The Truth About the Symptoms of Hashimoto’s Flare-Ups

How to Live Well with Hashimoto’s

If you have Hashimoto’s thyroiditis, there are two very different reasons why you may be experiencing symptoms:

  • Immune system activation (inflammation)
  • Low thyroid function (hypothyroid)

Standard treatments for Hashimoto’s disease tend to focus on treating hypothyroidism. But this is only part of the equation and it leaves many patients struggling with unresolved symptoms.

In this article, we’ll explore how you can calm your immune system, lower inflammation, and feel better. But first, let’s take a closer look at the two distinct reasons for Hashimoto’s symptoms.

Symptoms of Hashimoto's Flare up: Antibodies attacking thyroid gland of a woman

Immune System Activation

Hashimoto’s disease is an autoimmune disorder that affects thyroid function. As with all autoimmune diseases, the body’s immune system attacks its own tissues in a case of mistaken identity. With Hashimoto’s, this overzealous immune response causes thyroid inflammation or thyroiditis.

When you experience symptoms of Hashimoto’s flare-up, it’s likely that you are having an autoimmune flare. This means that your immune system has gone into overdrive and is generating inflammation.

For many thyroid patients, the root cause of an inflammatory flare is linked to poor gut health in what’s known as the gut-thyroid connection [1]. Improving your gut health can calm inflammation, reduce symptoms, and can also decrease thyroid autoimmunity [2 Trusted SourcePubMedGo to source, 3 Trusted SourcePubMedGo to source, 4 Trusted SourcePubMedGo to source, 5 Trusted SourcePubMedGo to source, 6 Trusted SourcePubMedGo to source, 7 Trusted SourcePubMedGo to source, 8 Trusted SourcePubMedGo to source, 9 Trusted SourcePubMedGo to source].

Low Thyroid Function

Over time, the inflammatory process can damage the thyroid gland and impair thyroid function, eventually leading to hypothyroidism.

If you are hypothyroid, your thyroid gland does not produce enough T4 thyroid hormone. This causes your metabolism to slow down. Symptoms of hypothyroidism (low thyroid function), include:

  • Fatigue
  • Dry skin
  • Hair loss
  • Weight gain
  • Brain fog
  • Poor mood
  • Decreased heart rate
Symptoms of Hashimoto's Flare up: Hypo vs Hyper Thyroid Symptoms Infographic

Hypothyroidism is easily treated with thyroid replacement hormone. Levothyroxine (Synthroid) is the most commonly prescribed thyroid medication.

If you are taking thyroid medication and your lab results are normal, you shouldn’t experience symptoms of hypothyroidism. However, many patients do continue to struggle with tiredness, brain fog, poor mood, and other symptoms, despite taking medication.

In this case, your symptoms are likely caused by inflammation and dysfunction in the gut-thyroid connection, not a lack of thyroid hormone.

The Gut-Thyroid Connection

Fatigue, brain fog, and mood issues aren’t just associated with thyroid disease. They are also common symptoms of gut disorders. For example:

  • More than 50% of IBS (irritable bowel syndrome) patients have symptoms of fatigue, according to a meta-analysis of 17 studies [10 Trusted SourcePubMedGo to source].
  • Sixty-eight percent of patients with suspected non-celiac gluten sensitivity reported a lack of well being [11 Trusted SourcePubMedGo to source]. These patients also reported tiredness (64%), headache (54%), anxiety (39%), brain fog (38%), and other non-digestive symptoms.
  • In a systematic review, IBS patients were three times as likely as healthy subjects to have either anxiety or depression [12 Trusted SourcePubMedGo to source].
  • Depression is prevalent in both IBS and IBD (inflammatory bowel disease) patients [13 Trusted SourcePubMedGo to source].

Other studies associate gut conditions with sleep disorders [14 Trusted SourcePubMedGo to source], headaches [15, 16 Trusted SourcePubMedGo to source], dermatitis [17], rosacea [18 Trusted SourcePubMedGo to source], and joint pain [19 Trusted SourcePubMedGo to source].

What Happens to Thyroid Health When Gut Conditions are Treated?

3D illustration of the digestive system with E.coli bacteria zoomed in

One small study found a remarkable average 2029 drop in TPO antibodies (a marker of thyroid autoimmunity) when patients were treated for H. pylori gut infections [20 Trusted SourcePubMedGo to source]. Other studies show that treating H. pylori can improve TSH levels [21 Trusted SourcePubMedGo to source, 22 Trusted SourcePubMedGo to source, 23 Trusted SourcePubMedGo to source].

Treating Blastocystis hominis (a parasitic gut infection) has been shown to reduce inflammatory markers, thyroid antibodies, and TSH levels [24 Trusted SourcePubMedGo to source].

Gut treatments have also been shown to improve thyroid-like symptoms, including fatigue [25 Trusted SourcePubMedGo to source, 26, 27 Trusted SourcePubMedGo to source], mild to moderate depression [28 Trusted SourcePubMedGo to source], and anxiety [29].

Eliminating common trigger foods can also be helpful for some thyroid patients. In one study, lactose restriction led to a significant decrease in TSH levels for thyroid patients with lactose intolerance [30 Trusted SourcePubMedGo to source]. Another study found that a gluten-free diet reduced the need for thyroid medication in patients with atypical celiac disease [31 Trusted SourcePubMedGo to source].

Improving your gut health is an important part of an overall plan for better thyroid health.

How To Prevent Hashimoto’s Flare-Ups

Steps for Hashimoto's health

If you have Hashimoto’s disease and are struggling with symptoms of Hashimoto’s flare-up, there’s a lot you can do to feel better and regain your energy.

Take a step-by-step approach to address the most fundamental health foundations first. For some patients, symptoms will start to resolve after taking a few steps. Other patients will need to complete more steps.

1. Get Your Thyroid Hormone Levels in Range

An important first step is to resolve true hypothyroid symptoms with medication.

Standard blood tests for thyroid hormone levels are simple, straightforward, and very accurate:

  • High TSH and low free T4 indicate hypothyroidism
  • Low TSH and high free T4 indicate hyperthyroidism (overactive thyroid)

If you are hypothyroid, a thyroid medication like Synthroid (levothyroxine) will help get your TSH and T4 levels in range.

Once your TSH levels are normal, don’t try to optimize your medication for better results. Focus your next steps on calming the immune system and reducing inflammation.

2. Make Lifestyle Improvements

An unhealthy lifestyle can contribute to your autoimmune condition. Along with poor diet, here are the most common lifestyle issues I see in thyroid patients:

  • Lack of sleep
  • Not exercising
  • Over-exercising
  • Overly stressed
  • Poorly controlled blood sugar

If you identify any of these issues as problem areas for you, take steps to improve your lifestyle and work on practicing better self-care.

3. Eat an Anti-Inflammatory Diet

Eating a simple, real food diet is the foundation of gut and thyroid health [32 Trusted SourcePubMedGo to source, 33 Trusted SourcePubMedGo to source, 34 Trusted SourcePubMedGo to source, 35 Trusted SourcePubMedGo to source, 36 Trusted SourcePubMedGo to source]. A healthy diet can reduce the burden of inflammation in your body, improve your gut health, and reduce symptoms.

There’s no one-size-fits-all thyroid diet. However, these dietary approaches are often helpful:

  • Eat real, unprocessed foods, free of additives and chemical preservatives.
  • A lower-carb diet may be helpful for some Hashimoto’s patients.
  • Identify and remove foods that trigger your symptoms. A gluten-free diet(or gluten-reduced) may be helpful for some.
  • A low-iodine diet may be helpful for thyroid patients [37 Trusted SourcePubMedGo to source].

If you want to follow a specific diet template or meal plan, the paleo diet is anti-inflammatory, lower in carbs and trigger foods, and suitable as a long-term diet.

If a paleo-type diet doesn’t resolve all of your symptoms, the AIP diet (autoimmune paleo or autoimmune protocol) is a good next step. The AIP diet is an elimination diet intended to help you identify food triggers that cause inflammatory symptoms.

4. Take Probiotics

Probiotics are effective because they work to balance the community of microorganisms that live in your gut [38 Trusted SourcePubMedGo to source], fight harmful microorganisms [39 Trusted SourcePubMedGo to source, 40 Trusted SourcePubMedGo to source, 41 Trusted SourcePubMedGo to source], promote a healthy immune response [42 Trusted SourcePubMedGo to source, 43 Trusted SourcePubMedGo to source, 44 Trusted SourcePubMedGo to source], and reduce inflammation [45 Trusted SourcePubMedGo to source].

A study of hypothyroid patients found that probiotic supplements reduced the need for thyroid medication and reduced fatigue [46 Trusted SourcePubMedGo to source].

5. Take Supplements

Vitamin D may improve your thyroid health and lower thyroid antibodies [47 Trusted SourcePubMedGo to source, 48 Trusted SourcePubMedGo to source, 49 Trusted SourcePubMedGo to source]. Safe sun exposure is free and the most bioavailable way to get adequate vitamin D. Supplemental vitamin D is recommended during winter months in higher latitudes.

Selenium supplements can reduce TPO antibodies in thyroid patients [50 Trusted SourcePubMedGo to source, 51 Trusted SourcePubMedGo to source]. However, long-term supplementation is less beneficial [52 Trusted SourcePubMedGo to source, 53 Trusted SourcePubMedGo to source]. Consider 3-6 months of supplementation to boost your selenium levels.

Supplementing with HCI (betaine hydrochloride) can increase stomach acid levels, and may help with the absorption of iron, vitamin B12, and thyroid medication. Up to 40% of hypothyroid patients may have low stomach acid [54 Trusted SourcePubMedGo to source, 55 Trusted SourcePubMedGo to source].

Some thyroid patients may benefit from iron supplementation. If your blood tests show serum ferritin (the storage form of iron) levels significantly below 100 mg/l with iron, supplementing with iron may help to improve fatigue [56 Trusted SourcePubMedGo to source].

6. Treat Gut Infections

If lifestyle improvements, diet, and probiotics haven’t fully resolved your symptoms, the next step is to look for hidden gut infections.

Research shows a correlation between thyroid problems and gut infections, including SIBO (small intestinal bacterial overgrowth) [57 Trusted SourcePubMedGo to source, 58 Trusted SourcePubMedGo to source],  H. pylori infection [59 Trusted SourcePubMedGo to source, 60], and B. hominis infection [61 Trusted SourcePubMedGo to source].

Testing for and treating gut infections is best done with the help of an experienced health practitioner

7. Adjust Thyroid Medications

As your gut health improves, you may absorb your thyroid medication better. Lab tests and consultation with your doctor can help to determine if you need to fine-tune your thyroid medication.

Some patients may need alternative thyroid medication, such as T4/T3 combination therapy, but this is not the majority.

Should You Be Concerned About Thyroid Antibodies?

Thyroid tests for TPO antibodies measure the degree of autoimmune activity in Hashimoto’s disease [62]. TPO levels over 35 IU/mL are generally considered positive for autoimmunity.

Many patients are able to significantly reduce TPO levels through diet and lifestyle changes or by treating a gut infection. However, it’s not necessary to reduce your TPO levels to zero. In fact, striving to do so can create stress and be counterproductive.

Research shows that patients with TPO levels below 300 are unlikely to become hypothyroid [63 Trusted SourcePubMedGo to source] and patients with TPO levels below 500 have minimal risk of becoming hypothyroid [64 Trusted SourcePubMedGo to source]. Essentially, there is not enough autoimmune activity to significantly damage the thyroid gland at these levels.

If your TPO levels are high, a sensible goal is to get your TPO level below 500.

You Don’t Need to Be Tired and Frustrated with Hashimoto’s

If you struggle with symptoms of Hashimoto’s flare-up, don’t expect thyroid medication to solve all of your problems.

Poor gut health is a very common cause of symptoms like fatigue, brain fog, poor mood, weight gain, and more. This may be a bigger contributor to your symptoms than your thyroid hormone levels.

Luckily, focusing on your gut health and attending to your daily habits like sleep or stress management can help you manage and resolve symptoms of Hashimoto’s flare-ups.

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2 thoughts on “The Truth About the Symptoms of Hashimoto’s Flare-Ups

  1. I’ve addressed all the steps you’ve outlined except the probiotics. I have found taking probiotics causes GI problems for me. I’ve tried soil-based (those were the least problematic) and I’ve tried adding saccharomyces boulardii. I tend towards gas and bloating when my GI trouble starts. (Ps I’ve resolved SIBO with herbal antibiotics over two years ago and have TPO at <75. I’m also one of the rare cases that needed T3/T4 to feel better). Question: I still have GI symptoms of gas and bloating when eating high amounts of fiber (flax, cruciferous veggies, etc). What can I do to reduce bloating when eating high fiber foods?

    1. Hi Karri,

      Thanks for your question and for sharing your situation. As far as probiotics go, you might want to start *super small* and work up from there. Like 1/16 of a tsp, stay there for a week or two, then move up to 1/8 of a tsp. It can take some people’s bodies a while to adjust to probiotics and that’s ok. Re: fiber, it just doesn’t work for everyone and not everyone should be eating high amounts. You may also find that soluble fiber works better for you than insoluble. Here are some resources on that: https://drruscio.com/improve-constipation-reduce-fiber-intake/
      https://drruscio.com/truth-fiber-everything-need-know-fiber-consumption/
      Hope this helps!

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