites.  Blood testing usually should be utilized when more serious adrenal problems are suspected, including Addison’s disease, Cushing’s syndrome, or an adrenal tumor.

Hashimoto’s Triggers Book Update: I just wanted to remind you that my new book on Hashimoto’s Triggers will be released on Monday, March 5^th.  It will be available in both paperback and Kindle format, and the first few days after its release I will be offering a special discount on the Kindle version, along with a few free bonus gifts for anyone who purchases either the paperback version or the Kindle version.  If you would like to check out a free chapter of my book you can do so by clicking here.

Last Friday I spoke on Facebook Live about food triggers and Hashimoto’s.  I thought the presentation went well, but I decided to put together a different presentation on the same topic.  You can watch the video by clicking here, or if you prefer to read the information I also will give a summary in this blog post.  By the way, I plan on appearing on Facebook live every Friday at 1:30pm EST up until the release of my new book, and then even after the release I hope to continue doing them on a regular basis.  Although I’ll be focusing on Hashimoto’s the next few weeks due to my book release, a lot of the information discussed will also benefit those who have Graves’ Disease.

For those who prefer to read rather than watch videos, here is a summary of what I discussed in the video:

I started off by talking about the triad of autoimmunity, which involves 1) a genetic predisposition, 2) an environmental trigger, and 3) an increase in intestinal permeability, which is also known as a leaky gut.  I then briefly mentioned a few of the common triggers of Hashimoto’s.  Besides food allergens such as gluten and dairy, other common triggers include stress, infections, and environmental toxins.  In my upcoming book “Hashimoto’s Triggers” I discuss all of the different triggers in detail, along with how to detect and remove your specific triggers.

Why Is Food A Trigger In Some People?

I then briefly explained the difference between IgE food allergies and IgG food sensitivities.  IgE allergies usually elicit an immediate response, whereas food sensitivities don’t always produce symptoms, and when symptoms do appear they can sometimes take place a few days after eating the food you’re sensitive to.  I also mentioned how having an IgE allergy or IgG food sensitivity doesn’t necessarily mean this food is a direct trigger of your autoimmune thyroid condition.

For example, some people have an IgE peanut allergy, but this doesn’t mean that this is the trigger in someone with Hashimoto’s.  In fact, in all likelihood the person with such an allergy will avoid peanuts.  As for food sensitivities, just because you’re sensitive to a certain food also doesn’t mean it’s an autoimmune trigger.  For example, I just consulted with someone who has digestive symptoms whenever she eats Brussels sprouts.  This doesn’t mean that Brussels sprouts are a direct trigger in her situation, although if she has a sensitivity to Brussels sprouts and continues to eat them, this probably will cause gut inflammation, and thus it would be a good idea to avoid this food.

I briefly spoke about molecular mimicry and food triggers.  According to one theory, gliadin has an amino acid sequence that resembles the thyroid gland, which in turn causes the immune system to attack it.  And so essentially this is a case of mistaken identity, as the immune system attacks the thyroid gland because it looks like gluten.  I do want to add that as of now this is still a theory, although in the research there is a molecular mimicry mechanism involving certain pathogens.

Food Isn’t a Trigger In Everyone

I then spoke about how food isn’t a trigger in everyone with Hashimoto’s, and this is one reason why some people don’t feel better when eliminating common allergens such as gluten.  This is also a reason why some people don’t feel better when following an autoimmune Paleo diet.  However, I also mentioned how the lack of symptoms when eating certain foods doesn’t mean it’s not a trigger.  I discussed how when gluten isn’t a “direct” trigger it can cause a leaky gut.  In fact, there is strong evidence that gluten causes a leaky gut in everyone.

I then discussed “direct” triggers vs. “leaky gut” triggers.  This is discussed further in my book on Hashimoto’s.  I also mentioned how it’s possible to have multiple triggers.  In fact, I will add that it’s common to have more than one trigger.

The Problem With Gluten, Dairy, and Corn

I’ve spoken about gluten in numerous other blog posts, and during this presentation I spent a few minutes on this.  I started by discussing how many people are sensitive to gluten.  I then differentiated between celiac disease and a non-celiac gluten sensitivity.  In both cases you ideally want to avoid gluten on a permanent basis, and if you test for gluten, please keep in mind that you need to be eating gluten for the test to be positive.  And the reason for this is because if you don’t eat gluten, your body won’t produce antibodies to the proteins of gluten, even if you have a gluten sensitivity.  I then reinforced how the research shows that gluten causes a leaky gut in everyone.

Some question whether the problem isn’t with gluten or wheat, but instead is with glyphosate.  I dedicated an entire chapter to glyphosate in my book, and while this is a big problem, the truth is that both gluten and glyphosate are problematic.  Sure, there might be some cases where someone is reacting more to the glyphosate than the gluten, and vice versa.

Dairy is another common allergen, and it also cross-reacts with gluten.  In other words, consuming dairy products can lead to the production of gliadin antibodies.  And while some people do fine eating healthier forms of dairy (i.e. raw dairy), this isn’t the case with everyone.  In other words, some people have problems with dairy, regardless of the source.

Let’s not forget about corn, as this also is a common allergen, and, like dairy, corn also cross-reacts with gluten.  In addition, most corn is genetically modified.  There of course are other food allergens, and in my book I discuss food triggers in much greater detail.

Should You Follow An Autoimmune Paleo Diet?

I also have had plenty of articles and blog posts that focused on an autoimmune Paleo (AIP) diet.  In the video I explained the difference between an AIP diet and a “standard” Paleo diet, and if you want to learn more about this you can either watch the video or read a blog post I wrote entitled “Should Everyone With Graves’ Disease and Hashimoto’s Thyroiditis Follow an Autoimmune Paleo Diet?“.  But essentially an AIP diet eliminates the most common allergens AND foods that can interfere with gut healing.

As for who should follow an AIP diet, in the video I mentioned two specific categories:

Category #1: Those with an autoimmune condition.  This not only includes those with Hashimoto’s, but Graves’ Disease and other autoimmune conditions as well.

Category #2: Anyone who has a leaky gut.  As I mentioned earlier when discussing the triad of autoimmunity, everyone with an autoimmune condition has a leaky gut.  However, it of course is also possible to have a leaky gut in the absence of an autoimmune condition.

How long should someone with Hashimoto’s (or a different autoimmune condition) follow an AIP diet for?  I recommend to follow an AIP diet for at least 30 days, and if someone is thriving after 30 days then it makes sense for them to continue following it for a few additional months.  On the other hand, if they don’t feel better and are struggling with the diet then I’m open to them reintroducing some of the excluded foods.

I finished up the video by listing the following action steps you can take:

• Consider avoiding gluten, dairy, and corn
• Avoid refined foods and sugars
• If you want to go a step further, follow an AIP diet for at least 30 days
• Also try to avoid genetically modified foods
• Reminder: a lack of symptoms when eating a certain food doesn’t mean it’s fine to eat that food
• Should you consider food sensitivity testing?
• Many times following an elimination/reintroduction diet can help identify foods you’re reacting to

Most of these are self-explanatory, although if you read through these steps you might wonder what my thoughts are on food sensitivity testing.  I’m definitely not opposed to such testing, although I will say that most of my patients don’t obtain this type of testing.  And the main reason for this is because false results are common.  I usually recommend an elimination diet to my patients, and while I’ve written about both the elimination diet and food sensitivity testing in past blog posts, I go deeper in my book.

That essentially is a summary of the video.  Speaking of which, I hope you found this information to be valuable.  If so please let me know in the comments below, and if the feedback is positive I’ll try to write a summary with future videos as well.  I realize that while some people love watching videos, others prefer reading information, and so I think it would be a good idea to do both.  But of course what I think doesn’t matter, as my goal is to serve you, which is why I want to get your opinion.

One thing that was in the video that I didn’t mention here (until now) was the opportunity to get a free chapter of my book, Hashimoto’s Triggers.  You can get this chapter by clicking here.

Most people with Hashimoto’s thyroiditis are told to take thyroid hormone replacement, and nothing is ever done to address the cause of the problem.  Endocrinologists know that Hashimoto’s is an immune system condition, but we need to keep in mind that they aren’t immune system specialists.  This is one reason why they don’t do anything to improve the health of your immune system.  But the main reason why endocrinologists ignore the immune system is because they simply aren’t trained in medical school to address the cause of Hashimoto’s.

For someone who does well on thyroid hormone this might not seem like a concern, and the truth is that many people who are diagnosed with Hashimoto’s simply follow the advice of their medical doctor.  And for those reading this who are taking thyroid hormone replacement due to the advice of an endocrinologist, or another type of medical doctor, I’m not suggesting that you shouldn’t take it.  But I am here to say that there are risks of taking thyroid hormone without improving the health of your immune system.  Here are two of these risks:

Risk #1: Many people take Synthroid, which has numerous fillers, as well as artificial ingredients.  While I’m not opposed to someone taking synthetic thyroid hormone, there are better options available than Synthroid.  An example is Tirosint, which is a hypoallergenic form of synthetic T4.  Taking natural desiccated thyroid such as Armour, Nature-Throid, or WP Thyroid is also something to consider, as many people do better on these than synthetic thyroid hormone.

I realize that Synthroid is probably a less expensive option, and perhaps even covered by your health insurance, but we all know that you usually get what you pay for.  For example, purchasing organic food is more expensive than non-organic food, but the reason why many people are willing to pay extra money for organic food is to minimize their exposure to the chemicals that are present in non-organic food.  One problem is that many people who take Synthroid don’t read the ingredients, while others don’t realize that there are hypoallergenic forms of synthetic thyroid hormone available (for those who can’t take or prefer not to take desiccated thyroid).

Risk #2: People with Hashimoto’s have an increased risk of developing other autoimmune conditions in the future.  This is in the research, and it’s a big reason why EVERYONE with Hashimoto’s needs to be proactive and try to detect and remove their autoimmune triggers.  While nobody wants to be diagnosed with Hashimoto’s, and some people with this condition have extreme fatigue, brain fog, and other symptoms, keep in mind that some other autoimmune conditions are arguably worse to have.  For example, while many people are able to function normally when taking thyroid hormone, this might not be the case for someone who has been diagnosed with multiple sclerosis, rheumatoid arthritis, or other autoimmune conditions.

Just to be clear, I’m not advising anyone to stop taking their thyroid hormone replacement.  But for those who do this without improving their immune system health, you are at risk of developing other autoimmune conditions in the future.

What Does It Mean To “Reverse” Hashimoto’s?

The headline of this blog post is “Can Hashimoto’s Be Reversed?”  The answer to this question is “yes”, it is possible to reverse Hashimoto’s.  But what exactly does this mean?  Well, when I use the word “reverse” I’m suggesting that the autoimmune component can be reversed.  In other words, it’s possible to detect and remove the autoimmune triggers and normalize the thyroid antibodies.  I’m not suggesting that this is easy to accomplish, as without question some cases of Hashimoto’s are more challenging than others.  And then even when the autoimmune component has been reversed, for some people it is challenging to maintain a state of remission.

This is true with all autoimmune conditions.  As many reading this know, I was diagnosed with Graves’ Disease in the past, and I have been in remission since 2009.  Since then, I have helped many people with Graves’ Disease and Hashimoto’s achieve a state of remission.  The primary key to helping people with these autoimmune thyroid conditions achieve a state of remission is to find and remove the person’s triggers.  I’ve written about this in past articles and blog posts, have conducted webinars on this topic, and soon I will be releasing a new book that focuses on helping you find and remove your specific autoimmune triggers.

Yes, I know there are currently books on Hashimoto’s that focus on natural treatment methods.  In fact, I’m friends with many of the authors of these books.  But I promise you that my upcoming book is going to be the most comprehensive book to date with regards to discussing the different triggers of Hashimoto’s, along with helping those with this condition detect and remove their triggers.

As for when the book will be released, I don’t have an exact date yet, but I’m 99% certain that it will be released in the first quarter of this year.  In fact, the editing process has been completed, and it’s now in the hands of the formatter.  I’ll add that the first week it’s released there will be a huge discount, along with a few special bonuses for those who purchase the book.  In a couple of weeks I’ll have another update, and I’ll also include a copy of the cover.

In past articles and blog posts I have discussed some of the different conventional medical treatment options for hyperthyroid conditions, but I haven’t discussed something called block and replace therapy.  One of the main reasons for this is because this is rarely recommended to those with hyperthyroidism and Graves’ Disease, although every now and then I’ll work with someone who was recommended to receive this treatment by their endocrinologist.  As a result, I figured it was time to put together a brief post on this topic.

So what exactly is block and replace therapy?  Well, many people with hyperthyroid conditions are told to take antithyroid medication, which includes Methimazole, Carbimazole, and PTU.  These are given to “block” the production of thyroid hormone, and antithyroid medication accomplishes this by inhibiting an enzyme called thyroid peroxidase.  What it specifically does is inhibit the metabolism of iodide and the iodination of tyrosine residues in the thyroid hormone precursor thyroglobulin by thyroid peroxidase (1).

One problem with antithyroid medication is that people who take it commonly become hypothyroid.  So for example, it’s common for someone with elevated thyroid hormone levels to get a prescription for antithyroid medication, and when doing a follow-up thyroid panel their thyroid hormone levels will be low, while their TSH will be on the high side.  When this is the case, the medical doctor will usually lower the dosage of antithyroid medication and hope that the next thyroid panel will show a lower TSH and higher thyroid hormone levels, but at the same time prevent the person from becoming hyperthyroid again.

The “Seesaw” Effect of Antithyroid Medication

Sometimes this can become a frustrating process for the patient, as I’ve worked with people who were told to take a higher dosage of antithyroid medication, and then when the thyroid panel revealed a hypothyroid state the dosage was greatly reduced, and in some cases the patient was told to stop taking the Methimazole, and the person became hyperthyroid again.  So for example, a person with Graves’ Disease or toxic multinodular goiter might be told to take 40mg of Methimazole, and the next thyroid panel presents with hypothyroid numbers (elevated TSH and low thyroid hormone levels), and so the person’s dosage is reduced to 10mg, only to have the person become hyperthyroid again.

With block and replace therapy, the person isn’t only put on antithyroid medication to “block” the production of thyroid hormone, but they are also given thyroid hormone replacement (i.e. levothyroxine).  So it’s almost like a balancing act, as the antithyroid medication will prevent the person from becoming hyperthyroid, but the person is also given some thyroid hormone to prevent them from becoming hypothyroid.  Block and replace therapy is usually reserved for moderate to severe cases of hyperthyroidism, as with this treatment higher doses of antithyroid medication are usually taken by the patient.

Why Is Block and Replace Therapy Seldom Used?

Rarely does an endocrinologist in the United States recommend block and replace therapy, and it also isn’t commonly recommended by medical doctors in other countries.  One reason for this is because the relapse rates are comparable to someone who is taking antithyroid medication alone, but another reason is because side effects seem to be more common with block and replace therapy (2).  Another thing to keep in mind is that most endocrinologists are far more concerned about managing hyperthyroidism, which is why many will recommend radioactive iodine or thyroid surgery as the first line of treatment.  In other words, many aren’t concerned if their hyperthyroid patients become hypothyroid by taking antithyroid medication.

This doesn’t mean that there aren’t times when block and replace therapy can be beneficial.  For example, pregnant women with hyperthyroidism are usually told to take antithyroid medication.  While many people are understandably concerned about the effects of these medications on the liver, another concern during pregnancy is that antithyroid medication can lead to hypothyroidism.  And of course thyroid hormone is very important for the developing fetus.  Block and replace therapy during pregnancy was discussed in a case study involving a 36-year old woman, as the authors explained how it is challenging to keep the free T4 in the upper range of normal with antithyroid medication alone, and that block and replace therapy can prevent fetal hypothyroidism from developing (3).

Graves’ orbitopathy might be another situation where block and replace therapy is indicated, as a study showed that using long-term block and replacement therapy until Graves’ orbitopathy becomes inactive might be a good option (4).  One thing to keep in mind was that the patients in this study were treated with block and replace therapy for an average of 41 months, and many endocrinologists would refuse to have their patients take antithyroid medication for that long, even if the liver enzymes were fine during treatment.

The truth is that block and replace therapy might be beneficial in certain situations, but most endocrinologists are trained to prescribe antithyroid medication alone, which is why they commonly recommend this to their patients with hyperthyroidism and Graves’ Disease.  In fact, some endocrinologists aren’t even familiar with block and replace therapy, and one reason for this is because only a small percentage of their patients have hyperthyroidism and Graves’ Disease.  It is far more common for endocrinologists to deal with patients who have Hashimoto’s thyroiditis.  As a result, those with a hyperthyroid condition can expect to be advised to take antithyroid medication by their endocrinologist, or to receive radioactive iodine or thyroid surgery.

In summary, block and replace therapy involves taking both antithyroid medication and thyroid hormone.  So essentially the goal is to block the production of thyroid hormone, but at the same time have the patient take thyroid hormone replacement to prevent them from becoming hypothyroid.  Block and replace therapy is rarely recommended by endocrinologists, and two reasons for this are because 1) the relapse rate is comparable to taking antithyroid medication alone, and 2) side effects are more common.  However, pregnancy and Graves’ orbitopathy are two situations when this type of treatment might offer some benefits.

It’s common for people with hypothyroidism and Hashimoto’s Thyroiditis to have low levels of triiodothyronine, also known as T3.  Sometimes the T3 levels will be within the lab reference range, but less than optimal.  On the other hand, sometimes they will be outside of the lab reference range.  Either way, the goal is to try to bring the T3 to an optimal level, and in this blog post I’ll discuss seven ways to increase low T3 levels.

Before I discuss the seven ways to increase low T3 levels, you might wonder why I’m not talking about T4 in this post.  In 2016 I did release a blog post entitled “7 Causes of Low T4 Levels”, and while some of the same factors will cause low T3 levels, there are different causes as well.  In addition, I usually recommend to test for the free T3 levels, and from an optimal perspective you want to see these levels between 3.0 and 3.5 pg/ml, although some sources will suggest a tighter range (i.e. between 3.2 and 3.5 pg/ml).

It’s also important to mention that not all medical doctors will test the T3 levels.  Many will only test the TSH and T4, while some will test the TSH alone.  The reason for this is because in most cases the T3 isn’t going to change their recommendations, as most medical doctors will 1) base their recommendations off of the TSH, and 2) prescribe synthetic thyroid hormone to just about all of their patients with a hypothyroid condition. If this describes your doctor then you might want to consider switching to a different doctor, or another option is to try to order free T3 on your own.

With that being said, let’s go ahead and look at the seven ways to increase low T3 levels.  Please keep in mind that I’m not listing these in the order I recommend.

1. Take synthetic T4.  Although I’m starting with synthetic T4 because this is the most common recommendation by medical doctors to address both low T4 and low T3 levels, this isn’t my first preference.  And the reason for this is because while taking thyroid hormone replacement is necessary at times, this doesn’t do anything to address the underlying cause of the problem.  In addition, Synthroid is the most common brand of synthetic thyroid hormone medication recommended, and it has a lot of fillers, along with artificial ingredients.  As a result, if someone absolutely needs to take synthetic T4, they should look into a more hypoallergenic form, such as Tirosint.

Some reading this might wonder how taking synthetic T4 will increase low or depressed T3 levels.  Well, T4 converts into T3, and so if someone has healthy levels of T4, then they should be able to convert the T4 into T3.  However, if someone has a problem converting T4 to T3 then taking synthetic T4 won’t be effective in raising T3 levels.

2. Synthetic T3.  If someone has low or depressed T3 levels, then it might make more sense to take synthetic T3 rather than synthetic T4.  Synthetic T3 is also known as liothyronine, with Cytomel being a common brand.  A recommended starting dosage is 25 mcg per day, although some will start with lower doses (i.e. 5 mcg).  While some medical doctors will recommend synthetic T3 if someone has low T3 levels, since T3 is the active form of thyroid hormone, many are cautious about doing this out of fear that the person will develop hyperthyroid symptoms.

Earlier I mentioned that it might make more sense for someone who has low or depressed T3 levels to take synthetic T3 instead of synthetic T4, although it depends on the situation.  For example, if someone has depressed levels of both T4 and T3, then it wouldn’t make sense to only have the person take synthetic T3.  In fact, as I mentioned previously, if the person is able to convert T4 to T3 then in this scenario they might be fine just taking synthetic T4, although in some cases taking both synthetic T4 and T3 might be warranted.  On the other hand, if someone has normal levels of T4 and low or depressed levels of T3, then this might be a good indication that synthetic T3 is needed.

However, just as is the case with taking synthetic T4, synthetic T3 doesn’t do anything to address the cause of the problem.  And so while taking synthetic T3 might be necessary in some cases, the obvious goal should be to fix the conversion problem and/or address the autoimmune component (for those who have Hashimoto’s), which I’ll discuss later in this post.

3. Natural thyroid hormone.  If someone needs to take thyroid hormone replacement, desiccated thyroid hormone should be considered.  Brand names include Armour, Nature-Throid, and WP Thyroid.  These all include T3 and T4, along with other thyroid cofactors (T1, T2, and calcitonin).  This type of thyroid hormone replacement can especially be helpful if someone has low or depressed levels of both T4 and T3.  Although over the years I have had many patients take Armour and do fine, I prefer Nature-Throid and WP Thyroid because they are hypoallergenic.  And while many people do fine taking synthetic thyroid hormone, some people don’t do well on this, yet thrive when taking desiccated thyroid hormone.  On the other hand, a small percentage of people don’t do well on natural thyroid hormone, and actually do better when taking synthetic thyroid hormone replacement.

4. Thyroid glandular supplements.  For those who are unable to get a prescription for Armour, Nature-Throid, WP Thyroid, or a different brand of natural thyroid hormone, there are thyroid glandular supplements that contain desiccated thyroid hormone, and don’t require a prescription.  Some of these thyroid glandular only include T3, while others have both T4 and T3.  It’s common for these thyroid glandular supplements to also include nutrients and/or herbs that support thyroid gland function.  Common nutrients included include selenium, tyrosine, and zinc, and ashwagandha is an adaptogenic herb that is added to some thyroid glandular supplements.

5. Compounded thyroid hormone medication.  Compounded T4/T3 is made by a compounding pharmacist, and is another option to consider.  One advantage of compounded T4/T3 is that the doses can be customized.  Another advantage is that the product can be formulated to be hypoallergenic.  Some compounding pharmacists can also put together a custom formulation using desiccated thyroid.  However, getting T4/T3 through a compounding pharmacy can be considerably more expensive.

6. Correct the conversion problem.  So far I have focused on different types of thyroid hormone replacement.  But even if you need to take thyroid hormone, it makes sense to address the cause of the problem.  I mentioned earlier that ideally T4 should convert into T3, but many people have problems converting T4 to T3.   If someone’s thyroid panel reveals normal T4 levels and low or depressed T3 levels, then this is a pretty good indication of a conversion problem.  However, it’s also possible for BOTH T4 and T3 to be low and to have a conversion problem.  When this is the case it can be more challenging to determine if the person has a problem converting T4 to T3, although reverse T3 may be elevated in this situation.

There are numerous factors that can interfere with the conversion process, but three of the more common reasons why people have a problem converting T4 to T3 include 1) liver problems, 2) gut dysbiosis, and 3) elevated cortisol levels.  As a result, these are the primary areas I focus on, and while most of the time doing so will correct the conversion problem, in some cases this can be challenging.  For more information I would read my blog post entitled “6 Factors Which Can Affect The Conversion of T4 to T3”.

Should Someone Take Thyroid Hormone Replacement While Fixing The Conversion Problem?

As for whether someone who has a conversion problem should take thyroid hormone, this depends on the person.  While the cause of the problem needs to be addressed, we also need to remember that T3 is the active form of thyroid hormone.  As a result, if someone has very low or depressed thyroid hormone levels then we don’t want these to be low for too long.  The reason for this is because thyroid hormone affects every cell and tissue in the body.

In addition, while sometimes the T3 levels will increase relatively quickly while addressing the cause of the problem, this isn’t always the case.  Sometimes it can take many months to correct the conversion problem.  There can be a few reasons for this.  One reason is because it can take time to address the liver, gut, or adrenal imbalance which are responsible for the conversion problem.  Another reason is because sometimes we greatly improve the health of these areas, only to find another factor is responsible for the poor conversion of T4 to T3.

7. Detect and remove the autoimmune trigger.  Most people with hypothyroidism have Hashimoto’s Thyroiditis, which is the reason behind their low or depressed T4 levels, and low or depressed T3 levels are common as well.  So when someone has low T3 (and T4) levels as a result of Hashimoto’s, the goal is to do everything necessary to detect and then remove the autoimmune trigger.  This is easier said than done, and over the years I’ve written many articles and blog posts on some of the different triggers, and I also talk about this during my free webinars.  In my upcoming book on Hashimoto’s I’ll go into even more greater detail about triggers, including an entire section dedicated to how to detect all of the different triggers, and another section that focuses on removing your triggers.

While some people with Hashimoto’s don’t need to take thyroid hormone replacement, others need to take it while addressing the cause of the problem.  And there are those who need to take it on a permanent basis.  It depends on how much damage to the thyroid gland has taken place.

Can There Be Other Factors Responsible For Low T3 Levels?

Although having Hashimoto’s and/or a conversion problem are the most common reasons why someone has low T3 levels, there can be other factors.  I’m not going to get into great detail about these here, and ideally you want to work with a natural healthcare professional to address this.  But here are some other potential causes of low T3 levels:

Dysregulation of the hypothalamic-pituitary-thyroid (HPT) axis.  Although T3 is produced during the conversion process, some T3 is also produced in the thyroid gland.  TSH is a pituitary hormone, and it is responsible for signaling to the thyroid gland to release T4 and T3.  The hypothalamus communicates with the pituitary gland.  As a result, if there are problems with the communication between the hypothalamus and pituitary gland, this in turn can affect the communication between the pituitary gland and thyroid gland, which can result in low T4 and/or T3 levels.

Direct inhibition of the thyroid gland.  Although most cases of hypothyroidism are a result of Hashimoto’s, some factors can directly inhibit thyroid hormone production.  For example, certain environmental toxins such as mercury can inhibit thyroid hormone production, although sometimes environmental chemicals can cause an immune system response.  Either way, in this situation the goal should be to reduce your toxic load.

Some people are concerned about goitrogenic foods inhibiting thyroid hormone production.  Although I would be cautious about eating soy, eating cruciferous vegetables usually won’t cause any problems.  I spoke more about this in a blog post entitled “5 Things To Know About Goitrogenic Foods”.

Problems with T3 binding to the carrier proteins.  Both T3 and T4 are carried through the bloodstream bound to certain proteins.  Thyroxine-binding globulin (TBG) is one of these, although it has a higher affinity for T4 than for T3.  Both T4 and T3 bind to serum albumin, although these hormones have a higher affinity for TBG.  So for example, if the TBG level is low due to a person taking corticosteroids, this will result in lower levels of thyroid hormone in the blood.

In summary, many people with hypothyroidism and Hashimoto’s have low or depressed levels of T3.  Unfortunately many medical doctors don’t test the T3 levels, as they will only test for the TSH, and perhaps T4.  Ideally you want to increase T3 levels by addressing the cause of the problem, which is usually either damage to the thyroid gland caused by the immune system, or a problem converting T4 to T3.  However, thyroid hormone replacement can also increase the T3 levels, and some of the different options include synthetic T4, synthetic T3, desiccated thyroid hormone, thyroid glandular supplements, and compounded T4/T3.

It’s common for people with thyroid and autoimmune thyroid conditions to have thyroid nodules.  It’s also common for people to be concerned about them, and to wonder whether their nodules are malignant, if there is a way to shrink nodules, etc.  While I have written a few articles in the past on this topic, I figured I’d put together an updated post that discusses five things anyone with thyroid nodules should know.

1. Many people have thyroid nodules.  As I mentioned in the opening paragraph, it is very common for people to have thyroid nodules.  One journal article mentioned that while 4 to 7% of the population have palpable thyroid nodules, ultrasonography reveals that up to 67% of the population has them (1).  Another study mentioned that up to 35% of the population have thyroid nodules show up on an ultrasound (2).  Even if we go with the lower number, 35% is quite high, as this means that roughly one third of the population has thyroid nodules.  The incidence of thyroid nodules increases as we age, and the prevalence is higher in women (2), although they are more likely to be malignant in men, especially those over 70 years of age (3).

2. Most thyroid nodules are benign.  Only around 5% of thyroid nodules that are detected through palpation are malignant (1).  But most thyroid nodules are not detected through palpation.  And for those thyroid nodules evaluated by a biopsy, the prevalence of malignancy ranges from 4% to 6.5% (4).  So while at least one third of people reading this will test positive for thyroid nodules, only a very small percent of these nodules will be malignant.

With that being said, the incidence of thyroid cancer has increased substantially in the United States over the last four decades (5), as the American Cancer Society estimated that 62,450 people in the United States were diagnosed with thyroid cancer in 2015 (6).  Most people with thyroid cancer are diagnosed with papillary thyroid cancer.  According to the American Cancer Society, both stage one and stage two papillary thyroid cancer have a 5-year relative survival rate of nearly 100%, and in stage three it’s 93% (7).  In stage four, the 5-year relative survival rate drops down to 51%.

Follicular thyroid cancer also has a near 100% 5-year relative survival rate in stage one and two, with a 71% 5-year relative survival rate in stage three, and a 50% 5-year relative survival rate in stage four (7).  Medullary thyroid cancer has a pretty good 5-year relative survival rate in stages one through three, but only a 28% survival rate in stage four.  Anaplastic thyroid cancer has a 5-year relative survival rate of only 7%, but fortunately only 1-2% of all thyroid cancers are anaplastic.

The reason why I’m talking about these statistics is to show you that while there without question is a risk of untreated thyroid cancer, the progression is much slower when compared to other cancers, and overall the 5-year relative survival rate is pretty good.  By comparison, the 5-year relative survival rate for the four most common malignancies in developed countries is 73-89% for breast cancer, 50-99% for prostate cancer, 43-63% for colorectal cancer, and only 12-18% for lung cancer (8).

If you’re wondering when a biopsy is necessary, please read an article I wrote in the past entitled “Is It Necessary To Get A Biopsy For Thyroid Nodules?”

3. A radioactive iodine uptake test won’t confirm or rule out malignant nodules.  For those are diagnosed with hyperthyroidism, a radioactive iodine uptake test is commonly recommended.  One reason is to confirm or rule out Graves’ Disease, as most people with this condition will have a high uptake of radioactive iodine, although I’ll add that testing positive for thyroid stimulating immunoglobulins is not only a better way of diagnosing Graves’ Disease, but is less invasive.

Besides trying to confirm a diagnosis of Graves’ Disease, another reason why endocrinologists will recommend this test is to detect thyroid nodules, as well as to differentiate between benign and malignant nodules.  And the way it tries to accomplish this is by looking at “hot” and “cold” nodules.  About 80 to 85% of thyroid nodules show up as being cold on the uptake test, and about 10% of these nodules are malignant (9).  Hot nodules account for only 5% of nodules, although the likelihood of these being malignant is less than 1%.  So essentially you’re hoping to see a hot nodule, but are far more likely to see a cold nodule, and 90% of these will be benign.

I’m not suggesting that the radioactive iodine uptake test has no value, but in my opinion it makes more sense to first get a thyroid ultrasound.  First of all, this is less invasive than the radioactive iodine uptake test.  Second, it can provide an accurate measurement of the size of the nodule, which isn’t the case with the uptake test.  And third, other characteristics of the nodule on an ultrasound can give an indication if it is potentially malignant, and thus warrants a biopsy.  It’s also worth mentioning that for those who don’t have health insurance, a thyroid ultrasound usually costs a lot less than a radioactive iodine uptake test.

The truth is that neither an uptake test or a thyroid ultrasound are perfect methods for confirming or ruling out malignant nodules.  But since the uptake test is more invasive and costs more, it makes sense to start with the thyroid ultrasound.

4. Problems with estrogen metabolism is a common cause of thyroid nodules.  According to the research, estrogen is a potent growth factor both for benign and malignant thyroid cells (10) (11).  Estrogen is also a factor with uterine fibroids, and one study involving 1144 participants looked at the relationship between thyroid nodules and uterine fibroids (12).  The authors concluded that uterine fibroids in women were definitely associated with the presence of thyroid nodules, and that estrogen might play a pivotal role in the occurrence of both of these.

As a result, if you have one or more thyroid nodules, doing things to support estrogen metabolism is a good idea.  One of the best ways to accomplish this is by eating plenty of cruciferous vegetables, as these help to support estrogen metabolism due to the compounds Indole-3-Carbinol and 3,3′-diindolylmethane (DIM) (13) (14).  Another option is to take DIM in supplement form.

For those women who are taking estrogen, I came across one study involving 33 women who received estrogen therapy for one year, and it did not seem to increase the growth of thyroid nodules (15).  While I can’t say that I’m a big fan of estrogen therapy, I realize that some women can benefit from taking estrogen (preferably bioidentical estrogen).

5. There are no specific herbs or supplements to shrink thyroid nodules.  Although supporting estrogen metabolism can help to shrink thyroid nodules, the truth is that this isn’t always effective.  Shrinking thyroid nodules can be challenging, but here are a few other factors to consider:

An iodine deficiency can cause thyroid nodules.  A few studies show a relationship between iodine deficiency and thyroid nodules (16) (17) (18).  Of course iodine is very controversial in the world of thyroid health, which I have discussed in past articles and blog posts.  Although many people with thyroid and autoimmune thyroid conditions don’t do well with iodine, at the same time we can’t ignore an iodine deficiency.  This doesn’t mean that everyone with thyroid nodules should supplement with iodine, but it probably would be wise for those with thyroid nodules to do a urinary iodine spot test, and if they are iodine deficient they should work with a healthcare practitioner who can help them correct this deficiency over time.

The main reason some people don’t do well with iodine, even when they have an iodine deficiency, is because they are also deficient in antioxidants.  While some doctors will recommend for their patients to take antioxidants while administering iodine supplementation simultaneously, I have found that a safer approach is to first increase the person’s antioxidant status over the course of a few months before having them supplement with iodine.  And when the person starts supplementing with iodine they should start with smaller doses.

Thyroxine may help to suppress thyroid nodules.  It is thought that levothyroxine-induced suppression of TSH secretion can shrink thyroid nodules, as it prevents the growth-promoting effect of TSH on thyroid cells (19).  Of course this would only be an option for those people with hypothyroidism and Hashimoto’s Thyroiditis, as you wouldn’t want a person with hyperthyroidism to take thyroid hormone.  I’ll also add that this treatment isn’t always effective, as a study involving 40 patients with confirmed benign nodules showed that suppressive therapy with levothyroxine didn’t decrease the size of benign nodules (20).

Ethanol ablation.  Percutaneous ethanol ablation for cystic thyroid nodules was introduced in 1989.  Yes, injecting ethanol into thyroid nodules can actually shrink thyroid nodules (21) (22).  This wouldn’t be my first option if I had thyroid nodules, but I would probably consider this procedure before surgery.  Ethanol ablation has been reported to have a success rate of 82-85% reduction after an average of two sessions in the management of thyroid cysts (23) (24).  However, it doesn’t seem to be as effective in shrinking solid thyroid nodules.

Laser thermal ablation.  This is a relatively new treatment option, and it can be effective with minimal complications (25).  In addition, while ethanol ablation seems to be more effective for shrinking cystic nodules, laser ablation can help with solid nodules.  It also seems to be less costly than other procedures.

I came across a journal article on laser therapy (26) which discussed a study involving 1531 patients who underwent laser ablation for 1534 nodules.  According to the study, 83% of the nodules were treated with a single session of laser ablation, and the average reduction in nodule volume at 12 months was 72% (26).  There were 17 complications, with 8 of them being major, although all of them recovered completely after they were treated with steroids.  So there are some risks, but of course this is also the case with the surgical removal of the thyroid gland, which is what many doctors recommend when someone has nodules.  A more recent meta-analysis from 2017 showed that percutaneous laser ablation was safe and useful in shrinking benign thyroid nodules, improving thyroid function, and relieving symptoms related to pressure (27).

While laser ablation for thyroid nodules seems promising, I’m not sure where someone would go to get this procedure done.  Not surprisingly, it doesn’t seem like there are many of practitioners who offer this type of treatment.  In addition, we need to keep in mind that this treatment doesn’t do anything to address the cause of the problem.  On the other hand, if someone takes a natural treatment approach but the thyroid nodules don’t shrink, then they might want to consider this procedure.

So hopefully you learned a few new things you didn’t already know about thyroid nodules.  Although many people have thyroid nodules, the good news is that most of these are benign.  Problems with estrogen metabolism and an iodine deficiency are common causes of thyroid nodules, and while addressing these imbalances is essential, there are other treatment options to consider.  Thyroid surgery is an option, but should be the last resort.  Other options include thyroxine therapy, ethanol ablation, and laser ablation.