How to Assess and Manage Your Thyroid Health - Dr. Michael Ruscio, DC

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How to Assess and Manage Your Thyroid Health

A One-Stop Resource for All Your Thyroid Concerns

Key Takeaways:

  • Some thyroid conditions are easier to diagnose, as lab interpretation is less subjective, as in the case of overt hypothyroidism, hyperthyroidism, and Graves’ disease.
  • Others, like subclinical hypothyroidism and Hashimoto’s thyroiditis, are more subject to misinterpretation and can often lead to a hypothyroid misdiagnosis and overmedication. 
  • Symptoms of thyroid dysfunction are generally non-specific, meaning they are often reflective of another disorder, like a GI condition, leading to misdiagnosis. 
  • Healing your digestive system can help heal your thyroid and allow you to discontinue or optimize your medication and reduce your symptoms. 
  • An anti-inflammatory diet and probiotics are great tools for healing both digestive and endocrine health.

Thyroid health is a topic we take seriously here at The Ruscio Institute in our venture to educate and empower people on their journey to better health. I’ve even dedicated much of my time to uncovering the many myths and misconceptions that surround thyroid health — like the overuse of iodine and the epidemic of hypothyroid misdiagnosis. 

I cover these, and many more thyroid topics, in great detail here on the blog and my podcast, but today we are shifting the focus to a more zoomed-out view of how to assess and manage this tiny, butterfly-shaped gland.

From assessing thyroid symptoms and labs to taking a bottom-up approach to healing your thyroid through your digestive health, this overview should answer many of your thyroid health questions. If you’re currently struggling with your thyroid, I’m also happy to announce our self-paced, online course that allows you to take your health into your own hands. 

But first, let’s start with an overview. 

Article Snapshot: Thyroid Health

Before we jump into our first topic on thyroid assessment, here’s a look at what’s covered in this article:

  • Thyroid Assessment:
    • Interpreting thyroid labs
    • Overdiagnosed thyroid conditions
    • Assessing thyroid symptoms
  • Thyroid Management Basics:
    • Overview of thyroid medications
    • Discontinuing medications
  • Natural Thyroid management
    • Thyroid-healthy diets
    • Probiotics for thyroid health

We have many articles that cover these topics in great detail, but if you’re looking for a broad overview of how to assess and manage your thyroid health, you’re in the right place.

How to Assess Your Thyroid Health

There are two overall aspects to assessing thyroid health and function: labs vs. symptoms. While most thyroid health specialists use a combination of both to guide the diagnosis and treatment of thyroid disorders, there tends to be general confusion regarding  laboratory values in both functional and conventional medicine. 

Traditional medicine often leans heavily on certain labs — like thyroid-stimulating hormone (TSH) — which can result in overdiagnosis and overmedication of certain conditions. However, the functional/integrative medicine field is subject to its own share of misinterpretation when it comes to thyroid disorders. There’s a tendency to hyperfocus on minor lab fluctuations and over attribute non-specific symptoms to thyroid dysfunction. 

Unfortunately, this is where many well-intentioned practitioners veer off-course, contributing to issues in thyroid diagnostics. Many people with abnormal thyroid labs live symptom-free, while others can have “normal” labs with significant symptoms. This dependence on using lab values can lead to over-treatment in the first group and under-treatment in the latter. 

Knowing when labs vs. symptoms matter is vital for correct assessment and treatment. While there are certainly exceptions, there are some general guidelines that can help point you in the right direction. 

Thyroid Labs

Thyroid disorders are diagnosed through blood tests and ultrasound imaging, and rarely with a thyroid biopsy. The following thyroid function tests are most often used to assess for thyroid abnormalities:

  • Thyroid-stimulating hormone (TSH)
  • T4 (thyroxine)
  • T3 (triiodothyronine)
  • Thyroid peroxidase antibodies (TPO-Ab) 
  • Thyroglobulin antibodies (Tg-Ab) 
  • Thyroid stimulation antibodies (TSI-Ab)
  • TSH receptor antibodies (TRAb)
  • Radio-active iodine uptake (RAIU)

Home testing by taking your basal body temperature just upon waking has become a popular, but highly inaccurate, way to detect hypothyroidism. Research shows that there is less than a 0.02-degree difference between normal and hypothyroid populations, making this method diagnostically irrelevant [1].

The chart below gets into the details regarding lab values for thyroid disorders and we have other articles that go into this topic in-depth. However, here is a general idea of how common (but not all) thyroid disorders present:

  • Overt hypothyroidism: high TSH, low T3 and T4
  • Subclinical hypothyroidism: high TSH, normal T3 and T4
  • Hyperthyroidism: low TSH, high T3 and T4
  • Hashimoto’s thyroiditis: TPO/Tg antibodies most common with normal or low T3/T4
  • Graves’ disease: Thyroid receptor and TSI antibodies with elevated T3/T4

Please note lab values may vary slightly, depending on the specific lab provider you are referencing (and units can vary as well).

Thyroid ConditionTSHFree T4Free T3Antibodies
SubclinicalHypothyroidism4.6-9.9 mIU/LNormalNormalN/A
Overt Hypothyroidism> 4.5 mIU/L< 1.77 ng/dLNormal OR < 4.4 pg/mLN/A
Hashimoto’s ThyroiditisNormal OR > 4.5 mIU/L 
Normal OR < 1.77 ng/dL
Normal OR < 4.4 pg/mLTPO antibodies > 35 IU/mL

Levels > 500 IU/mL pose moderate risk for hypothyroid progression
 Tg antibodies > 0.9 IU/mL

Levels > 9 IU/mL pose potentially greater risk for hypothyroid progression 
Overt Hyperthyroidism< 0.45 mIU/L< 0.82-1.77 OR normal< 2.0-4.4 OR normalTRAb > 2.0 IU/LTSI antibodies > 0.55 IU/L

There are specific cases where abnormal labs can be used for a direct diagnosis and determining treatment, such as in the case of overt hypothyroidism and hyperthyroidism. Even if you have no symptoms, if these conditions go unmedicated for too long, it can pose a health risk. 

However, other thyroid problems like Hashimoto’s thyroiditis and subclinical hypothyroidism can be detected through labs but often don’t require medication intervention. This is where discernment of the patient’s symptoms — and where they are really arising from — plays an important role in guiding treatment. 

Immediately jumping to medications in these cases can not only mask the underlying issues (like poor gut health) but can leave people overmedicated and overdiagnosed. 

The Epidemic of Overdiagnosis in Hypothyroidism and Hashimoto’s

Perhaps the most obvious example of this issue pertains to the overdiagnosis of hypothyroidism. Many people go through temporary fluctuations in their TSH levels, which are the main diagnostic markers for thyroid conditions. 

However, these fluctuations cause many providers to jump into giving a hypothyroid diagnosis and medication management. And research shows that 74% of those with this subclinical hypothyroid presentation have normalized TSH test levels after 6 months without medication [2].

Additionally, 34-60% of those previously prescribed hypothyroid medications who discontinued them had normal thyroid function and labs within 6-8 weeks after stopping their medication [3, 4]. Keep in mind that this most likely pertains to those with true subclinical hypothyroidism, while those with overt hypothyroidism do have to take medication (at least until underlying issues are resolved).

Those with Hashimoto’s thyroiditis — an autoimmune condition where antibodies attack the thyroid gland — can also fall into the trap of being overmedicated. Labs can detect Hashimoto’s with the presence of TPO and/or thyroglobulin antibodies, but the vast majority will have normal TSH and thyroid hormone levels (T3 and T4) and are asymptomatic. 

However, lab values aren’t the complete story of Hashimoto’s, and further investigation shows that only a small subset of these antibody-positive populations have ultrasound findings on their thyroid that support a Hashimoto’s diagnosis. 

Further complicating this, Hashimoto’s is the most common cause of low-functioning thyroid, leading many to consider it synonymous with hypothyroidism. However, progression to hypothyroidism only occurs in 9-19% of those with elevated TPO antibodies [5, 6], and the meticulous monitoring of labs in both appropriately and inappropriately diagnosed populations. makes them more susceptible to an incorrect hypothyroid diagnosis. 

Slight variations in thyroid hormones in those with Hashimoto’s frequently lead to the immediate use of prescription medications, leaving those with Hashimoto’s to be an overmedication population 

This is not to say that thyroid labs and medication don’t have a time and place, but it’s essential to find a provider that understands these nuances so that you can get a proper diagnosis and treatment tailored to you. 

Are Thyroid Symptoms More Reliable?

How to Assess and Manage Your Thyroid Health - Hypo vs Hyper Thyroid Symptoms L

The evaluation of thyroid symptoms is susceptible to the same issues as labs as they are typically not a reliable indicator of thyroid disease and can also lead to confusion and overdiagnosis. This is due to the symptoms being non-specific  — meaning they overlap with many other conditions. 

One study found confirmed that the following symptoms of hypothyroidism are more prevalent, but not strong predictors for thyroid disease [7]:

  • 81% experience fatigue
  • 63% report dry skin
  • 51% have shortness of breath
  • 30% notice hair loss

Other symptoms include unwanted weight gain, constipation, unwanted body weight, and muscle weakness.

The more hypothyroid symptoms you have, the more likely it becomes that hypothyroidism is truly the issue. However, especially if you only have a few of these symptoms, there may be many possible causes. 

As you can see, these symptoms are associated with numerous health conditions, including hormonal imbalances like PCOS and menopause, metabolic syndrome, and autoimmunity. This point is driven home by the fact that TSH levels often don’t correlate with the presence of these symptoms [8]. 

One system that’s often overlooked when it comes to treating these concerns is digestive health. But many people have an unhealthy gut, even in the absence of digestive complaints, that can wreak havoc on other parts of the body — including the thyroid. I find that healing the gut will lessen these thyroid-related symptoms, help normalize labs, and can allow people to discontinue their medication (under the guidance of a practitioner).

It’s necessary to note that this issue regarding symptoms and overdiagnosis is most prevalent in hypothyroidism. Hyperthyroidism is more cut and dried, as its symptoms are more distinctive from other disorders and include [9]:

  • Chronically elevated heart rate and palpitations
  • Muscle weakness and tremors
  • Unexplained weight loss
  • Goiter (thyroid enlargement)
  • Thyroid nodules
  • Anxiety
  • Excessive sweating
  • Ophthalmopathy (bulging, painful, and/or blurry eyes)
  • Grave’s dermopathy (thickened skin on shins)

Labs and symptoms lie in a delicate balance when learning how to assess and manage your thyroid health. If you would like guidance in navigating the world of thyroid labs, symptoms, and treatment, the practitioners at the Ruscio Institute of Functional Medicine are all highly experienced in this topic. 

Thyroid Management Basics

As alluded to above, in order to receive the appropriate treatment, it’s essential to know when symptoms are directly related to an issue originating in the thyroid gland (such as in overt hypothyroidism), or when the dysfunction is caused by something a bit deeper, like an unhealthy digestive system.

Those with subclinical hypothyroidism and Hashimoto’s thyroiditis often see great benefit from healing their gut, such as normalized labs and symptom resolution. And those with overt hypothyroidism and hyperthyroidism also benefit and can often optimize their medications by addressing their digestive health. Before we get into the natural management of thyroid conditions, let’s run through an overview of thyroid medications.

Thyroid Medications: An Overview

Generally speaking, there are two different categories of thyroid hormone replacement: natural desiccated thyroid, which comes from porcine (pig) thyroid glands, and synthetic medication. It’s important to stop and note that simply because desiccated glandulars are “natural”, they are not automatically superior to synthetic hormones. 

While many of those with overt hypothyroidism do well on glandulars, the tissue is still seen as foreign in your body and can worsen an already haywire immune response in Hashimoto’s disease. Many diagnosed with Hashimoto’s who have true, overt hypothyroidism find that they do better on synthetic thyroid hormone. 

Common hypothyroid medications include:

  • Levothyroxine (T4)
  • Synthroid (brand name of levothyroxine)
  • Liothyronine (T3)
  • Cytomel (brand name of liothyronine)
  • Armour thyroid (desiccated thyroid)
  • NP-Thyroid (desiccated thyroid)
  • Nature-Throid (desiccated thyroid)
  • WP thyroid (desiccated thyroid)

Hyperthyroidism, which causes too much thyroid hormone production, uses antithyroid medications that suppress the thyroid instead. Medications and procedures that perform this function are:

  • Propylthiouracil (PPU)
  • Carbimazole
  • Radioactive iodine
  • Partial thyroidectomy (removal of the thyroid gland)

Other medications, like beta blockers, can help manage the symptoms of hyperthyroidism. Unfortunately, these therapeutics can be harder on the body and have a larger side effect profile compared to those used in hypothyroidism. 

Fortunately, you can decrease autoimmunity and heal an overactive thyroid by addressing your gut health. You may not be able to discontinue your medications completely, but you can reduce your medication dose, along with any side effects, and prevent invasive procedures like thyroid surgery.

Hypothyroid Medications: Natural vs. Synthetic Hormones

Most people with hypothyroidism are prescribed levothyroxine, the synthetic version of T4. T4 is known as the “storage form” of thyroid hormone and is present in higher quantities in the body than the active form of thyroid hormone, T3. However, T4 converts to T3 in the body’s tissues which is why it has beneficial effects, and T4 still has a smaller effect on the body.

Desiccated thyroid hormone contains a combination of T3/T4, which may give it an edge over the most popularly used medication, levothyroxine. However, the exact amounts/proportions of thyroid hormones in these glandulars can be difficult to standardize, and variations between prescription bottles are possible. 

If you are not a good candidate for desiccated thyroid and are still symptomatic with low T3 levels, your practitioner may increase your levothyroxine dose to increase conversion to T4, or start you on T3 medication, like Cytomel. While some people prefer combination therapy, many do not find greater benefit from T3/T4 combination therapy over T4 therapy alone [10, 11].

What’s important to note here is that changes in medication shouldn’t solely be done based on lab values. When you are medicated for true hypothyroidism and are symptom-free, small fluctuations in hormone levels are not an immediate cause for concern (with some exceptions, like pregnancy).

But what if you were diagnosed with hypothyroidism and don’t feel better on your medications? It’s probably time to take a deeper look into what else could be going on. Remember that thyroid medications do have the potential to mask the real issue and lead you to believe that your treatment options end at medication. 

Weaning Off of Thyroid Medication

I dedicated an entire article to this topic that explains how to wean off your thyroid medication, so be sure to check it out for weaning schedules and a step-by-step process for discontinuing thyroid medications. But the most important thing to know is you should never abruptly stop your medication — especially if you have overt hypothyroidism or hyperthyroidism. 

It’s also imperative that you work alongside a healthcare provider that can monitor your labs to prevent large swings in thyroid hormones, can adjust your medication dose, and help your monitor your symptoms. 

There are many reasons why you may want to discontinue your medication. Common reasons are that you think you were incorrectly diagnosed and medicated, have symptoms that aren’t responding to medications, or are looking to optimize your health and lower your medication dose.

It is possible to stop your thyroid medications, which will most likely be if you were originally diagnosed with lab values in the subclinical hypothyroidism range. The best way to do this is through healing your gut to optimize thyroid health, which we will get to in a moment. 

As a final note, those with overt hypothyroidism and hyperthyroidism may be able to use the following strategies to heal their thyroid to the point where they can optimize and lower their medications, but often aren’t good candidates for completely discontinuing them. 

So let’s get into how you can meet your thyroid health goals. 

Natural Thyroid Management: Heal Your Gut

As previously stated, poor gut health is a common culprit of thyroid-like symptoms or an underactive thyroid. This is because high levels of inflammation in the gut can cause leaky gut and body-wide inflammation that disrupts hormones and increases the risk of autoimmunity [12, 13, 14, 15, 16, 17, 18, 19, 20]. 

Research even shows that certain infections, like H. pylori, are linked to thyroid dysfunction, and have a particularly strong association with Graves’ disease [21]. Eradication of this bacteria may reduce antibodies, normalize TSH, and eliminate the need for medication in hypothyroidism [22]. 

Suboptimal gut health can also lead to malabsorption to the point where you are no longer able to get enough nutrients for thyroid function, like iron, iodine, selenium, and zinc. It may cause decreased absorption of your thyroid medication, which is why healing your digestive system can help optimize medications.

Eat Your Way to a Healthier Thyroid

A diet that calms inflammation and soothes the gut can do wonders for your digestive and thyroid health. The most effective way to do this is to eliminate the foods that are uniquely triggering an inflammatory response in your gut. This can be accomplished through a personalized elimination diet, which we walk you through in detail here, but here’s a brief overview of the most popular options.

Elimination diets: A Paleo-style elimination diet works great for many with thyroid disease, though a low FODMAP diet can be more effective in those with significant digestive symptoms, gut pathogens, or a microbial imbalance like small intestine bacterial overgrowth (SIBO). We recommend you work your way through the elimination diet protocol to figure out which diet is right for you.

Gluten-free diet: The above diets are helpful in that they remove gluten and cut carbs, which is closely tied to thyroid autoimmunity. Research shows that a low-carbohydrate diet (which often eliminates gluten-containing foods) can reduce antibodies in Hashimoto’s by 44% [23], and a specifically gluten-free diet shows similar benefits [24, 25]. 

AIP diet: Many with autoimmunity, like in Hashimoto’s thyroiditis and Graves’ disease, jump straight into the autoimmune protocol (AIP) diet. However, this may be unnecessary and it’s highly restrictive in what foods you can eat. Even if you have positive antibodies, we opt for a less-restrictive diet first at the clinic. 
Low-iodine diet: Iodine and thyroid have a tricky relationship, as low and high levels can lead to thyroid dysfunction. It’s likely best that you don’t overly restrict or supplement with iodine to help keep your levels in a good range, and Paleo is a great low-iodine diet (but not too low). Iodine supplements may be out, but there are many others that work well to heal the gut and thyroid. However, there is one important stand-out before we bring this article to a close.

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A Spotlight on Probiotics

Probiotics address thyroid disease in numerous ways, from fighting gut pathogens and balancing the gut flora to sealing up a leaky gut and calming autoimmunity. Once you have seen maximum benefit from changing your diet, probiotics are often effective for resolving persistent thyroid symptoms. Research shows that probiotics help reduce:

  • Intestinal permeability: Leaky gut syndrome is associated with worse symptoms in Graves’ and other thyroid diseases [13], and probiotics are effective at healing the gut lining [26, 27, 28, 29, 30]. 
  • Dysbiosis: Thyroid autoimmunity and hypothyroidism are linked to SIBO and H. pylori [21, 31, 32], which probiotic supplements are helpful in rectifying [33, 34, 35].
  • Prescription medication needs: One study found that probiotic use reduced the need for medication and increased energy levels in hypothyroidism, likely due to its positive benefits on the digestive microbiome [36].  
  • Autoimmunity: While there are no direct studies on the effectiveness of probiotics on thyroid antibodies, there is evidence that it reduces autoimmunity risk, symptoms, and inflammation in other autoimmune diseases like type 1 diabetes, multiple sclerosis, and rheumatoid arthritis [37, 38, 39]. 

An anti-inflammatory diet and probiotics are a great place to start when it comes to managing your thyroid health, but there are many other options available to you, so feel free to check out our other articles on thyroid health. 

Become A Thyroid Health Expert

Learning how to assess and manage your thyroid health can take some time, but hopefully, this article helped get you started. We addressed the importance of labs and symptoms in thyroid diagnostics, the overdiagnosis of thyroid conditions, the difference between common thyroid medications, coming off thyroid medications, the importance of gut health, and natural thyroid management. 

You can learn more about how to become a thyroid expert in our online thyroid course, or you can further explore the thyroid-gut axis in my book, Healthy Gut, Healthy You.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.

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