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Microsoft word - thyroid_disorders.doc

By Dr Nicky Baillie Thyroid disorders and depression are often described as ‘the great masqueraders’. This is because they can have such a varied and variable presentation. People with these conditions may present with what seems to be something completely unrelated, but on further investigation the underlying cause is underactive thyroid activity or depression. It is therefore prudent for health professionals to always be on the alert for thyroid disorders, and to actively investigate this possibility. Hypothyroidism in particular, can be gradual in onset, and difficult to diagnose unless one is looking for it. Thyroid disorders can appear to be complex. The aim of this article is to try and simplify the issues, and offer practical approaches that can be used in your clinic. The most common thyroid disorders will be addressed i.e. primary hypo- and hyperthyroidism. Disorders related to pituitary problems (secondary hypo- and hyperthyroidism) will not be covered. Some of the issues addressed in this article will be: *Goitre - one can have a goitre with hyperthyroidism or hypothyroidism, or one can have a goitre and have normal thyroid function. How does this work?? *Autoimmune disease can be a cause of hypo- and hyperthyroid disorders. What is the best way to approach this herbally? *Thyroid tests – making sense of them. Is basal temperature an accurate indicator of thyroid function? *Where does iodine deficiency fit in nowadays?? *The majority of the medical profession promotes synthetic thyroid hormone replacement, others swear by whole thyroid extract of animal origin. What are the pros & cons of each option?? THE THYROID GLAND The normal thyroid gland is about 20-30g and sits just below the Adam’s apple, partially wrapped around the trachea. Despite how tiny this gland is, it is essential for life. Thyroid hormones affect every cell in the body. They have two main effects: Increase in protein synthesis in almost every cell in the body, Increase in oxygen consumption by increasing the activity of the sodium pump, particularly in those cells responsible for basal oxygen consumption i.e. liver, kidney, heart and skeletal muscle. (4) It is easy to see from these effects, how metabolic rate is integrally connected with thyroid function. A quick review of thyroid hormone physiology is shown below. Although many nutrients are essential for normal thyroid function, the main ones are included in the diagram. The thyroid releases both T4 and T3, although 80% of T3 comes from conversion of T4 to T3 in the circulation. T3 is at least three times more active than T4. The thyroid gland actively traps iodide. This mineral is essential in production of thyroid hormones. HYPOTHALAMUS TRH ANTERIOR PITUITARY VITAMIN A,E TSH THYROID VITAMIN B2,3,6 THYROID FUNCTION TESTS Thyroid function tests are relatively simple to interpret, and should always be done whenever thyroid disease is suspected. The medical approach has generally been, if the blood tests are in the normal range all is well with the thyroid gland. There is some evidence to suggest however, that these tests should be looked at more closely, as early changes of thyroid function can be detected, and are best treated. The three main tests of thyroid function are: TSH Normal range 0.3 - 5 T4 Normal range 10 – 24 T3 Normal range 2.5 – 5 Thyroid autoantibodies can be done if autoimmune thyroid disease is suspected, and specifically TSI (thyroid stimulating immunoglobulin) in Grave’s disease. Hyperthyroidism A recent comment in the J Clin Endocrinol Metab, 2002 (87:2):489-499, noted that thyroid laboratory values are grossly outdated in the USA (this would also apply to NZ). They determined that a TSH value of 1.5 was the upper limit of normal in a disease free population, and that anyone with a TSH greater than 1.5 should be considered to have mild hypothyroidism. In hypothyroidism, the first change is increasing TSH, in order to maintain T4 & T3 output from the thyroid gland. This report adds weight to the view that mild hypothyroidism is underdiagnosed and often untreated. Dr Broda Barnes from USA, was an avid proponent of treating subclinical (or mild) hypothyroidism, and developed the Barnes Basal Temperature Test (BBTT) as a more accurate indicator of mild hypothyroidism. This involves measuring basal temperature each morning by placing a mercury thermometer under the arm for 10 minutes. This must be done immediately on waking. It is important to remain as still as possible during this time. Menstruating women must do the test from Day 2 –7 of the menstrual cycle, men, postmenopausal women and children can do the test at any time. The temperature is recorded for 5 consecutive days. The normal range is considered to be 36.5 – 36.75. Readings consistently below 36.5 are thought to be indicative of mild hypothyroidism. Although this test has not been embraced by the medical profession in general, there does seem to be some value in using it as a more accurate indicator of thyroid function. In anyone with suspected thyroid problems, my advice is to organise thyroid function blood tests, and basal temperature readings. If the TSH is above 1.5, or the basal temperature consistently below 36.4 assume mild hypothyroidism. If both these tests are completely normal, thyroid disease is unlikely. If there are signs of thyroid under or overactivity, then thyroid auto-antibody tests should be ordered, to exclude autoimmune disease. Remember hypothyroidism is a great masquerader. If in doubt – test for it. HYPOTHYROID CONDITIONS In my experience, it is difficult to treat people successfully with hypothyroidism, without using some sort of thyroid hormone replacement. This is particularly true when the thyroid gland is damaged which is usually the case in longer term hypothyroidism. In mild hypothyroidism, again people respond best to thyroid replacement hormones. It is certainly advisable to look at the whole picture and treat herbally/nutritionally alongside thyroid hormone replacement. In mild hypothyroidism, there is no harm trialling herbal/nutritional therapies for a few months, and only adding in thyroid hormone replacement if a person is not responding i.e. feeling no better, basal temperature not changing, TSH not reducing. Hypothyroidism is estimated to affect 1-4% of the population, with another 10-12% having mild hypothyroidism. Some experts believe the true rate of hypothyroidism (including subclinical) could be up to 25% of the population. The common symptoms of hypothyroidism are listed in many texts. (A comprehensive list is found in (9).)The main ones are: lethargy, dry skin, constipation, intolerance to cold, depression, poor memory. Menstrual problems are often linked with hypothyroidism. GENERAL CONSIDERATIONS Diet Apart from general dietary advice, in people with hypothyroidism it is advisable that they reduce consumption of foods known to block thyroid activity (goitrogens). e.g.cabbage, cauliflower,broccoli, brussel sprouts, mustard greens, Chinese greens The thyroid inhibiting effect of these foods can be Cassava, sorghum, pulses, millet, linseed. Nutritional Supplements The major nutrients involved in healthy thyroid function are listed in the chart. It can be helpful to supplement these in all people with thyroid disorders. Vitamin A 10,000 – 20,000 IU/day Vitamin C 1000-3000mg/day Vitamin E 200-500IU/day Vitamin B complex Fish oils 2000mg/day, Evening primrose oil 1000mg/day Zinc 15-30mg/day Selenium up to 150mcg/day Exercise Exercise should be encouraged in anyone with hypothyroidism. Exercise can increase thyroid hormone output and also increase tissue sensitivity to thyroid hormones. 1) Hashimoto’s Thyroiditis (High TSH, Low T4, Normal T3, Autoantibodies This is nowadays one of the most common causes of hypothyroid conditions, particularly in the Western world where iodine deficiency is rare. It affects women more than men (4:1) and whites more than blacks (4:1). It is an autoimmune thyroid condition, in which thyroid tests are normal in the early stages but eventually progress to hypothyroid. Thyroid autoantibodies are positive, and thyroid tissue shows signs of lymphocyte infiltration and gradual destruction. There is sometimes a brief phase of hyperthyroidism early on in the disease due to breakdown of thyroid follicles and release of thyroid hormones. The thyroid gland can be slightly enlarged, but later in the disease is generally shrunken and fibrotic. There is some evidence that Hashimoto’s is triggered by a viral or bacterial infection, with triggering of immune dysfunction and auto-attack of the thyroid gland. As with any autoimmune disease however, there must be some underlying susceptibility. TREATMENT Herbal medicine is most likely to be effective early on in the disease. Once thyroid gland destruction has occurred, thyroid hormone replacement is generally essential. The approach here is as for any autoimmune condition. Kerry Bone has published some excellent information on treatment of autoimmune conditions, and Berris Burgoyne on autoimmune thyroid conditions. (5,9) Obviously a full case history needs to be taken, identifying any possible triggers, previous infections or factors which may have made a person susceptible to an autoimmune condition. a) Treat recurrent or chronic infection, or triggering infection Antiviral or antibacterial herbs can be used depending on the situation. If there is a clear history of preceding viral infection, or ongoing recurrent viral infections, antiviral herbs are more appropriate. Diet is obviously very important here, identifying food sensitivities and reducing inflammatory foods such as red meat, foods high in trans-fatty acids e.g. takeaways, margarines, fried foods etc. A low allergenic diet may be appropriate for a short while to allow gut repair. Probiotics e.g. acidophilus yoghurt or capsules Anti-inflammatory Herbs c) Promote optimal digestion and elimination Bitters, cholagogues and laxative herbs can be used here if required. d) Address/minimise exposure to chemicals/toxins. Exposure to toxins is inevitable and unavoidable, but minimising this exposure is possible. Some chemicals have a thyroid blocking effect, others put added stress on the detoxification pathways in the body, especially the liver. Apart from the many well-known toxins in our environment that are harmful, some that have been found to affect thyroid function in particular are: Resorcinols and phthalates, common industrial wastes. Phthalate esters are added to plastics to give them flexibility. It would be advisable to minimise use of plastics and plastic containers, especially soft plastics such as gladwrap, beverages from plastic containers, and heating plastics in microwaves. Drink as pure water as possible. (14) Tobacco contains small amounts of cyanide which is converted to thiocyanates in the body. These are thyroid Alcohol – excessive use may block the response of TSH to Fluoride – there is much debate about fluoridation of water supplies. Fluoride is a potent inhibitor of thyroid function especially at high doses, and with concurrent iodine deficiency. (14,p35) Certain drugs are known to block thyroid function e.g. lithium, antidepressants, antidiabetic drugs, amiodarone. Pesticides, herbicides, and household cleansers may also affect the immune system and thyroid function. Immune enhancing herbs can be beneficial in autoimmune disease. Autoimmune disease is complex with overactivity of parts of the immune system and underactivity of other parts. Herbs such as Echinacea work mainly on the input side of the immune system by enhancing phagocytosis. This can be very beneficial in resolving chronic infection and preventing recurrent infection. Immune suppressant herbs can also be useful short-term in autoimmune disease such as Hashimoto’s. Immune enhancing f) Antioxidant and anti-inflammatory approaches This is to protect damage to tissue from inflammatory chemicals, and aid healing of inflamed tissue. e.g. g) Encourage adequate rest, relaxation, exercise, lifestyle changes. SPECIFIC HERBS FOR HASHIMOTO’S THYROIDITIS The seaweeds are often recommended for any hypothyroid condition. This is probably based on historical factors, when iodine deficiency was more common. With iodine being very prevalent in Western diets the use of seaweeds is likely to contribute little to management of an autoimmune thyroid condition. One exception to this is if a person is on a very low sodium diet, or obviously nutrient deficient e.g. people with anorexia, low-caloric diet. Bladderwrack is considered a specific for hypothyroidism – it is possible it has some beneficial effects apart from its iodine content. Can stimulate thyroid function by increasing cAMP. TSH requires cAMP as a second messenger. 5mls/day of 1:2 extract is required to stimulate thyroid function. (15) An active constituent of this plant, z-guggulsterone, has shown strong thyroid-stimulating activity – these were animal, not human studies. (7) According to Tieraona Lowdog, milk thistle improves the conversion of T4 to T3. This conversion process can be affected, particularly if the adrenals are weak. A sample formula for someone who had developed Hashimoto’s thyroiditis following a recent URTI would be: and Ulmus powder 2 tsp daily, acidophilus capsules/yoghurt, diet and (High TSH, low T4, normal T3, Autoantibodies This is now an uncommon cause of hypothyroidism due to ample iodine intake in our diet. It is always accompanied by enlarged thyroid gland (goitre), and when occurring in children affects mental and Iodised salt - 1g salt contains 76mcg iodine. The average person has at least 3 g salt per day = 228mcg iodine. The RDA for iodine is 150mcg/day. There ar only small amounts of Even if people avoid iodised salt, they will generally get enough iodine from other foods such as bread, crackers, many processed foods, ocean fish, oysters, clams, lobsters, kelp, watercress. Too much iodine from iodised salt or kelp/seaweed can suppress thyroid function and aggravate hypothyroidism. This is why bladderwrack, a rich source of iodine, must be used carefully in hypothyroidism when iodine intake is adequate. 3) Idiopathic (High TSH, Low T4, normal T3, Autoantibodies negative) Idiopathic hypothyroidism means the cause is unknown. As a medical herbalist/naturopath it is useful to act as a detective and go through all the possible factors that can suppress thyroid function i.e. dietary goitrogens, alcohol, smoking, nutritional deficiencies , chemical/toxin exposure, low grade infection - and to treat based on any factors that come to light. Once again, if the hypothyroidism is more severe and longstanding thyroid hormone replacement may be In mild hypothyroidism with no autoantibodies, if iodine deficiency is suspected, bladderwrack/kelp may be used. Otherwise it is reasonable to trial coleus or gum guggul. David Hoffman recommends the use of Damiana Turnera diffusa, Wormwood Artemisia absinthum, Nettles and Oats. (12) Certain treatments for hyperthyroidism can induce hypothyroidism e.g. radioactive iodine. Other drug causes of hypothyroidism are listed above. THYROID HORMONE REPLACEMENT There are two forms of thyroid hormone replacement – synthetic thyroid hormone, or extracts of animal thyroid tissue, commonly porcine thyroid extract. In the past, only animal thyroid tissue was available. This was first used in 1892 and was the only form of thyroid extract available for 50 years. It contains T4, T3, and also T2 – which has an unknown role. Synthetic thyroxine was predominantly used from the1950’s onwards. It was thought to be superior as it could be standardised to a certain dose, and there were no problems with high T3 concentrations after use. However, it did mean only T4 was being replaced. This was not thought to be a problem as T4 is converted into T3. A recent study however, suggests that T3 replacement is important. 33 people with hypothyroidism were treated with their usual dose of thyroxine for 5 weeks, and then a combination of thyroxine (T4) and triiodothyronine (T3) for another 5 weeks (in a randomised order). At the end of the study, cognitive performance and mood assessment tests found that people had improved mood and neuropsychological function on the T4/T3 combination. (8) So, maybe people with hypothyroidism do need T3 as well?? I am not keen on using animal thyroid extract for a number or reasons. For those that are, 60mg of whole thyroid extract is equivalent to about 0.1mg(100mcg) of thyroxine. People are generally started on 15-30mg daily of whole thyroid extract. It is possible to get synthetic T3 (tertroxin). If a person is not improving as much as hoped on T4 alone, I will often add in a low dose of synthetic T3 (10-20mcg). This can certainly make a difference to some people. For those with patients who you feel may benefit from some T3, in addition to the T4, it would be worth copying the article from the NEJM, and sending it to the person’s GP with a request for a trial of T3 alongside theT4 replacement. HYPERTHYROID CONDITIONS Some people with hyperthyroid conditions will return to normal thyroid function after a period of time. Supporting these people with herbal/nutritional treatments until this happens can be very effective. In other situations, hyperthyroidism is chronic, and can be quite resistant to any sort of treatment. Once again, if hyperthyroid activity is marked, prescription drugs may be required, initially at least. Supportive herbal/nutritional approaches can still be used alongside prescription medicines however. GENERAL CONSIDERATIONS Diet Obviously high consumption of goitrogenic foods, as listed above, can be beneficial in reducing thyroid overactivity. Nutritional supplements As for hypothyroidism. These will not aggravate hyperthyroidism, but will assist in normalising thyroid function. 1) Grave’s Disease (Toxic Diffuse Goitre) - Low TSH, High T4, High T3, Autoantibodies positive, particularly TSI. Grave’s disease is a complex autoimmune condition of unknown cause. As with Hashimoto’s thyroiditis, there is some evidence that it may be triggered by an infection. It consists of hyperthyroidism with goitre, opthalmopathy, which causes bulging eyes (exopthalmos) and rarely dermopathy (<1%) (thickening of skin over tibia). It is more common in women than men (4:1), no racial factors known, peak age 20-40, and again at menopause. The symptoms of hyperthyroidism are weight loss, tremor, rapid pulse, palpitations, anxiety, heat intolerance, frequent stools. 30% of people with Grave’s disease will go into remission after 1-2 years. Medical treatment is to use thyroid-inhibiting drugs such as carbimazole, or radioactive iodine treatment, and occasionally surgery. TREATMENT Because Grave’s disease is an autoimmune condition, the general approaches to autoimmune conditions are also useful in Grave’s – as discussed previously. Despite certain chemical/toxins being thyroid inhibiting, it is not recommended people use these medicinally for obvious reasons!! SPECIFIC HERBS FOR GRAVE”S DISEASE Lycopus virginicus (or Virginian water horehound) Lycopus europaeus (European cousin of bugleweed) These two closely related herbs have been used traditionally for the treatment of overactive thyroid conditions. Lycopus is naturalised in some wet areas of NZ and Australia. Caffeic acid, and its derivatives rosmarinic and chlorogenic acid, have been shown to exert antithyroid activity. These are the components in Lycopus species which are likely to be responsible for its antithyroid effect. (16) Lycopus appears to have several mechanisms of action: Inhibition of receptor binding of TSH (2) whole extracts bind to and inactivate the thyroid- stimulating autoantibodies produced in Grave’s disease, possibly by binding to the TSH receptor. (3,11) Inhibition of iodine metabolism and release of thyroid hormone, by cyclic AMP inhibition at thyroid membrane (11) Oral doses of Lycopus inhibit the conversion of T4 to T3 in the peripheral tissues. (20) Hence, Lycopus is an essential herb to use in people with hyperthyroidism. Another very useful and safe herb to use in hyperthyroidism. Apart from its antithyroid actions, it also has a nervine relaxant effect which can be useful for the anxiety/irritability that often accompanies hyperthyroidism. autoantibodies to TSH receptors. (2, 11 p138) Inhibition of conversion of T4 to T3 by blocking the enzyme responsible for this conversion. (11) Gromwell is perhaps best known for it’s anti-gonadotrophic actions. It does appear to have antithyroid actions similar to lemon balm, by inhibiting the binding of TSH and thyroid autoantibodies to TSH receptors.(2) Motherwort can be beneficial for treating some of the symptoms of hyperthyroidism such as anxiety, palpitations, increased heart rate. Weiss does report it as having antithyroid activity also. (19) Self heal is one of the richest sources of rosmarinic acid (5%). (16 p25) As mentioned earlier this compound can exert antithyroid activity after oxidation. Theoretically, therefore, self-heal may have some anti-thyroid activity. Valerian is useful for symptomatic treatment of hyperthyroidism, as a nervine relaxant for anxiety, restlessness and insomnia. 2) Toxic Nodular Goitre Low TSH, High T4, High T3, Autoantibodies This is a common cause of hyperthyroidism in elderly people. It most often occurs in people with a long history of nodular goitre (enlarged thyroid gland with nodules, often euthyroid). Why some of these nodules become toxic and autonomous in some people is not known. The specific herbs for Grave’s disease can also be used in toxic nodular goitre. Also traditional herbs for ‘lumps and bumps’ e.g. calendula Calendula officinalis, pokeroot Phytolacca americana, and possibly red clover Trifolium pratense. 3) Subacute Thyroiditis (de Quervains thyroiditis) Low TSH, High T4, High T3, Autoantibodies negative This is generally a low-grade hyperthyroid condition resulting from either viral or autoimmune injury to the thyroid gland. It is usually self-limiting and It is a common cause of hyperthyroidism after childbirth. Often the thyroid is asymmetrically enlarged (goitre) and tender. Fever and lethargy can be present in the early stages Any herbal treatment should have a strong focus on the immune system. Immune suppressant herbs if no clear history of preceding viral illness. SAMPLE HERBAL FORMULA FOR SUBACUTE THYROIDITIS EUTHYROID GOITRE Goitre simply means enlarged thyroid gland. In some cases, it can be so enlarged as to exert pressure on the windpipe and surrounding tissues. People who are hyperthyroid normally have a goitre, people who are hypothyroid sometimes have a goitre. However, people can have a goitre in the presence of ‘normal’ thyroid function. If thyroid hormone production is blocked, the TSH will initially increase. This increased stimulation of thyroid tissue can cause a goitre, with initially normal T4. With recurrent stimulation/involution of the thyroid gland nodules may form (nodular goitre). Whenever goitre is present, an ultrasound should always be performed, to exclude more sinister causes of thyroid enlargement such as cancer. If the thyroid blood tests are normal, check basal temperature readings. Also note if the TSH is above 1.5 (normal range 0.3-5) it can suggest mild hypothyroidism. In any case, if goitre is present there is some thyroid imbalance occurring, and most often it is mild hypothyroidism. Once again, it is up to the herbalist/naturopath to exclude any factors which may be blocking thyroid hormone production i.e. dietary goitrogens, prescription drugs, iodine deficiency, chemical/toxin exposure etc. Low dose thyroid hormone replacement may be indicated if any signs of hypothyroidism. Herbal treatments as discussed – bladderwrack, gum guggul, coleus, milk thistle and addressing any specific concerns. Nutritional supplementation as for hypothyroidism, and exercise. If there is a nodular goitre, it is worth trialling a topical cream applied to the nodules as well as internal herbal treatment. Herbs that could be tried in the cream are red clover, pokeroot, calendula, ginger. SUMMARY Herbal medicines and nutritional support can play an important role in thyroid conditions, either alone, or alongside prescription drugs. The advantage of the medical herbalist/naturopath is that conditions underlying thyroid disorders can be more fully explored and addressed. REFERENCES 1) Andreoli, Carpenter, Plum, Smith. Cecil essentials of medicine. WB 2) Auf’mkolk, M et al. Endocrinology 115(2), 527-534;1984. In Burgoyne, Berris. Autoimmune diseases of the thyroid. Modern Phytotherapist. Vol 4, No 1:1998;1-10 3) Auf’mkolk, M et al. Endocrinology 116(5), 1687-1693;1985. In Burgoyne, Berris. Autoimmune diseases of the thyroid. Modern Phytotherapist. Vol 4, No 1:1998;1-10 4) Berkow et al. The Merck Manual. 16th Edition . Merck Research Laboratories, 5) Bone, K. Treating Autoimmune Disease. The Modern Phytotherapist Vol1 No 6) Bone, K. Phytotherapy for Autoimmune Diseases. Mediherb InClinic 7) Bone K. Clinical applications of Ayurvedic and Chinese herbs. Phytotherapy Press, Warwick :1996. In Burgoyne, Berris. Autoimmune diseases of the thyroid. Modern Phytotherapist. Vol 4, No 1:1998;1-10 8) Bunevicius R, et al. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. New England Journal of Medicine 1999 Feb 11’340(6):424-9. 9) Burgoyne, Berris. Autoimmune diseases of the thyroid. Modern 10) Coiro V, Vescovi P. Effect of pyridostigmine on the thyroid-stimulating hormone in abstinent alcoholics. Clinical Experimental Research, October 1997:21;1308-1311 In Langer S, Scheer J. Solved: The riddle of illness. Keats Publishing, USA 1984, 1995,2000. 11) Fisher C, Painter G. Materia medica of western herbs in the southern hemisphere. 651 West Coast Rd, Oratia, Auckland, 1996. 12) Hoffman D, The New Holistic Herbal. Element Books Ltd, 1983,1990. 13) J Clin Endocrinol Metab, 2002 (87:2):489-499 14) Langer S, Scheer J. Solved: The riddle of illness. Keats Publishing, USA 2000. 15) Lauberg P. FEBS Lett 170, 273-276, (1984). In Burgoyne, Berris. Autoimmune diseases of the thyroid. Modern Phytotherapist. Vol 4, No 1:1998;1-10 16) Mills S. Bone K. Principles and practice of phytotherapy. Churchill Livingstone, 2000. 17) Mueller, B et al. Impaired action of thyroid hormone associated with smoking in women with hypothyroidism. New England Journal of Medicine, October 12, 1995:333(15);964-969. 18) Utiger R. Cigarette smoking and the thyroid. New England Journal of Medicine, October 12, 1995:333(15):1001-1002. 19) Weiss Rudolph. Herbal medicine. Medicina Biologica, 1988.Portland, USA. 20) Winterhoff, H et al. Arzneim-Forsch/Drug Res 44(1), 41-45;1994 In Burgoyne, Berris. Autoimmune diseases of the thyroid. Modern Phytotherapist. Vol 4, No 1:1998;1-10

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