Today let’s cover a case study from my office. This case study provides valuable insight regarding the gut-thyroid connection. I will detail the specific tests and treatments that allowed this patient to obtain results after not improving with numerous other providers.
Dr. Michael Ruscio, DC: Hey, guys. Before we jump into the body of today’s show, there were a few things that I wanted to share with you. Essentially, I want to share with you a summary of a case study that I think exemplifies some very important philosophical points I often touch on. One is not over treating. And the other is knowing how to use gut treatments discerningly. So we’ll get into some more details in a moment.
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Dr. R’s Fast Facts Summary
Patient – 76-year-old female
- Over supplementing
- Diagnosed with IBS
- Complains of diarrhea, nausea, stomach pain, belching
- Joint-pain and fatigue
- Mistreated for Thyroid
- Turned out to be age appropriate subclinical hypothyroidism
For the list of testing that was ordered and results – see details in transcript below
Phase 1 Program prescribed by Dr. Ruscio
- More sleep – in bed before midnight
- Start walking – slowly and gradually
- See local physical therapist for leg cramps
- Diet and supplements prescribed
- Continue diet – Low FODMAP/SCD (with goal to broaden diet once symptoms improve)
- Discontinue current supplements
- Digestive enzyme with bile and HCL, S. boulardii and Magnesium
- GI symptoms improved
- Patient feels better after stopping her initial supplements
- Joint pain is the same
Phase 2 to address GI findings
- Felt poorly, symptoms flared
- Likely an allergic reaction to herbal antimicrobials
- Ordered to discontinue herbal antimicrobials
Overzealousness in functional medicine can be problematic, keep an eye out for:
- Having patients overspend on labs and supplements
- Getting too bogged down by lab results vs the patients symptomatic feedback
- Adverse reactions to supplements if symptoms do not improve
- Age range of patients when looking at subclinical hypothyroidism
Low FODMAP Diet has an effect on the intestinal endocrine cells in those with IBS
- A low FODMAP diet can lead to a normalization (an increase) in serotonin and other cell density in IBS patients
- The densities of cells are abnormal in the stomach, duodenum, ileum and colon of patients with IBS
- The low FODMAP diet tends to change these densities toward the values measured in healthy controlled subjects
And also I want to discuss some key points regarding the low FODMAP diet and how understanding some of the mechanism can actually help—especially if you’re a clinician—talk your patient into doing the low FODMAP diet, in light of them potentially having read on the internet that the low FODMAP diet may have a negative impact on your microbiota.
So these are a couple of pearls, and I’ll provide a summary of each of these. These actually are ultimately derivatives of different issues of the Future of Functional Medicine Review clinical newsletter.
Future of Functional Medicine Review
If you’re new to our audience, or if you haven’t heard this before. The Future of Functional Medicine clinical newsletter is a monthly paid access newsletter where I go into case studies, and I illustrate how we go from the very first visit and listening to a patient’s symptoms, and background, and history, and context and use that to craft what testing to order, what dietary recommendations to make. And how does that evolve further into tracking the patient and helping people get these outcomes with minimal testing and treatment when, in many cases, they’ve seen other doctors or other providers, and been unable to attain results.
So, I want to showcase some of this because the feedback that we’ve been getting from clinicians, and practitioners, providers, nutritionists, health coaches, what have you, or even enthusiastic lay people has been overwhelmingly positive.
And also, to make it easier for you to join the Future of Functional Medicine Review clinical newsletter, for the month of September, if you purchase access, you can obtain your first month of access for only $1. Which includes access to back issues of almost 2 years. So I’ve made it very easy for you to access the newsletter, look through all the back issues, and really get a sense if this is something that can help you. And if it is, then I would love to have you on board so that we have more people out there with a sharpened skill set in functional medicine who can use these tools discerningly and obtain better patient outcomes at a lower cost.
Again, we’ll put the link in the transcript. But essentially if you go to DrRuscio.com/review you can access this page. You can plug in for your first month of access for only $1. So let’s talk about this case study, and then on the tail of that we’ll talk about some issues regarding the low-FODMAP diet mechanisms.
So this case study is entitled “Age Associated Subclinical Hypothyroidism, Candida, and False Positive Parasitology.” So this is someone who comes in, and we have to grapple with how to make sense of all this data.
Case Study Patient Review
So Anna is a 76-year-old female. Her previous diagnoses include IBS, and she is on no prescription medications. Her chief complaints are diarrhea, with a severity of 9/10, stomach aches with a severity of 5/10, bloating, with a severity of 8/10, reflux with a severity of 6/10, weakness and fatigue with a severity of 5, joint pain severity of 8. And also some belching, nausea, and mucus in the throat.
So, here’s essentially my impression after her history and exam. “Anna presents as a pleasant, 76-year-old female who is on a limited diet, inactive due to leg cramping and weakness, but has a great demeanor. She has done a lot of health research, and I fear her eagerness has been exploited by other providers. She has been diagnosed with IBS, and is on no Rx. Her chief complaints seem to have started after food poisoning in 1985, and persisted somewhat ever since. Her conventional workups have all come back normal.
Her presentation is highly consistent with post-infection IBS, SIBO, and histamine intolerance. Other diagnoses are possible, including high acid/ulcers, or even potentially mercury tissue burden.
Acid lowering supplements have helped her in the past, while probiotics may cause diarrhea. The low-FODMAP with SCD food list resonates with what she notices she can eat. So, she’s inadvertently eating the low-FODMAP with SCD diet.
We will work through the standard GI model. And since she has done no functional medicine GI work, there is much potential. But due to the long course of her illness, this might be a poor prognostic indicator. So her prognosis is fair to good.
In short summary, initial impression, Anna is a great example of a patient who would do anything, highly motivated. And sadly, her binder of frivolous tests and her thinking that she has 10 different diagnoses was a testament to how damaging some complementary and alternative medicine and/or functional medicine can be. She has spent a lot of money, felt no better, but was convinced she had a lot wrong with her, all thanks to her other providers.
Her case should be relatively straightforward, but there are a few unusual observations. She is elderly, and this population is at highest risk for low stomach acid. However, she feels better on supplements that decrease stomach acid. She also may have a negative reaction to probiotics.
Ok, so that kind of gives you the intro to Anna. Now, at her second visit, we lay out the testing recommendations and our initial treatment recommendations. So the tests ordered, Arrow diagnostics glucose SIBO breath test. And I’ll give you the rationale here in a moment. Doctor’s Data comprehensive stool with parasitology 3X. Discomfort, what I determine GI 15, which is a selection of 15 markers a la carte. And a custom blood panel, including a CBC with differential, metabolic panel, lipid panel, iron assessment, a few inflammatory markers like CRP and ESR. Insulin fasting, hemoglobin A1c, TSH, and free T4.
So the testing rationale. We of course wanted to rule out SIBO. She was very reactive to FODMAPs. So lactulose may have flared her, hence supporting the decision to use glucose. Although I can say that I typically will avoid lactulose if someone has FODMAP sensitivity. However, in her case, it just seemed like perhaps the right fit.
Additionally, since this all started after food poisoning, a good evaluation of parasitology is indicated. I made a note here, if I could run this again, I would have added an H. pylori breath test and serum antibodies testing at LabCorp, as her symptoms are suggestive of H. pylori. So I would have potentially added those additional in there.
As part of these case studies, I sometimes give you reflections because this case study, I think, was from a patient two years ago. Or 2.5 years ago, roughly. And then I wrote this up about a year and a half ago, or a year ago. So I’ll provide some reflective notes on what I would have done differently had I been seeing this patient now.
And then blood panel was an assessment for any common metabolic imbalances like diabetes, hypothyroid, anemia, etc.
And her recommendations. Continue with your previous, personalized elimination diet. If she has got herself to the point where she’s essentially on the low FODMAP with SCD diet, it’s hard to do much better than that. And that seems to work for her.
Now, the goal will be to get her on a broader diet in the longer term. But for right now, I’m hard pressed to say she really needs to modify her diet much more. And I made a note: do your best to start walking. Start slowly and gradually. See a local therapist to help with the leg cramping. Consider someone who practices ART active release technique or something similar. Do your best to be in be before midnight. She was going to bed kind of late.
From a dietary perspective, I asked her to please perform a two to four-day liquid fast. Then resume her previous diet for two to four days. And then try two to four days on a semi-elemental diet.
Regarding supplements, we put her on a digestive enzyme with bile and HCl formula. Plus S. boulardii. And I’ll give you the rationale there in a moment. And she was previously on magnesium, and we asked her to continue with the magnesium.
Now, the rationale. Her diet was already restrictive and based on her own elimination and reintroduction. So I didn’t feel much change was needed there. I did want to evaluate the effect of fasting, and perform a short trial on the elemental formula.
Now, even though she had noted previously that she had responded well to acid lowering supplements, I was curious to evaluate if she would be aided by HCl, hence the trial here. I also decided to try S. boulardii since she had reacted to other probiotics previously, but knowing that S. boulardii can help with diarrhea. This comes back to something I’ve talked about previously, which is not all probiotics are the same. She had essentially reacted to a category 1 probiotic in the past. That does not mean she would react to a category 2. This is where a little bit of discernment can potentially go a long way.
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So, about 30 days later we follow up. The labs show a peak hydrogen of 4. So she does not have hydrogen SIBO. A peak methane of 3, so we could label her a methane producer, but not methane SIBO positive. Her Doctor’s Data profile showed candida plus one, yeast were found many times on the microscopy, and in all 3 of the samples. So 3X.
Her diagnostics profile flagged antibodies for Ascaris lumbricoides, which is giant roundworm, and Entamoeba histolytica. Both of these are very concerning.
Her LabCorp panel showed mildly elevated cholesterol, nothing I was concerned about. It did show a hemoglobin A1c of 6, so that’s something to look at. And her thyroid stimulating hormone, her TSH was 5.1. And I’ll come back to that in a moment, because that’s important.
So summary. She was a methane producer, not methane SIBO positive. In fact, I probably would tell someone they do not have SIBO very clearly because what I don’t want to do is for someone to take a methane of 3 and start conflating that with severe cases of SIBO they read about on the internet. So, that methane of 3, yes, there’s some correlation that’s been published. But I’m not very concerned about a methane of 3 at all. So at best, we could label her a methane producer.
She also had candida and yeast, of course. And she had what I would consider, and this is what the research shows, an age-normal subclinical hypothyroidism. So that 5.1 is actually normal. Or as best as we can ascertain what would be considered normal for someone in the geriatric population. Someone who is 76.
She has potential, emphasis word potential Ascaris lumbricoides and E. histolytica. The reason I say potential is because we did not see that reinforced on any other of her lab tests, and the lab test that we did find positive were antibodies markers, which are imperfect. So we want to be careful not to rush to a diagnosis when we only have antibody confirmation. And she had mildly elevated cholesterol.
Continuing with the summary, SIBO is essentially negative. Candida/yeast appear the main issues or imbalances. I had a suspicion that the Ascaris and the E. histo were false positives, but irrespective, the herbal candida treatment will act against these also. So whether they’re present or not, if we end up using any type of herbal antimicrobial therapy, we will have action against those, as well.
We will also include the Ascaris and E. histo in our retesting to be sure. So these are two where I feel retesting would be salient. Especially the E. histo, because it’s highly pathogenic.
And regarding the TSH, this is normal, given her age, as I mentioned a moment ago. The hemoglobin A1c elevated in isolation is less suggestive of a problem, in my opinion. Although I think that is debatable. But I’m not going to overly focus on that right now. I’m going to focus on her gut, because, again, the A1c elevated in isolation is not, in my mind, hugely problematic. Again, although I do think you could make a somewhat viable counterargument against that. And again, her cholesterol being a little bit elevated might be normal, given her age.
Ok. So, how did she feel 30 days later? We’ve gone over her labs. And before we get too sucked into what her labs say, how did she feel after 30 days on the initial program? Because this is really important. This is what people often gloss over. She is feeling better after discontinuing the handful of supplements she was previously taking.
And I put a reminder here, I ask all new patients to stop all supplements when we start our work together. And there is definitely a subset, as she is illustrating, who feel much better when they get off of the handfuls of supplements that they’re taking.
Patient Symptoms Post Treatment
She did not perform the modified fast or the elemental diet. She felt the program was helping her. And all of her digestive symptoms were improved. Her joint pain was the same. We did not get an evaluation of the fatigue. And likely—if you don’t mind me being a little bit candid here—likely what happened is she was so verbose in all of her answers, there just was not enough time to go over everything and get the assessment of all of the symptoms I wanted.
This is one of the reasons why I recommend patients try to apply the 80/20 rule when they go into their visits because there’s a checklist of things I’m trying to work through in my mind. And if there are 30 questions that the patient has, they may be very important in the patient’s mind, but they don’t help me get through the checklist in my mind. So in this case, I did not get an assessment of her fatigue.
I’m assuming the fatigue was better, because we know that IBS symptoms correlate with anxiety, depression, and fatigue. And when those symptoms improve, it’s fairly common to see fatigue also improve. But essentially, her main complaints were a confection of GI symptoms, and all of those symptoms had improved. Joint pain was the same. And fatigue was likely improved, ostensibly.
So, my overall impression, looking at all of this. We are off to a good start with Anna. She was over supplementing, and this appeared to be causing much of her symptoms. So this is one of the reasons why I’m critical of functional medicine. I’m not just trying to be critical to be a jerk. I see stuff like this fairly frequently.
And this is also key. When seeing her high TSH, she informed me that this was found a year ago by her naturopath, and her ND aggressively recommended starting on thyroid prescription. Anna complied, and noticed that her fatigue became much worse after doing this.
So, this is one of the reasons why it’s important to look at the evidence because there are some thyroid fanatics out there who would have you believe that any minor perturbations in thyroid hormone require direct treatment. And that is not true.
I’m open to some experimentation to helping people find if they’re an outlier who potentially has subclinical hypothyroidism, which is age-associated normal. As Anna did. And trying a thyroid hormone and seeing if she improves. But unfortunately, her previous ND does not seem to be up to date with what the literature clearly shows. Which is to have a mildly elevated TSH in a geriatric, someone 76, is not abnormal and does not require treatment.
Why is that relevant? Because negative reactions are fairly commonly reported to thyroid hormone. When they’re given when they’re not needed. So these things are important. We don’t want to just be throwing out thyroid hormone with no discrimination as to who the appropriate person may be.
And finally, I told Anna that I think the best approach right now would be to wait and see. Since nearly all of her symptoms had improved. However, Anna really wanted to address her GI findings. So I agreed to start her on herbal antimicrobials.
Now, I’m going to just paint a little foreshadowing here. I’ve said many a time that we don’t have to always directly treat everything we find on labs. Especially when it comes to gastrointestinal dysbiosis. Now, yes. Entamoeba histolytica and Ascaris lumbricoides, those are not dysbiotic. That’s not an overgrowth of commensal bacteria, like as in SIBO or candida or yeast. These are overt and direct pathogens. And we want to not fool around with those.
However, the method of diagnosis of these is not highly official. Antibodies, in this case salivary antibodies, don’t give you necessarily a direct measure. It’s like, diagnosing a fire because you saw smoke. But you don’t know if that smoke was coming from something else or if the fire is out, and that smoke is just residual and hasn’t fully dissipated yet. So, it’s important to bear that in mind.
Program Addressing GI Findings
And it’s important to also bear in mind that if you’ve gotten to the clinical end point, in this case, a patient who all of her digestive symptoms are gone from a select probiotics and also some digestive support, and getting off of the handfuls of unnecessary supplements, it’s not necessary to always treat the labs. And this is fairly commonly recurring. But let’s see what happens.
So recommendations, continue with your previous diet, with the walking, with the local therapist. With the enzyme bile and HCl formula, and the S. boulardii probiotic and the magnesium.
Now, start on essentially oregano and an antimicrobial blend and artemisinin. The same protocol that I lay out in Healthy Gut, Healthy You. And the recommendation rationale, we will evaluate if any additional benefit can be achieved with the herbal antimicrobials.
So about 30 days later, we follow-up. And what does she report subjectively? Anna felt about the same, except for the following reactions: hot flashes, fatigue, sore throat, nausea, and stomachache. So a pretty marked regression.
My impression, given the fact that the reaction lasted longer than a week, it is likely an allergic reaction or an irritation reaction and not a die off. This is good support for acting conservatively, as I had advised Anna at our last visit.
So my recommendation, discontinue the herbal antimicrobials, and continue with all other previous recommendations. Retesting, since we’ve already completed a month of antimicrobials. Let’s repeat the previous testing, the Doctor’s Data, especially the diagnostics profile, to assess if that Entamoeba histolytica and Ascaris lumbricoides worm are still present.
Patient Symptoms Post Phase 2 Treatment
So we follow-up about 30 days later. The flare has subsided. All of her digestive symptoms are significantly improved. The joint pain is still present, but Anna feels it is improving with her therapist. Which suggests this might be structural joint pain, and not so much inflammatory gut/joint inflammatory pain in the joints.
And the labs. Let’s talk about the labs now. She’s where we’d like her to be symptomatically. The labs show that the candida has cleared. And the yeast went from many on 3X of the samples to only 1X. So there is some objective improvement there.
The diagnostics profile is now negative. So we could have cleared the Ascaris lumbricoides and Entamoeba histolytica. They also could have been false positives because antibodies tend to lag behind. So if you have an antigen, stool antigen, meaning you’re trying to find a parasite in the stool. Once you kill that parasite, it no longer shows up in the stool. But the antibodies take weeks to die down. Because the immune system doesn’t change on a dime.
So the fact that this was only a couple of weeks after she ended the antimicrobials, and the antibodies were normalized, my mind is more suggestive that the findings were a false positive. Meaning they weren’t actually there. Than that we eliminated these. You could make a case either way, but I think the strongest case is there.
So the lab summary, the Doctor’s Data profile has greatly improved. Since Anna is now asymptomatic, these findings are likely inconsequential. So she does have a little bit of yeast on that Doctor’s Data profile. But, if you find mild indicators of dysbiosis in an asymptomatic patient. In someone with no symptoms. You don’t need to keep treating them. In fact, she felt worse when we did that.
And the Ascaris lumbricoides and E. histo could have been cleared or may have been false positives. Either way we are in good shape now.
And my overall impression, Anna’s gut is in good shape. Since her GI improvements did not result in any additional improvement, namely her joint pain. Meaning we put her on the initial protocol. The initial protocol seemed to help her. We then tried to do additional GI work with antimicrobials, and that didn’t lead to any additional improvement. So in light of that, the joint pain is likely more structural than it is driven by the GI.
And recommendations, experiment with coming off the supplements in your program. If a symptom regresses when coming off something, go back on it. If nothing happens, then discontinue. Do this for two months, and then follow-up. At your next visit, we will work to broaden your diet. Keep up the good work.
So, I believe we’ve seen Anna since this case closed. But essentially we got her to a point with very minimal supplements. Way less than she was initially on. And she’s feeling much better.
So here are my kind of closing comments. Anna’s case is a good example of how overzealousness in functional medicine can be problematic. She had spent a lot of money and performed much testing and treatment prior to seeing me. She did not feel any better from this. Perhaps because she is somewhat reactive to supplements, which no other provider caught. Likely because they were distracted by over testing and treatment.
Key, likely the reason why the reaction to supplements was missed was providers were testing too much, treating too much, and they couldn’t parse that out of all the other moving parts. No other provider caught this, again, likely because they were distracted by over testing and treatment. She was also overtreated for subclinical hypothyroidism, which was normal given her age.
She responded well to some basic therapies. When we attempted more aggressive treatments based upon her labs, the herbal antimicrobials, she started to feel worse. An important lesson here is to remember that if what you have already done is working, don’t feel pressure to do more. There is nothing wrong with waiting and seeing. You can always do more later.
Functional Medicine Tips
So that’s one case study that illustrates much of what I harp on. And hopefully this helps you understand that when I’m critical of testing, when I’m critical of treatment, when I’m critical of over-zealousness with the thyroid, it’s not because I’m trying to be a contrarian, or I’m trying to tear down other buildings to make my building look taller than it is. It’s because these types of cases walk into my office quite frequently. These cases where less testing and less treatment, and having a more precise understanding of what to do and when will attain the results. Right?
So this patient needed a different paradigm in functional medicine. She needed a practical, I guess more discerning paradigm, with less testing, with less supplements, with less money spent, and with feeling like less was wrong with her because I didn’t label her with all these fictitious diagnoses. She felt much better. So this is key.
One of the reasons why this is so key, in case it’s not apparent is because if you think you have to do more for every case, those cases that are like this that are requiring less, will never respond. And you will be spinning your wheels. And that’s not good for you. It’s not good for the patient.
So let’s now cover… So the case study was from the September 2017 Future of Functional Medicine Review issue. And this bit on the low FODMAP diet was from the November 2017 issue of the Future of Functional Medicine Review (subscription required to view).
Essentially, this is fairly brief. But I wanted to cover and summarize a research study that found the low FODMAP diet has an effect on the intestinal endocrine cells in those with IBS. And what I do here, and the research study summary is essentially, I take all the important points from the study. If you read a study, often times it may take you an hour or even longer to really read a study and thoroughly digest it. But it can be summarized down to maybe five to ten bullet points. So that’s what I give.
So instead of having to read it, I find the study for you. The important studies, which I think in and of themselves are super helpful because instead of you having to just wade through a sea of studies and try to ascertain which ones are worth reading and which ones are not, I’ve already done that for you and only brought the best studies into the newsletter. And then I summarize them for you very concisely.
Low FODMAP Diet
I’m not going to go through the full summary. But essentially, here’s one of my bullet points. “A low-FODMAP diet can lead to a normalization, an increase in this case, in serotonin and other cell density in IBS patients.”
So that’s the statement. I give you kind of a simple statement. “A low FODMAP diet can lead to a normalization of serotonin cells in IBS patients.”
And then I give you the quotes and links that back that up, as kind of a sub bullet. “The density of cells are abnormal in the stomach, duodenum, ileum, and colon of patients with IBS. And dietary guidance (low-FODMAP) tends to change these densities towards the values measured in healthy control subjects.” And I provide three links to PubMed abstracts that support that statement. And that statement is a quote from the research paper.
And there’s another quote here. “Then densities of serotonin cells in the duodenum (small intestine) and ileum (small intestine) significantly toward that measured in healthy control subjects.” So the density of serotonin cells in the duodenum and ileum change significantly toward that measured and healthy control subjects. And then two links.
So why this is relevant, and what does this do? This really arms clinicians, as I alluded to earlier, with important mechanistic information regarding the low-FODMAP diet. So if a patient comes in, and you will see this, who has said, “I heard the low-FODMAP diet might be bad for your microbiota. So I’m a bit tenuous about doing it.”
Well, that’s a fair question. But it’s very important to understand that other healing is occurring while on the low-FODMAP diet, so I wouldn’t let that dissuade you. Also, that statement that diversity or harm may be done to the microbiota via low-FODMAP diet is not supported. And I also summarize another study that essentially outlines that, and shows that the impact of a low-FODMAP diet on diversity is inconsistent at best. It certainly has not consistently shown a negative impact on the microbiota.
The one thing that we do see is a decrease in Bifidobacterium populations. But it happens in the context of a healthier patient. So that’s in another issue. But all these pieces are very helpful for a clinician who is going to work with a focus especially in GI. It’s important to understand these tidbits because you want to be able to help prevent the patient from knowing enough to talk themselves out of following the treatment that you’re recommending. So this is where having an understanding of both the efficacy and the underlying mechanisms of a low FODMAP diet can be helpful.
So, again, all of these details are contained in the Future of Functional Medicine Review clinical newsletter. It’s been receiving some amazing feedback. There are many, doctors of all stripes. Surgeons, medical residents, acupuncturists, nutritionists, chiropractors, naturopaths who have all seen nice improvements in their clinical practice by applying the lessons and using some of the pearls ascertained from the case studies in their practices.
If you haven’t seen this yet, if you sign up during the month of September, you can obtain your first month of access for only $1. I think you will find it absolutely well worth it. This will give you access to nearly 2 years of backlogs. Again, you can learn more and sign up at DrRuscio.com/review. And if you’re on the go, the link is in the description in your podcast player.
So I hope you will have a look. I hope you will join us. And help me in this community of practitioners who are trying to be better with functional medicine, so as to get better outcomes for our patients with less cost, with less money, and with less indoctrination.
All right. Now we’ll continue to the rest of the show.
Episode Wrap Up
All right, and I’m realizing that we’re about 30 minutes in here, so I will not be putting another show adjacent to this because that’s probably enough. So I hope that you got a lot out of this. I will talk to you guys next time. Thanks.
What do you think? I would like to hear your thoughts or experience with this.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.