Thyroid Treatment: Why it fails
This is for the people who don't respond well to thyroid treatment and appear to have hypothyroid symptoms despite being on thyroid replacement with normal blood test results.
As we know, T4 is the main hormone produced by the thyroid gland (supplemented with drugs like Synthroid ), and it's basically biologically inactive until the body removes an iodine atom, respectfully converting it into T3. Thyroid hormones are made up of many things, iodine being one of them and the numbers we use (T3, T4, etc.) represent how many iodine atoms are present in the molecule. Right, now your probably asking yourself, "Why should I care about iodine atoms?" In response, I'll just say that you shouldn't, however, you should be aware that the supplementation of which thyroid hormones you chose will greatly impact your ability to achieve a successful replacement protocol, stay symptom free, and actually utilize the drugs you are bombarding your body with.
Now then, when we talk about T4, we're talking about the storage hormone and it can stay active in the body for weeks, where T3 only lasts for days. (T3 actually deiodinates into T2, and then into T1, which have their own metabolic activities, but we'll stick to discussing T3, because it's the most vital. T3 is what's needed for the body's chemical reactions to progress at the right speed, and lack of results in hypo- symptoms). Most people on thyroid replacement are given T4 to start with and this is probably the worst approach, due to what we to call "thyroid resistance". Where T4 fits into the grand scheme of things, in relation to the "resistance" factor, is when the "wrong" iodine atom is removed from the molecule, thus effectively creating a mirror image of T3 that's not actually bio-active. When this T3-mimic, lets call it, fits into the T3 receptor it blocks T3 from acting on the body, and despite proper blood levels of TSH, T3, and T4, you'll still have hypothyroid symptoms. We call this wrong conversion "Reverse T3" (RT3). Most doctors don't check for this "Tissue Resistance to Thyroid Hormone" and as a result will claim it's very rare.
There are ways to correct this issue though, and that's the purpose of this thread, now that we've been educated on RT3. To start with, lets make sure you're being diagnosed correctly. You should have a ratio of about 20:1 Free T3 (FT3) to RT3. If it's less than that, you have an RT3 problem. If you only have a T3 reading (opposed to FT3) than your ratio should be about 10:1 T3 to RT3.
You can correct elevated levels of RT3 by preventing more from being made! If you stop the production of RT3, eventually your levels will decay. So, now that we know how RT3 is produced, we can go about killing it's manufacturer, T4, both endogenous and exogenous (natural and supplemented). To do this, start supplementing with T3 alone, and after about 6 weeks your body's level of RT3 should diminish and you'll start feeling better, however it takes upwards of 12 full weeks for the receptors to clear. I wouldn't recommend taking more than 125mcg of T3 throughout this clearing process. Also, be prepared to drop the amount of T3 you are taking when resistance clears, sometimes it can happen overnight, where you only need 1/2 of what you were supplementing with at the time of high resistance. Base your dose on symptoms of hypo-.
OK, so what causes RT3? Lets start by saying, it's not a bad thing as the body naturally produces it, but when the ratios of FT3 to RT3 sinks too low, that's when you'll have symptoms of hypo- despite replacement efforts. There are a variety of reasons the ratio can become unbalanced, a few of the following being most to blame.
Low Iron
Imbalance in Cortisol (too high or low)
Low B12
Extreme dieting (Lack of food, shouldn't be a problem here)
Type-1 Diabetes
Graves Disease
Low Iron:
Iron deficiency is shown to reduce T4-T3 conversion rates, increase RT3, and block the thermogenic properties of thyroid hormones. Symptoms of low iron can be the same as adrenal fatigue, anxiety, panic, uneven heart beats etc... These may already be present and, and surprising, when they worsen after a person is treated for their hypothyroid condition.
Iron forms part of the mechanism that transports thyroid hormones into cells, and can lead to the pooling of thyroid hormones in your blood while being metabolically hypo, which will skew Free T3 blood results. (This is part of the reason RT3 levels should be checked). This is another sort of thyroid resistance, and you can't just add more T3 to overcome it, you need to address the root problem.
You can measure your Ferritin (storage iron) and if it's below 70 you may end up with an intolerance issue. It's kind of a "catch-22" because low thyroid makes it hard to hang onto iron and low iron makes it hard to treat thyroid. Now, here's where it gets really confusing, sometimes Ferritin can be at a good level, yet there's still low iron in the body, and this is mainly because inflammation can cause false high's in Ferritin.
Some notes on iron testing. If you're Ferritin is in the 70-90 range, you should also check the saturation %, it should be between 35%-45% and any lower than 35% and you need more iron. (This can be checked by a full iron panel, Ferritin w/ TIBC). Iron serum should be at least 90. If your TIBC and UIBC are low, don't take too much iron, maybe 27mg daily, and as long as the % saturation and serum are good, you should be OK to treat thyroid.
Supplementing with iron should be done slowly over a week or two to allow your digestive system to adjust. Too much iron can cause constipation, and you want to ramp up your dose to 150-200mg a day split in 2 doses. Also, by taking a couple grams of Vitamin C with your iron supplement it will assist with absorption.
Cortisol too High/Low and Adrenals:
Well, low cortisol is another issue when it comes to thyroid treatment. It's another "catch-22" scenario, by being low in thyroid hormones it can actually cause adrenal stress. This is how it works, cortisol levels increase to make up for a lack in T3, and after prolonged elevated levels of cortisol the adrenals cease to be able to produce enough, thus resulting in adrenal apathy and constant decreased cortisol production. Now, there's a slew of symptoms related to adrenal fatigue, many shared by other hormone imbalances. Hypoglycemia and exercise intolerance being two common ones, as well as panic attacks, shakiness, difficult getting to sleep or staying asleep, uneven heart beats, strange temperature fluctuation, and inability to tolerate thyroid medications. The saliva test is the gold standard for cortisol measurement and isn't as skewed as a blood test (cortisol being a stress hormone, is more prone to fluctuate or spike when undergoing an invasive procedure such as a needle in a vain).
Adrenals and blood sugar:
Remember, the Adrenals relate to your blood sugar as well. For example, "a chocolate addiction" can be a symptom of adrenal problems. Or, if you ever wake up in the middle of the night at around 3-4 AM it can be be due to low nocturnal cortisol. Basically, cortisol reaches very low levels to the point where it causes hypogly***ia.
Lets say you eat a sugary carb meal right before bed or very late in the evening, the instant high sugar (in a candy bar, let's assume) triggers a strong insulin response. If your adrenals aren't healthy they will not make enough cortisol, specifically at night, to raise your glucose after that big surge of insulin dropped it. When you have low blood sugar the body produces adrenaline, and it just so happens that around 3-4 AM is the body's normal time to have the naturally lowest glucose levels, partly due to fasting for 5+ hours.
So basically, to recap, the reason you wake up, hypogly***ia causes production of adrenaline. And cortisol is responsible for helping to keep blood glucose stable via gluconeogenesis, which is the body's way of metabolizing glucose from non-carb sources, such as proteins and lipids.
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T3 tends to "use up" cortisol, and like iron, it's responsible for part of the mechanism that transports T3 into cells. Basal temperature is one of the ways to monitor your adrenal and thyroid function, it's the one you take first thing in AM before moving, when you first wake up, where oral temperatures are taken anytime during the day. Dr. Rind has a great website with a great example of metabolic temperature graphing, and gives a detailed insight on how to plot temperatures and determine metabolic health.
People with hypothyroid and adrenals are OK have steady but low temperatures, and people with possible adrenal fatigue and hypothyroid have significant variation in their temperature from day to day. Oral temps can be taken every 2 hours and should range between 0.2 degrees F each time.
An example of a healthy non-hypo individual is as follows:
5AM 98.2 (36.8)
10am 98.4 (36.9)
2PM 98.6 (37)
6PM 98.8-99( 37.1-37.2)
8PM 98.4 (36.9)
10PM 98.2 (36.8)
Adrenal apathy and therapy, like I mentioned is a different topic altogether. This was just a small insight into the clinical reasons most thyroid patients fail to receive proper replacement protocols, and can be strung on for years in attempts to find a correct treatment and Dr. I hope it helps.
* Barnes, Broda O., M.D., and L. Galton <Hypothyroidism-The
Unsuspected Illness> (New York: Harper and Row, 1976).
* The Barnes Foundation, P.O. Box 98 Trumbull, CT 06611, (203)
261-2101.
* Puglio, P. "Hypothyroidism: The Relationship to Menstrual
Disorders," <Women's Health Connections>, Complimentary Issue II;
available through the Barnes Foundation.
* Shannon, Marilyn, M. <Fertility, Cycles and Nutrition> (Cincinnati:
Couple to Couple League, 1992).
Special credits to Dr. Holtorf, Dr. Lowe, and Dr. Rind
