A Gut Health Case Study Treating SIBO, Support of Female Hormones Also Healed Low T3
In many cases, thyroid symptoms are the “smoke” and the “fire” is in the gut. In today’s episode, you’ll hear a case study of a patient who had low T3 along with digestive and hormonal symptoms like diarrhea, gas, rashes, and missing periods. After she received natural treatment for her gut health and hormonal health, she was symptom-free and became pregnant within six months. There was no need to treat her T3 directly. You’ll also get a breakdown of why a T4 plus T3 combo treatment should only be used in a minority of cases.
Dr. R’s Fast Facts Summary
Case study: April 2019 Future of Functional Medicine Review
Patient’s chief complaints: Diarrhea, Gas, Rashes and Amenorrhea
Menstruation had stopped since she discontinued birth control seven years ago
Testing showed SIBO and low T-3
Patient became symptom-free and pregnant in just over 6 months
Personalized the diet
GI treatments including some fasting, probiotics, antimicrobials
Female hormone supporting herbs
Case Study: July 2019 Future of Functional Medicine Review
T4 versus combination therapy, T4 plus T3
Some people will do better on T4 plus T3, but it is the minority
Try treating the gut and using T4 only
See the full review here: Dr. Ruscio’s Thyroid Medication Review
In This Episode
Episode Intro … 00:00:40 Healing Gut Heals Low T3 & More … 00:03:35 Misconceptions: T4 Vs. Combo Therapy … 00:09:36 Get a Valuable Thyroid Algorithm … 00:20:50
Dr. Michael Ruscio, DC: Hi, everyone. This Dr. Ruscio. Welcome back to another episode of Dr. Ruscio Radio. Let’s jump in and talk about a very interesting case study where improving gut health and supporting female hormones led to a great outcome. We’ll detail what that great outcome specifically meant in a moment.
In the same case, there was no need to directly address low T3. Yet another case study where, if you understand the situation between gut and thyroid appropriately, you understand when to act and when imbalances in the thyroid or symptoms that look like thyroid symptoms are actually just smoke, and the fire is the gut.
The other thing I want to elaborate on is a review of the evidence for combination thyroid hormone therapy. This is where one would combine both T4 and T3 hormone in one preparation (as in Nature-Throid or WP Thyroid) as compared to T4 therapy alone (as would be used in something like Synthroid). The evidence here gives us a pretty clear answer to the question of what is best. Surprise, surprise, it is at odds with what the majority of the field would have you believe.
We’ll jump into more details on these in a moment. Per the usual for this month of September, I wanted to make sure to make you aware of the fact that this information is coming from The Future of Functional Medicine Review Clinical Newsletter, which, again, is a monthly publication that I release with case studies and research studies—and a few other bits and bites on occasion—to help clinicians be as effective as they can.
Again, if you haven’t yet looked at this, I would highly recommend giving it a look over at drruscio.com/review. To make it as easy for you as possible to have a look and see what the experience of this newsletter is like, I’ve made it so anyone who signs up during September gets their first month of all access for only $1. So you’ll have access to everything behind the paywall, which is about three years of issues, for only $1.
That’s my way of trying to make the barrier to entry and the decision for you as easy as possible. I really hope you will head over there and read some of what we’re going to talk about today.
In this patient, her chief complaints were daily diarrhea, five years running, and pretty constant, gas, skin rashes, amenorrhea. Her period had stopped since she discontinued birth control seven years ago. Right to the punchline here, all of these symptoms were gone and she became pregnant—that’s the great outcome I was alluding to earlier—in six months.
Sometimes it’s easy to think, well, this case might need a lot to get better. Not really. This case needed more than the last case study we described, who essentially just needed to take a couple of vitamins and use a well-rounded probiotic protocol, but nothing that is over the top. Her testing did show SIBO and bacterial dysbiosis, and as I said earlier, low T3.
What was so important, I think, about this case study is it showed the living example of how when someone has inflammatory issues—in this case, we could assume that there’s inflammatory issues in the gut when there’s daily diarrhea, gas, rashes, and female hormone imbalances, as evidenced by her lack of periods—those can be what drive perturbations in thyroid hormone downstream.
In this case, the thyroid gland looks to be fine. TSH is normal. T4 is normal. After the thyroid gland is told by the brain to make thyroid hormone (that’s TSH) from the brain to the thyroid gland, the thyroid gland makes T4. That tells you the thyroid gland is fine and the communication from the brain is fine. When we look at T3, this tells us what’s happening in the periphery of the body. And this can be skewed by things like inflammation and stress.
What did we do in this case? Well, we had to evolve her diet over time, and we had to really personalize the best diet for her also, to make sure that she wasn’t being too restrictive with it. This sometimes will elude clinicians. Yes, there’s certainly a time and a place for eliminating inflammatory foods, reducing the FODMAP content of the diet, what have you. There are also some cases who are on pretty strict and restrictive diets, and the win for them is actually encouraging them to start reintroducing and opening up some of their dietary boundaries.
We also had to use a few different courses of GI treatments, including some fasting, probiotics, antimicrobials. I detail all of this in the case study. I should mention here that these case studies are not, “Here’s a bunch of information from the start. Here’s what we did and then she was great.” That is rarely how a case study plays out.
There need to be at least a handful of follow-up visits where you guide the patient through. Some things work. Some things don’t. Some things cause reactions. Some situations change. We detail that and chronicle how we evolved her treatment plan over the course of six months here. Again, we also used female hormone supporting herbs as part of this gut-centric approach. Because she was exhibiting signs of female hormone imbalances, we also supported those directly.
All of this is detailed in the case study write-up. But I wanted to point out yet another case that illustrates the power of the gut. It’s not to say there is not a time and a place for treating the thyroid directly. There clearly is, and we’ll come to some details in terms of when exactly that is in a moment. The reason why I keep pointing this out is so many clinicians pursue erroneous perturbations in thyroid hormones, thinking that that is the cause of the problem.
It gets so egregious, as we talked about in our last podcast case study, where a person was squarely normal for their TSH and their free T4, yet they were put on thyroid hormone. I just shudder inside at the thought of what would happen to this case study if she found herself in front of an overzealous thyroid provider. Almost for certain, she would be having thyroid hormone forced upon her.
T3 is oftentimes a byproduct of other things going on in the body. In this case, low T3, lack of periods, a multitude of gut symptoms. And this patient is pregnant and feeling much better within six months. There was no need to directly treat that T3.
Misconceptions: T4 Versus Combo Therapy (T4 & T3)
This dovetails in with the next component I wanted to discuss. This comes from July 2019, and was entitled “Dr. Ruscio’s Thyroid Medication Review: T4 Versus Combination Therapy (T4+T3).” This was a painstaking endeavor because there was a lot of evidence to go through. It’s not only challenging to go through all the evidence, but it’s also challenging to lay it out in a format where people can fairly easily read it and take away the conclusions. That’s what I hope we’ve done in the July edition.
A few notes that I want to share from this. (Again, all of the details are available in the newsletter write-up. If you subscribe, you’ll be able to click right through and view everything.) It can likely be intimidating for providers or even for patients alike, when you hear some thyroid guru matter of factly proclaiming that combination therapy, T4 plus T3, is the best, especially if you’re struggling with not feeling well. Whether that’s you as the patient or as the provider, when you’re not feeling well or you’re not getting the results, it’s much easier to say, “Well, let’s do what everyone else is doing.” It should hopefully be clear at this point that this sacred cow of thyroid being of utmost importance is not really supported. There is a time and a place, but we want to be careful not to overlook the gut.
Hey everyone. I’d like to thank Aerodiagnostics, my favorite SIBO lab, for making this podcast possible.
Again, Aerodiagnostics is the SIBO lab I use in my clinic. They have impeccable organization, customer service, test quality, and support. Regarding support, if you’re not highly proficient in reading SIBO labs, Gary definitely offers the best clinical support I’ve ever come across. He goes over labs in detail and offers insight analysis and really goes above and beyond.
Aerodiagnostics offers cash pay and insurance billing options, and they do a terrific job of keeping costs low and billing easy. They are for accounts for clinicians and direct-to-consumer testing and Aerodiagnostics, again, is my go-to SIBO lab.
If you’re wondering about how hydrogen sulfide ties into traditional testing of hydrogen and methane, please check out our recent podcast with Gary from Aero. Essentially, we’ve developed a simple questionnaire that will allow you to hone in on hydrogen sulfide SIBO, without needing additional testing or cost. Aerodiagnostics, check them out.
We’ve already talked in the past—in a previous podcast this month—about how by improving gut health (most namely the data here comes from clearing H. pylori) you can see a decreased thyroid medication dose, symptoms, and a decrease in thyroid autoimmunity.
There are also the case studies that we’ve covered of thyroid patients finally getting well after GI care. Dr. Mather’s case study did not require a personalized thyroid medication dose, but instead required addressing the gut. Dr. Abbott’s case study showed that the patient was erroneously diagnosed hypothyroid, and it was actually her gut that needed support to finally get a resolution of the symptoms. We’re starting to see these case studies supporting the same concept.
This now leads us to a review of the evidence showing combination therapy—meaning T4 plus T3—is only justifiable for about 10% of cases, as the evidence is really suggesting. Combination therapy is something to be considered, meaning if someone is on Synthroid (or levothyroxine), considering putting them on the addition of T3 (that might be via Cytomel, so they would take Synthroid plus Cytomel now), or switching them to a medication that’s a combination of the two (your WP Thyroid or your Nature-Throid). But the context here is really, really important.
The context here is, how do we organize this in the greater therapeutic approach? Or where does this go in the clinical hierarchy or algorithm? This is something that you’ll also see when you sign up for The Future Of Functional Medicine Review: my thyroid algorithm. It walks you through a stepwise process for sussing out, is it gut? Is it thyroid? Is it both?
What a lot of this boils down to is, yes, using a combination medication with T4 and T3 does have a time and a place, but they should really come after you take steps to improve gut health. If you rush to combination therapy, as you saw in Dr. Mather’s case study—this is the same thing that the evidence supports—patients oftentimes will feel worse. When you give someone who’s not a poor converter of T4 to T3 both T4 and T3, you overwhelm them with T3. No wonder why Dr. Mather’s patient suffered from an anxiety reaction when put on combination therapy. She didn’t need it.
This misunderstanding that T4 plus T3 (whether this be Armour or WP Thyroid or Nature-Throid or whatever) is better really comes from selective citation, or said another way, cherry picking from the studies to support what you think rather than helping you to learn.
As the quality of evidence one examines in the realm of thyroid medication increases, the support for combination therapy really diminishes. When we look at studies with better sample size, with controls, we start seeing that patients reporting preference for T4 plus T3 drops off sharply, as the quality of evidence improves and we counter against things like the placebo effect.
In fact, one of the studies that I review—as part of this review of the evidence—shows that the placebo effect has a strong impact on the patient’s reported preference. One study found that if the patient thought their medication was changed but it wasn’t, just the act of them thinking that their medication was changed led them to report they felt better.
What this looks like is, you have a group of patients on thyroid medication. Let’s say they’re all on T4. Then, researchers take away their medication and give them these bottles that are white-labeled, meaning they don’t know what’s in it. They just know you take one pill of this a day, like you were taking one pill of your last medication a day. They know that some people are going to be given T4. Some people are going to be given T4 plus T3 in a blinded fashion. So nobody knows. When the patients who were on T4 and went into the blinding and were given this white-labeled pill, if that pill was also T4 (the same thing they were taking before), they still reported feeling better.
When you look at trials where there’s no blinding—meaning a bunch of patients are taken off of their T4 and put on T4 plus T3—and they report, “We feel better,” you can’t rest too heavily on those results. Unless you have a control arm in blinding, you could be suffering from the placebo effect. That’s the point I’m making here. As we get to better quality studies with blinding and controls and/or larger sample size, we see the preference for combination therapy diminish.
That’s not to say it diminishes down to zero. The preference varies from study to study, but if you look at all the data, you can summarize this down to roughly a 10% preference. Or 10% of people prefer T4 plus T3. Although you have to be careful.
Here’s another example of where confusion can come from. There have been some studies that have taken a group of patients, all of whom reported they did not feel great on T4, and then put them on combination therapy. If you take a group of people who report not feeling well on T4, you’re selecting for patients that likely have a genetically poor ability to convert T4 into T3. Obviously, you’re going to see a higher distribution of people who prefer T4 plus T3 in that sample, because it’s a selection bias. You’re selecting people who show indications that they would prefer T4 plus T3. If we take a random selection of people, an even sample, it tends to show about a 10% preference. That also overlaps with about a 10% prevalence genetically in the population of people who are poor converters of T4 to T3.
So I break down all the evidence there and show you both sides. I show you the evidence that supports the majority of people feel better, or the same, on T4 only. Then, I juxtapose that with the evidence showing that people feel better on T4 plus T3. It’s very clear to see: the large, well-performed trials, in terms of having randomization and blinding, lean toward T4 only. Smaller trials show a preference for T4 plus T3. If you’re looking at patients who have not responded at all to T4, there’s a higher preference there. When we summarize all of this, what we come away with is, yes, some people will do better on T4 plus T3, but it is the minority.
Get a Valuable Thyroid Algorithm
So here’s the challenge. People read on the internet that the reason why you’re not feeling well with your hypothyroid medication is because you’re not converting it. They go see doctors, like the famous thyroid doctor I was mentioning earlier, and they get put on hormone when they don’t need it. Or they get put prematurely on T4 plus T3, like Dr. Mather’s case did, and patients feel worse. Only if a patient is lucky do they find a provider who will look to their gut health first, and then later consider a combination therapy. That’s essentially what’s codified into the thyroid algorithm that I share, also in the newsletter.
There’s a lot here. But when you zoom way out and you look at the algorithm, it’s actually quite simple. You can work through in a stepwise process, understanding the rationale behind why only a minority of patients prefer T4 plus T3 and why we should wait to administer T4 and T3 until after we’ve improved someone’s gut health.
That’s a bit more academic, and that’s a bit more granular. When you zoom way out after looking at all those details, you can see a very clear picture emerge: start patients on standard T4 therapy, while also considering going to work in their gut health. Reevaluate. If you clean up their gut and they still have symptoms, then you can consider the addition of T4 plus T3. Now you’ve ruled out or taken care of a problem in the gut. So the symptoms that the patient is complaining about are now much more likely to be coming from their thyroid, thus requiring T4 plus T3, and not coming from their gut because that issue has been addressed.
Again, all of this is various excerpts of only the first six months of 2019’s Future of Functional Medicine Review Clinical Newsletter. If you go to drruscio.com/review, for $1, you can sign up for your first month of access to every issue that’s been published in nearly three years. I very much hope you will. It’s a minimal investment. If you like what you read, I hope you’ll stay on board, and that you will read for a few months, learn and then apply this. Then you can submit a case study to me that I can publish in the newsletter, gloating how awesome your results have been with applying the information contained in the newsletter, as I feel so honored and fortunate to be able to have done with Dr. Abbott and Dr. Mather.
Please check out the Future of Functional Medicine Review if you have not yet done so. I will keep publishing the most relevant and impactful research there, as well as insightful case studies from my clinic, and from your clinics as you have these success stories. You can send them in so we can all learn together, share what we’ve learned, and really contribute to enhancing the quality of care that we offer our patients. And so we can help grow referral-based and secure practices that we can all thrive in, enjoy, and be stress-free in (or at least the minimum stress possible).
Anyway, drruscio.com/review. Check it out. I hope you guys learned some stuff throughout the month here, with me sharing these bits and bites from case studies and various research studies. And I will talk to you next time. Thanks.
I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!
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