The most important thing you may not know about hypothyroidism

hypothyroid patientAn estimated 20 million Americans have some form of thyroid disease. Up to 60 percent of these people are unaware of their condition. One in eight women will develop a thyroid disorder during her lifetime. Levothyroxine, a synthetic form of thyroid hormone, is the 4th highest selling drug in the U.S. 13 of the top 50 selling drugs are either directly or indirectly related to hypothyroidism. The number of people suffering from thyroid disorders continues to rise each year.

Hypothyroidism is one of the most common thyroid disorders. One recent analysis suggested up to 10% of women over 60 have clinical or subclinical hypothyroidism. It is characterized by mental slowing, depression, dementia, weight gain, constipation, dry skin, hair loss, cold intolerance, hoarse voice, irregular menstruation, infertility, muscle stiffness and pain, and a wide range of other not-so-fun symptoms.

Every cell in the body has receptors for thyroid hormone. These hormones are responsible for the most basic aspects of body function, impacting all major systems of the body.

Thyroid hormone directly acts on the brain, the G.I. tract, the cardiovascular system, bone metabolism, red blood cell metabolism, gall bladder and liver function, steroid hormone production, glucose metabolism, lipid and cholesterol metabolism, protein metabolism and body temperature regulation. For starters.

You can think of the thyroid as the central gear in a sophisticated engine. If that gear breaks, the entire engine goes down with it.

That’s why people with hypothyroidism experience everything from weight gain and depression to infertility, bone fractures and hair loss.

One of the biggest challenges facing those with hypothyroidism is that the standard of care for thyroid disorders in both conventional and alternative medicine is hopelessly inadequate.

The dream of patients with thyroid disorders and the practitioners who treat them is to find that single substance that will magically reverse the course of the disease. For doctors, this is either synthetic or bio-identical thyroid hormone. For the alternative types, this is iodine.

Unfortunately, in the vast majority of cases neither approach is effective. Patients may get relief for a short period of time, but inevitably symptoms return or the disease progresses.

So what’s the problem? Why have replacement hormones and supplemental iodine been such dismal failures?

Because hypothyroidism is caused by an autoimmune disease.

Studies show that 90% of people with hypothyroidism are producing antibodies to thyroid tissue. This causes the immune system to attack and destroy the thyroid, which over time causes a decline in thyroid hormone levels.

This autoimmune form of hypothyroidism is called Hashimoto’s disease. Hashimoto’s is the most common autoimmune disorder in the U.S., affecting between 7-8% of the population. While not all people with Hashimoto’s have hypothyroid symptoms, thyroid antibodies have been found to be a marker for future thyroid disease.

Most doctors know hypothyroidism is an autoimmune disease. But most patients don’t. The reason doctors don’t tell their patients is simple: it doesn’t affect their treatment plan.

Conventional medicine doesn’t have effective treatments for autoimmune disease. They use steroids and other medications to suppress the immune system in certain conditions with more potentially damaging effects, such as multiple sclerosis, rheumatoid arthritis and Crohn’s disease.

But in the case of Hashimoto’s, the consequences – i.e. side effects and complications – of using immunosuppressive drugs are believed to outweigh the potential benefits. (Thanks to conventional medicine for a relative moment of sanity here.)

So the standard of care for a Hashimoto’s patient is to simply wait until the immune system has destroyed enough thyroid tissue to classify them as hypothyroid, and then give them thyroid hormone replacement. If they start to exhibit other symptoms commonly associated with their condition, like depression or insulin resistance, they’ll get additional drugs for those problems.

The obvious shortcoming of this approach is that it doesn’t address the underlying cause of the problem, which is the immune system attacking the thyroid gland. And if the underlying cause isn’t addressed, the treatment isn’t going to work very well – or for very long.

If you’re in a leaky rowboat, bailing water will only get you so far. If you want to stop the boat from sinking, you’ve got to plug the leaks.

Extending this metaphor to Hashimoto’s disease, thyroid hormones are like bailing water. They may be a necessary part of the treatment. But unless the immune dysregulation is addressed (plugging the leaks), whoever is in that boat will be fighting a losing battle to keep it from sinking.

What the vast majority of hypothyroidism patients need to understand is that they don’t have a problem with their thyroid, they have a problem with their immune system attacking the thyroid. This is crucial to understand, because when the immune system is out of control, it’s not only the thyroid that will be affected.

Hashimoto’s often manifests as a “polyendocrine autoimmune pattern”. This means that in addition to having antibodies to thyroid tissue, it’s not uncommon for Hashimoto’s patients to have antibodies to other tissues or enzymes as well. The most common are transglutaminase (Celiac disease), the cerebellum (neurological disorders), intrinsic factor (pernicious anemia), glutamic acid decarboxylase (anxiety/panic attacks and late onset type 1 diabetes).

In the next post we’ll look more closely at why Hashimoto’s can’t be treated successfully without addressing the autoimmune component, and why both the conventional and alternative approaches to treating hypothyroidism are destined to fail from the start.

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  1. Chris Kresser’s avatar

    The idea that bio-identical thyroid products like Armour have unreliable doses is a myth. Armour has a standardized dose of 4.22:1 T4:T3.  It has been tested and confirmed over and over again.

    In fact, as you may be aware, Synthroid was pulled from the market because of unreliable doses and was only re-approved in 2004 I believe.

  2. Tula’s avatar

    I would be curious to know if autoimmune thyroid issues could be a secondary result of other autoimmune conditions. I have had severe rheumatoid arthritis since I was 16 (28 years) and in the last couple of years have had rapid weight gain, extreme menstrual irregularities, and hair loss. According to my doctors, my thyroid is normal. Yet, nothing else seems to account for all of these symptoms.
    I get the brush off when I try to press for more in-depth diagnosis. The GYN blames my medication, the rheumatologist blames my diet (low-carb and < 1000 calories per day), the thyroid specialist found a nodule on the thyroid, but says everything else is normal and since the node has shrunk over the past year, everything is fine.
    Why is it so hard to get anyone to pay attention? I’m hardly a hypochondriac. Having a chronic condition has left me very in tune with my body, so I know when things are minor and can be ignored and also when they’re just not right. It seems like the doctors’ eyes start to glaze over the minute I mention hair loss and weight gain. So frustrating…

  3. Chris Kresser’s avatar

    The short answer is yes. Hashimoto’s is often part of a polyendocrine immune disorder involving multiple tissues. The same is true for other autoimmune conditions. The way to figure it out would be to find a health care practitioner willing to test for antibodies to other tissues commonly attacked by antibodies. Also, as I’ll explain in a future article, many people with autoimmune diseases are gluten intolerant. If you’re not already gluten free, I would highly recommend it.

  4. Jan’s avatar

    As someone who was diag. about 2 years ago with hpothyroidism, I take synthroid daily.  Would I do better on the Armour?  I am a nurse, but never see it ordered, always the synthroid.

  5. Chris Kresser’s avatar

    There are several factors that determine which thyroid hormone is best for each person. I’ll be writing about them in a future article.

  6. sharon williams’s avatar

    I had a total thyroidectomy and was diagnosed with Hashimotos in june 2010.  Since the thyroid was totally removed how does this affect the hashimotos?  My doctors seem very content ordering Synthroid and testing TSH and T4. Doctor says will take about a year to get on right dose of Synthroid and thinks all symptoms will subside.  Should I be on a gluten free diet?  I am very bloated and cannot lose weight also have bad joint pain and pain in bottoms of feet.  My blood sugar is also high but doctor feels it will go down once meds regulate. I am extremely tired all the time and have temperature fluctations with profuse sweating. 

  7. Chris Kresser’s avatar

    Removing the thyroid gland is somewhat akin to removing chewing gum from a shoe. It’s nearly impossible to remove the whole gland, because it is so close to the trachea / voice box and other important anatomical structures. What this means is that, if you have Hashimoto’s, autoimmune attacks on the thyroid can persist even after thyroidectomy. Therefore all of the information in these articles still applies to you.

  8. Meredith’s avatar

    I’ve found your series on the thyroid very interesting.  My question is that I was diagnosed with hypothyroidism 7 yrs. ago, but have never tested positive for the antibodies that would indicate it is caused by hashimoto’s.  I’ve researched, but I can’t find a cause for the hypothyroidism.  BTW, I was on Synthroid for a few years, then took myself off of it – never felt any different on or off.  I just had bloodwork done – TSH was high at 8.9, Free T4 on the low end of normal at .98 (range of .82-1.77).  New doctor recommends restarting synthroid, although they aren’t pushing it.  But they did recommend an ultrasound of my thyroid, although she (nor any other past doc.) feels anything unusual upon exam.  Do you have any insight for me as to what could be causing the hypothyroidism?  I hate to treat without a real understanding of the cause.  My symptoms are not severe – some fatigue,but not unusual, don’t like the cold.
    Thank you!

  9. Dulce Leon’s avatar

    I had hashimotos thyroditis AND papillary thyroid cancer.  I ahs a total thyroidectomy.  My question is this:  Since hashimotos attacks the thyroid cells and gland, is it not possible that even after a thyroidectomy, that the hashimotos could continue to attack thyroid cells in the wholw body since thyroid cells are found in the entire body?  I worry about this because it makes logical sense that hashiotos would attacj thryroid cells where ever they are which is the entire body.  Has anyone done a study of this?  Is this even medically conceivable?  Can you answer my question so  that I can understand this better and not have anxiety over what else is happening in my body?  Thank you for any help or guidance that you can probvide.

  10. Chris Kresser’s avatar

    Thyroid “cells” aren’t located throughout the body.  All cells do have receptor sites for thyroid hormone, though.  That’s not the same thing.

    However, a thyroidectomy is a bit like scraping chewing gum off the bottom of a shoe.  They rarely remove the entire thyroid gland.  It’s very close to other important structures in the throat so they have to be very careful.

    This means that, yes, if you have Hashimoto’s, it’s entirely possible that your immune system will continue to attack what’s left of your thyroid gland.  That’s why it’s so important to address the autoimmune component.

  11. Dulce Leon’s avatar

    but thryoid cells are what allows all cell metaboloism.  which means to me that thryoid cells are located throught the body in order for cell metabolism to take place.  Am I wrong about thryoid cells and cell metabolism?

  12. Chris Kresser’s avatar

    Yes.  Thyroid cells are in the thyroid gland.  Thyroid hormone is present throughout the body. Most cells have receptors for thyroid hormone.  That’s how thyroid hormone regulates metabolism.

  13. Dulce Leon’s avatar

    ok so the RECEptors  and thyroid hormone are what is throughout the body but not thryoid cells.  Am I correct?  In that case hashi’s would stay within the thryoid gland.  Correct? 

  14. Chris Kresser’s avatar

    The immune attack in Hashimoto’s is focused on the thyroid gland, but many Hashi’s patients also have antibodies to other tissues.  And of course the effects of Hashimoto’s are systemic – the entire body is affected.

  15. Patricia Kieley’s avatar

    Could someone please help me by answering one question. I was diagnosed with Hashimotos over 7 years ago and have been taking synthroid since then. The usual thyroid blood test (T3 ) has been performed intermittently since that time (during physicals, or when I had symptoms that I thought might be related to Hashimotos) and it always comes back “normal” according to my PCP. I suffer from depression – am being treated with medication – but have been through an especially difficult 2 years. I have many symptoms right now that are present in both depression and hypothyroid disorders and it’s become necessary for me to figure out what exactly is wrong because I seem to be getting worse rather than better. It’s ression or thyroid related, since so many are identical. My hair is falling out and I’m gaining weight despite not eating. My question is this: is their another blood test that will give an accurate picture of what is going on with the Hashimotos and if it is the cause of my worsening condition? I keep reading that the standard blood tests (T3, T4) do not give the complete picture and that if symptoms are present more examination is needed. My doctor doesn’t seem to give this view any credence and I always feel like a hypochondriac when I bring it up. Should I forget the PCP and see an endocronologist? Is that the only way to get to answers that I need? Any advice that makes sense would be greatly appreciated.

  16. Chris Kresser’s avatar


    The problem isn’t necessarily the tests you’re getting. It’s how they are interpreted. Watch this video to learn more about what I mean.

    Also, remember that Hashimoto’s is an autoimmune disease affecting the thyroid. To treat it properly, the immune system must be addresses since it – not the thyroid gland – is the underlying cause of the problem. Unfortunately, the conventional model doesn’t recognize this even though it’s abundantly clear in the scientific literature that this is what’s happening.

    You’re best bet is to find a functional medicine practitioner that understands these issues.

  17. renee’s avatar

    I just found this article while researching Hashimoto’s. Have you continued on this subject? I am in desperate need of more answers. Thank you.

  18. Chris Kresser’s avatar

    The entire series can be found in the Special Reports section.

    Here’s the link.

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