Thyroid Autoimmunity and Pregnancy with Dr. Jolene Brighten – Episode 45

Are you currently pregnant or plan to become pregnant? If so, you won’t want to miss this episode with Dr. Jolene Brighten, ND. You’ll learn how the thyroid plays an integral role during pregnancy, in the development of the fetus and why autoimmunity can walk hand in hand with pregnancy.

If you need help with your thyroid, click here.

Dr. R’s Fast Facts

  • Background
    • Subclinical hypothyroid correlates with infertility, specifically a TSH over 2.5 U/mL.
    • Elevated thyroid antibodies (TPO) increase risk of miscarriage.
    • Pregnancy can stimulate autoimmune thyroid in what’s known as post-partum thyroiditis.
    • Free T4 is the most important marker for thyroid availability for baby.
    • Address hormone levels immediately, return to underlying cause of autoimmunity later.
    • Preference for thyroid replacement hormone Rx:
      • TSH over 2.5 U/mL while pregnant indicated thyroid hormone should be started. Rx should include T4.
      • fT4 for baby and T3 for mom.
      • Synthetics: levothyroxine, Synthroid – but track metabolism to T3.
      • Start with levothyroxine if no symptoms, switch to combo if symptoms occur.
      • Natural: Nature-Throid or WP Thyroid.
  • Treating thyroid autoimmunity while pregnant:
    • Vitamin D 2-5,000 IUs per day, then higher dosing of 6,000 IUs while nursing.
    • Omega 3s EPA/DHA combo:
      • Mercury and fish – Monterey Bay Aquarium Seafood Watch List index for fish and seafood with high mercury.
    • Iodine – 300 mcg per day.
    • Folate (not folic acid) and methylated B vitamins.
    • Iron anemia
    • Selenium shown safe for autoimmune thyroid while pregnant.
    • NAC may be helpful and safe.
    • Turmeric, turmeric/ginger tea.
  • Diet and the gut – a major cause of autoimmunity:
    • Gluten-free
    • Paleo with adequate carbs.
    • Low FODMAP for IBS/SIBO and for colicky baby.
    • Probiotics
    • Certain herbal and Rx treatments shown helpful:
      • Herbal antimicrobials: garlic and/or allicillin can be used.
      • Rifaximin should not be used, nor should MotilPro.
      • Iberogast, ginger and low dose erythromycin appear safe.

 

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Topics:
Fast facts…..4:25
Dr. Jolene Brighten bio…..8:47
Monitoring the thyroid during pregnancy…..15:58
Thyroid hormone and fetal development…..24:10
Thyroid hormone replacement therapy during pregnancy…..27:53
Treating underlying causes of autoimmunity during pregnancy…..37:53
Fish, seafood, mercury and pregnancy…..50:45
Treating gastrointestinal problems during pregnancy…..55:26
Probiotics during pregnancy…..1:01:59
Dr. Brighten’s least healthy habit…..1:05:55
Episode wrap-up…..1:11:46

 

Links:

(1:12:03) http://www.drbrighten.com/

(1:12:25) http://www.drbrighten.com/labs

 

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Thyroid Autoimmunity and Pregnancy with Dr. Jolene Brighten

Welcome to Dr. Ruscio Radio, discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit DrRuscio.com and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.com.

The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor.

Now, let’s head to the show!

Dr. Michael Ruscio: Hey, guys, this is Dr. Ruscio, and before we go into our fast facts, I just wanted to let everyone know that I will be teaching a seminar in London that I’m really, really excited about. It’s a two-day event, January 16 and 17, in London with Melissa Hartwig and myself.

Day one will be a split between Melissa talking about the Whole30 Program and all the great stuff that entails implementing the Whole30 and how to navigate that and just the great program that she’s put together there.

The second half of day one I will come in with what are some first steps someone should go through if they’ve been on a healthy diet like Whole30 and they’re not able to respond fully. This is pretty much what I do in the clinic all day, so I’ll just be expanding upon that.

What I’m really excited about is the second day, which will be an even deeper expansion on all these issues in gut and with a little bit of expansion on thyroid. The second day is geared toward a more educated layperson or a patient who’s suffering with nonresponsive problems or, of course, a healthcare professional. We will be offering continuing education credits for that day, and some of the gut stuff should be really, really helpful. Of course, you’ve heard me talk about all sorts of gut “stuff,” to put it loosely, from testing to microbiota to treatments, so I’ll help outline what some of the most common causes of digestive problems are, what testing you can use to figure that out, and that is oftentimes much easier said than done, so knowing how to perform the right tests to get the right diagnosis and also doing it in a cost-effective manner is really what we’re going to be going after.

Another thing that I’m really excited about is a review of all gut and microbiotal interventions. If we’re talking about probiotics or prebiotics or fiber or FMT or fasting or an elemental diet, what kind of effect do those interventions have for things like IBS, IBD, weight loss, thyroid problems, celiac? I will break all of this down so that you will know for what condition you have—or for what conditions your patients have—what treatments are the most viable and the most validated. Then, of course, we’ll wrap that all together with an algorithm, if you will, or putting-it-all-together kind of action steps as to how to sequence this stuff. That will be about 60 percent of day two.

Then the tail section of day two will be on thyroid, something I haven’t talked a lot about lately on the podcast because we’ve been so inundated with gut stuff, but there’s certainly some very important thyroid stuff, as I’m sure many of you have heard me talk about awhile back regarding thyroid diagnosis, types of thyroid problems, and a simplified model of thyroid disorders. We’ll cover subclinical hypothyroidism, which is a pretty important issue. We’ll talk about iodine and give you some simple, straightforward treatments to navigate through thyroid.

I’m really, really excited about this. If you’re in the UK, I hope you can make it over to London to check it out. If you see the transcript, you will see the link for this, and if you’re just listening, if you google “Re-FIND Health” and then “Michael Ruscio,” you’ll see my name come up. Hopefully this will be something that some of you can attend, and I think it’ll be very well worth it.

OK, now we’ll jump into the fast facts. Thanks.

 

Fast facts

DrMR: Hey, guys. Just want to give you your fast facts for what was a great episode regarding thyroid autoimmunity and pregnancy with Dr. Jolene Brighten. Some background information:

Subclinical hypothyroid correlates with infertility, specifically a TSH of over 2.5.

Elevated thyroid antibodies, specifically TPO antibodies, increase risk of miscarriage.

Pregnancy can stimulate autoimmune thyroid in what’s known as postpartum thyroiditis.

Free T4 is the most important marker for thyroid availability for the baby.

Addressing hormone levels first, immediately—while pregnant or before becoming pregnant—and then returning to the underlying causes of autoimmunity is likely the best sequencing, and we’ll elaborate in the episode.

When using a thyroid prescription, a TSH of over 2.5 while pregnant indicates thyroid hormone should be started, and the prescription should include T4 for the reasons we mentioned a moment ago. T4 tends to be what the baby will utilize. T3 seems to have more of a bearing for mom’s symptoms.

Synthetics like levothyroxine or Synthroid are not a bad place to start, but remember to track metabolism to T3, and you may want to switch over to a T4/T3 combination like Nature-Throid or WP Thyroid should mom not have symptom resolution, but we also have to be careful because during pregnancy many symptoms can be due to the pregnancy itself and not necessarily due to hypothyroid.

Treating thyroid autoimmunity while pregnant: Things that can be used here would include vitamin D between 2000 to 5000 IU per day. Then while nursing, higher doses of about 6000 IU per day. Omega-3’s can be used, and we talked about the safety of fish consumption and mercury not being an overt risk, and Dr. Brighten does reference the Monterey Bay Aquarium index for high mercury content in fish, and I’ll see if we can grab the link for that. Iodine at about 300 mcg per day, which would essentially give mom the increased iodine that she needs but not give so much that it would potentially provoke thyroid autoimmunity. Folate over folic acid, and also B vitamins. Addressing iron anemia—this is also something to think about. Selenium has been shown to be safe for pregnant mothers and also helps with treating, of course, thyroid autoimmunity. Turmeric and ginger may also be helpful, as may be n-acetylcysteine.

Diet and the gut, in terms of what we can do for gut treatments during pregnancy: We can certainly do a gluten-free diet. We can certainly do a paleo diet with adequate carbs, or low-FODMAP for IBS or for SIBO management. And also, interestingly, for colicky babies, mother going on a low-FODMAP diet has shown some pretty impressive results. Probiotics, of course, can be helpful for managing gut conditions, and it can also have a positive benefit on the child. And in terms of antimicrobial or antibiotic treatments, garlic or Allicillin can be used. Rifaximin should not be used. For prokinetics, Iberogast can be used, ginger can be used, and low-dose erythromycin, but you’ll likely want to check in with the OB on this one or just with your managing physician. And finally, MotilPro should not be used.

With that, we will head into the show. OK, thanks.

 

Episode intro

DrMR: Hey, everyone. Welcome to Dr. Ruscio Radio. I am here with my good friend and naturopathic physician, Dr. Jolene Brighten. Hey, Jolene, welcome to the show!

Dr. Jolene Brighten: Hi, Michael! Thanks for having me! I’m excited to be here.

DrMR: It’s great to have you here. Jolene and I met last year at last year’s SIBO Symposium. She knew all the great places to eat in Portland, so she showed me around, and we’ve kind of stayed friends ever since. She’s pretty dialed in with some of the thyroid and pregnancy piece, and we got to talking and thought it would be a great idea to have her come on the show and share everything she’s doing in that realm.

 

Dr. Jolene Brighten bio

DrMR: I guess to kind of get us kicked off here, Jolene, would you mind telling people a little bit about your training and what you’re doing in clinical practice and then a little bit about your story, which I know is relevant to this whole piece?

DrJB: Of course. I am a naturopathic physician. I went to the National College of Natural Medicine, but before I even got started there, I actually studied nutrition and I was a nutrition science concentration at Cal Poly, San Luis Obispo, and that was borne a little bit out of my early experiences through my childhood of being a kid who was put on proton pump inhibitors and everything under the sun for my gut and then being told at age 17 that I’d be on medications for the rest of my life. That really was my springboard to go into nutrition science, and then I went on and completed coursework in molecular nutrition because I’m a really big nerd and I love the intricacies and the science behind metabolism.

Yeah, and then while I was in my graduate program, I found naturopathic medicine, and it was the perfect fit. It made sense because I had my own nutrition practice, I was a group fitness instructor, and I had private yoga clients that I would also coach with nutrition, and when I found naturopathy, it made so much sense because it was so much of how I was already approaching things in life. So that’s a little bit about my background.

Clinically I am a women’s health practitioner, and I focus in autoimmune disease. More specifically, I’m very passionate about postpartum care and the autoimmune conditions that develop out of postpartum. Long before I ever had a baby, I was studying under Datis Kharrazian who really got me my start and I have to credit him in thyroid health and started really diving into not only the mismanagement that I was seeing when I was in clinical rotations, but looking at how much we could do to prevent not only the development of thyroid disease, but appropriate treatment and preventing the progression of other autoimmune conditions.

That’s always been a really big passion of mine, and it was after I had my son and kind of the irony of the situation in that I loved thyroid; again, it’s that very mechanistic part of me, and taking all those little puzzle pieces and putting them together to have that big picture, and the thyroid affects so many tissues—well, just about every tissue—throughout our body, that it always captivated me. Fast forward to when I was postpartum, I started developing symptoms, and I had that classic picture of what’s called the hyperthyroid state, and before I even recognized what was happening—I was losing weight and had energy but was also very anxious and having trouble sleeping, and even when I had the opportunity to sleep, I couldn’t really sleep. The anxiety was a big point for me, and then I rolled into the hypothyroid state, and I remember things creeping up on me so slowly, not really having a chance to realize that I was hypothyroid, until I fell asleep with my son at the kitchen table. I literally just fell asleep right at the table. And when I woke up from that, I woke up to a screaming baby and a panicked husband saying to me, “What’s wrong?!” He started relaying all the symptoms back to me, and I realized in that moment, “Oh, my gosh. I’m hypothyroid.”

It was a really great experience for me because I got to go through a lot of the symptoms that my patients go through, and so now when a woman comes to me, I absolutely have the most purest and truest empathy for them because I know exactly what it feels like. But even more so, I had gone to several doctors because I realized something was wrong and something was going on, and I was given the brush-off multiple times by multiple practitioners. This isn’t like, “Oh, I went to a conventional doctor.” No. I saw a conventional doctor. I saw a naturopathic doctor. I saw a functional medicine doctor. I was seeing people, and I got the same story over and over. “Of course, you are tired! You’re a mom and that’s how it is.” Many things that were said to me I didn’t appreciate, but one of the things was, “Well, maybe if you slowed down and you weren’t going to work you wouldn’t feel this way.” Now when I hear patients say that, I really can truly feel for them, the things they come back and say to me, but it was a wonderful experience to be able to be a patient and just see really through the lens of a patient what they go through. You and I, we approach thyroid so differently, but there are even people within our space. It’s not that they’re bad doctors or bad clinicians at all. It’s just that thyroid isn’t really their thing, and quite frankly, a lot of people shy away from the pregnant and the postpartum woman, which is where I really see my role to step in and to advocate for these women. And I get it that a lot of doctors aren’t comfortable with it because there’s not a whole lot of research going on in pregnancy and breastfeeding women.

DrMR: Right.

DrJB: We don’t want to be messing with them too much, so it makes sense.

DrMR: Right. Your last point is a great one and I think a point that many doctors, including myself, struggle with because we don’t have a lot of great studies. We’ll work our way to some of the specifics on this a little bit later, but there are certain things that one may want to treat in order to help with thyroid autoimmunity while pregnant, and there are a lot of unknowns in terms of this treatment may clear X infection, but what kind of long-term effect may that have, we don’t really know. There are definitely some unknowns there, and that’s why I appreciate the fact that you’re specializing in this because I think it’ll give you a better ability to at least have the clinical sense for what to do with some of these unknowns.

But before we work our way over to that, just something to bring the listeners up to speed, if people aren’t familiar with this, it’s been fairly well defined that through the process of pregnancy, the immune system can oscillate, and that oscillation may trigger autoimmunity. As Jolene mentioned earlier, pregnancy is one of the initiating factors for autoimmunity, so there’s definitely a strong tie-in. And to maybe even take a step back even further, something I just want to mention is that even before getting pregnant, of course, thyroid hormone status is going to be important. And even something like subclinical hypothyroid, which wouldn’t be true hypothyroid, has been documented to cause or correlate with infertility. Definitely the thyroid and pregnancy piece are very closely intertwined, interwoven, and they influence each other quite a bit. Even the thyroid hormones affect female hormones, and vice versa, so there’s a lot of interplay here with thyroid, with pregnancy, with female hormones, and so I’m glad we’re going to be able to dive into this a little more deeply.

 

Monitoring the thyroid during pregnancy

DrMR: One question I wanted to ask you, Jolene, is how is this missed? Correct me if someone really made a major oversight here, but most pregnant women are going to be having pretty routine thyroid screenings. Were your TSH and T4 never run, or were you more of a subclinical case? What did that look like?

DrJB: Oh, my thyroid looked phenomenal before I became pregnant and while I was pregnant. It’s interesting that you say that, actually, because it’s something where when women are getting tested is really an issue. When I say this, OBs, gynecologists, and midwives, the people who will be managing your pregnancy, they’re not usually seeing you until about eight to ten weeks into your pregnancy. It’s generally a little more about the ten-week mark. And a lot of that is because they want to get you set up, they want to run the bloodwork, they want to make sure that the pregnancy is viable, and at that point you can hear the heartbeat as well. That’s a really big problem because from the time of conception, you should be having these thyroid markers looked at.

When we say thyroid markers, we’re looking at TSH, which is very important. That’s the thyroid-stimulating hormone, and that’s what your brain sends to your thyroid. It’s very important because we know that a TSH greater than 2.5 is correlated with increased risk of miscarriages and infertility itself, but we also know that even when TSH is normal that you can have a completely normal TSH, but that’s not always predictive of the availability of the hormones at the cellular level, and so you need to be looking at TSH, free T3, free T4, and what a lot of doctors and midwives don’t run in the early pregnancy—so the first trimester—is the anti-TPO antibodies. Now, I like to run antithyroglobulin as well, but anti-TPO is where most of the research is at, and what we know about anti-TPO antibodies is that about 10 to 20 percent of all pregnant women will have anti-TPO antibodies in the first trimester, and of those women, it’s about upwards of 50 percent will develop postpartum thyroiditis.

For your listeners to understand, there’s a different categorization of postpartum thyroiditis and Hashimoto’s thyroiditis. Now, postpartum thyroiditis is essentially a form of Hashimoto’s thyroiditis, but you don’t receive the diagnosis of Hashimoto’s until you’re 12 months postpartum because at that point the powers that be have decided now this is a permanent condition, which I think is a little bit ridiculous because if you have those antibodies, and as you know, if you have those antibodies, you can become hypothyroid, this can develop at any point. What used to be thought is that postpartum thyroiditis was just a transient state, and it was seen so often that it was just getting the brush-off of, “Oh, it’s just transient and it will go away,” but these women whom it had “gone away” for may develop Hashimoto’s anywhere from 12 months to 12 years later down the line. It’s something that a lot of experts in this field are starting to step back and say, “Whoa. Hold up. This is Hashimoto’s and it’s expressing itself.” So if this woman goes on to have another pregnancy and gives birth again… Let’s say, this woman, she went into remission. Fantastic. She doesn’t have the diagnosis of Hashimoto’s. She gets pregnant again; it’s almost a guarantee that she’s going to have postpartum thyroiditis.

And what’s even more scary—and I’d love to see more research around this, and it’s starting to come along—is that it’s not just about Hashimoto’s. This is the most common autoimmune condition you’re going to see in a postpartum woman, but we know there’s correlation between Hashimoto’s and celiac disease. There are correlations between pretty much the spectrum of autoimmune conditions, and it’s really what are your genes, and pregnancy is absolutely that triggering factor. To go a step further, what really can drive thyroid conditions and autoimmunity is inflammation. Well, your postpartum period is essentially a state of inflammation.

DrMR: So is it your thinking that the problem is there’s not enough thyroid autoimmunity follow-up once a woman has delivered? Or do you think maybe it’s not that they’re not doing enough testing, but there’s not enough treatment that’s rendered? Or is it a combination of the two?

DrJB: It’s definitely a combination of the two. It’s my opinion that all women should be screened as part of your exam if you go into your doctor. You may be having your Pap smear or your physical exam. You should be getting screened for your thyroid, and we should be looking for that, but especially a woman who wishes to become pregnant. In all my patients, I like to make it very clear that I don’t catch babies. I really love my sleep, so I don’t deliver babies! But within the Bay Area I have a lot of doctors and midwives who refer to me to manage their pregnant patients to manage their thyroid because they say quite frankly, “We’re not comfortable with this,” and this is something that I really live and breathe, and when I say that, I don’t say it lightly! I fall asleep reading journal articles on this a lot of the time. But we need to be screening early on.

In all my patients, if a woman comes to me and she says she wishes to become pregnant, I screen her thyroid, among other things, and then once she becomes pregnant, by the time we know she’s pregnant, it’s two weeks after she ovulated, approximately, so we’re starting to run labs at about what would be three to four weeks’ gestation to look at, “OK, where’s your thyroid at now?” Then if there’s a thyroid condition, we’re screening every four weeks until we’re getting closer to the third trimester. That’s because I’m a big advocate for mom and I love to take care of mom, but my job isn’t just to take care of mom. It’s also to make sure that we have the best pregnancy and we’re looking out for baby as well, and this is what feeds into we need to be running more than just the TSH, because if your TSH is fine but your T4 is inadequate… Sometimes I’ll have women and their T4 is about 0.6, and I really want to see that above 1. That T4 is what crosses the placenta and goes into baby’s brain. That T4 is absolutely crucial for motor skill and cognitive development. In the observational studies they’ve done, they’ve looked at women who have had inadequate T4 and they’ve watched these children over time, and there was one study that went so far as to watch the children up to 16 years of age and still found—and all of these studies find the same thing—that cognitively they’re behind their cohorts, their peers. They’re behind. I think that piece is really important.

And then I screen all of my patients at six weeks postpartum, and I have an entire panel that I do on these women because if we can catch these things early, like, if I start seeing that there are autoimmune changes or the thyroid is not functioning appropriately, we can step in, and there are a lot of things that we can do to get a woman’s thyroid back on track. But, I think, even more important is to give her her health and her vitality so she can mother in the way that she has really dreamt of. A lot of women, they’re having that dream kind of stolen from them when they approach a doctor and say something’s not right and the doctor doesn’t listen. So I run labs again at six weeks postpartum, and then depending on what we find, we go from there. It’s my perspective that if we can intervene sooner and save the thyroid and never put a woman on medication, we’re much better off than allowing that destruction of the thyroid gland.

DrMR: Gotcha.

 

Thyroid hormone and fetal development

DrMR: Now, you make several great points. There are a few different directions I want to go from here, but maybe one of the first ones, just a clarifying point for people listening, in terms of the fractions of thyroid hormone that are most indicative of the developmental effects on the fetus, have you found or does the research show that T4 is the most important or free T4 or T3 or total T3? I believe you had said total T4, but I just want to clarify that.

DrJB: The majority of research publications I’ve looked at, it’s free T4 that they’re looking at. This is an important distinction because when you become pregnant, there’s a whole mechanism of estrogen levels rising, and when estrogen rises, we see sex hormone-binding globulin rises. Well, we also see thyroid-binding globulin rises. So it’s important that we’re not looking at just total T4. Now, I love to see total T4 and total T3 and then also look at the free fractions as well to see what’s going on big picture, but if you’re looking at only total T4, you’re not really going to have a good understanding what’s happening in this pregnant woman. It’s just a really important distinction to make because a lot is changing and a lot of things are different.

We can even see that the TSH will drop down in the first trimester, and that’s because the HCG… now, HCG is the hormone that we are using for pregnancy tests to confirm a positive pregnancy. It’s a weak thyroid-stimulating hormone, so you can see the TSH will sometimes drop in women. I had a patient recently that a midwife sent her to me and said, “Oh, my gosh. I think she’s hyperthyroid.” That was based on the TSH alone, and when we ran the full panel and looked at everything, “No. Your HCG is doing its job, and your thyroid is responding.” The thyroid should be kicking out about 50 percent more hormone during pregnancy, and so part of that role of that HCG is to stimulate that.

But just to clarify and go back to your original question, yes, we’re looking at the free T4. It’s the free T4 that crosses the placenta, and it’s that T4 that’s getting into the brain as well. T3 is what makes mom feel really good, but I like to make that distinction in caution because sometimes patients will come to me and they’re like, “Well, I feel really good on 25 mcg of Cytomel, and I don’t want to take any T4, and I’m going to become pregnant.” Well, but if your T4 levels are low, you’re going to need some T4. Whether that’s a natural form or that’s a synthetic form, you need some T4 if your thyroid isn’t producing enough itself. That’s just an important distinction for women who have progressed Hashimoto’s or autoimmune conditions. Maybe they had thyroid ablation. Maybe their thyroid was removed. If you’re not making your own T4, you’re going to need some synthetic T4 for baby.

DrMR: Gotcha. Thank you for clarifying that. I thought you said T4, and I just wanted to clarify it was free because physiologically it would make more sense that the free T4 would have more of an impact in bioavailability, but I just wanted to check on that.

 

Thyroid hormone replacement therapy during pregnancy

DrMR: That’s a great transition into another question, and maybe to kind of give people a 30,000-foot orientation on this—and if you have a different stance, please let me know. Sometimes patients come in and they don’t want to go on a drug. They look at thyroid hormone like a drug. I mean, yes, it’s classified as a prescription, but it’s also a hormone that your body naturally makes, so in my mind, I look at this much less like a drug and more like hormone replacement therapy. It’s not a foreign molecule like maybe a statin medication that’s not something that your body naturally produces on its own, whereas thyroid hormone is.

Sometimes women will come into the office, concerned about not wanting to go on thyroid hormone because they don’t want to, something along the lines of, be on a drug or become dependent upon a medication or what have you. And I really try to be direct in my dialogue on this with them, which is it is crucially important that your thyroid hormone levels are in the normative range while you’re pregnant because you risk developmental impact on your child.

With that, Jolene, what are you finding is the best approach for treating hypothyroidism while pregnant? You alluded to some of it already, but do you have any more specifics in terms of… It sounds like you’re going to favor a T4/T3 combo potentially instead of just the T4, but if we had to look at this as in giving T3, giving T4, giving T3 and T4, do you have any maybe general recommendations for the listeners or general thoughts on that?

DrJB: Yeah. I really love that you’re making this point. I don’t get to get into this a lot when I talk about this, so I really love that you’re bringing this up because it’s absolutely something we see as clinicians. Patients come to us because they see us as the “natural” clinicians who won’t push a medication, but here’s the deal: If you don’t have adequate thyroid hormone, nothing’s going to work right in your body. It’s something I really lay down with patients, that you absolutely are dependent on having adequate thyroid hormone. Our goal is absolutely to get you to a point where you’re not dependent on medication, but sometimes that’s not always how it works. That’s life. We do the best we can.

When it comes to pregnancy, I actually don’t have much of an issue with my pregnant patients because usually they’ve been seeing me for their fertility, so we’ve built a lot of trust around this, but when it comes to thyroid medication, I’m a fan of whatever works. Now, the Endocrine Society, they actually recommend that all women start on 50 mcg of levothyroxine if their TSH is above 2.5, and that’s pretty well accepted. Levothyroxine, to clarify, is the synthetic form of T4, and the American Thyroid Association also recommends this. T4 is not the active hormone. We’ve already talked about how this is what baby needs, and so that’s really what they’re concerned about, and any woman who has ever been pregnant or had a baby will know that everyone’s concerned more about baby than they are about you, so it’s recommended that you go with the synthetic T4. I’m a fan of whatever works, so if we need to do synthetic T4, so we’re doing levothyroxine, and maybe we need to add a little bit of Cytomel, which is a synthetic T3, I’m OK with that. But we have to be very careful with synthetic T3 because if you have too much, that’s going to be very problematic as well.

It’s really important for people who are listening who think, “Well, I want to become pregnant, but I don’t want to take a medication,” to understand that if you have elevated anti-TPO antibodies, you have about a two- to three-time increased risk of miscarriage. If you don’t have adequate thyroid hormone on top of that and you do become pregnant, we know that there are receptors in the endometrial tissue, in the ovaries, in the placenta, in the fetal-maternal unit during implantation. There are receptors so dependent on this thyroid hormone that if you don’t have this, it’s a pretty good chance that you’re going to miscarry. For any woman that has ever had a miscarriage, it’s not only physically painful, but emotionally it’s devastating. It’s extremely painful to go through, but on top of that, miscarriage alone can be a trigger for autoimmunity. So even if you didn’t have those antibodies or maybe you have low-level antibodies, having that miscarriage could send you into an autoimmune flare. A lot of my patients I’m seeing, they’re in their 30s to 40s. They want to get pregnant right away, and that can really set you back.

Now, in terms of the natural desiccated thyroid hormone, I tend to start with something… if we’re going to use a natural thyroid hormone, I tend to go with something like Nature Throid or Westhroid Pure. I know there are a lot of clinicians who are fans of Armour Thyroid. I’ve had enough patients not do well on Armour that it always gives me pause, but again, it’s about what works for the patient. I like to just present, “Hey, this is what’s in the natural thyroid hormones. This is what’s in the synthetic hormone. This is the difference. This may work, may not work,” and have that dialogue and let the patient decide for themselves.

The other caveat is because I’m not the monitoring their pregnancy and I’m not going to oversee their birth, sometimes their OB is really, really uncomfortable with the natural thyroid hormone, so at that point, we’re like, “Well, maybe we need to do synthetic hormone and see how you do with that.”

An important thing to note about using levothyroxine, the synthetic T4, which is also known as Synthroid, is that you depend on your body to convert that. You have to convert T4 to T3 for you to feel good, so your doctor should also be looking at your T3, the free T3 levels, and your reverse T3 levels, and if you’re not converting that to T3, that’s going to be a good reason to think about trying Cytomel or trying a natural thyroid hormone.

Now, once you’re pregnant, we don’t want to be messing around too much with thyroid hormone. If you’re not pregnant, we can say, “OK, we’ll try this and we’ll slowly go up, and if that doesn’t work, we can back it off,” and there are different approaches we can take, and of course, we’re being very careful, but we have to be very careful in pregnancy that we’re not going too high with T3 and we’re getting adequate doses of T4 as well.

DrMR: Gotcha.

DrJB: Does that make sense? Does that answer your question?

DrMR: It does. Now, if someone discovered that they were hypothyroid or subclinical hypothyroid during pregnancy, do you think it’s best practice—and I know sometimes it’s hard to make a blanket statement, but do you think it’s best practice to start with a combo or just a T4 isolate?

DrJB: I usually like to start with a combo if there are symptoms, if they’re having symptoms as well, but here’s the thing: It’s really tricky because your first trimester symptoms look a lot like hypothyroidism! You’re completely fatigued.

DrMR: Gotcha.

DrJB: But the thing is that you’re not usually cold. The fatigue, as you know, a lot of people, that’s the presenting symptom—for a lot of things. It doesn’t always mean that it’s thyroid. Yeah, it always just really depends on what that patient’s history looks like, but usually I’m starting with something like Nature Throid, which is the desiccated thyroid hormone, because I just find that women feel better with it.

DrMR: And that would be a T4/T3 combination, just for our listeners?

DrJB: Yes, and then we’re monitoring that TSH. And just to make it really clear, if you want to become pregnant, that TSH should never be above 2.5, and there are a lot of clinicians that will actually keep your TSH below 2 because usually in that first trimester the demand on the thyroid is so high that if you miss the mark on that, a woman may experience a miscarriage.

I also need to say, though, and make it very clear that when we look at pregnancy—I mean, you have to think about this—every cell has to divide pretty perfectly just to be able to form this human, and a lot can go wrong. It’s not always your thyroid. Sometimes when there’s a miscarriage, it’s because your body’s being really wise and recognizing that this life that has begun, it’s not viable. It’s not something that we’ll be able to take to completion.

I really like to make that point because a lot of women, they get it in their mind that—and especially when we’re talking about thyroid—like, “If I had done something different with my thyroid or I had done this or I had done that, then I wouldn’t have had a miscarriage, and this is somehow my fault.” It’s very unlikely it’s your fault. I just want to say that. It’s very unlikely that it’s your fault. There are a lot of things that have to be orchestrated. When you stand back and you think about it, it’s pretty amazing that we’re here and that it even works out that we’re born! I’m always in awe. My son, he’s going to be three here in a few days, and it’s really funny because he has just gotten the concept where he’s like, “You grew me in your body?!” And I’m like, “Yeah. That’s pretty amazing, right?! I grew you!” It’s just so amazing what a woman’s body can do.

DrMR: I think that’s a fantastic point. And maybe just to echo that, I am in complete agreement, and I think it’s not oftentimes unusual for someone to beat themselves up if something doesn’t go right, and certainly pregnancy would be a very extreme manifestation of that because there’s so much that is at stake. But I think you make a terrific point that if you do miscarry, then that’s likely your body’s attempt to stop a process that was not looking good and preventing something that may have been more harmful or damaging or dangerous in the long run. I think that’s an excellent point, and not making it your fault and just trusting your body that it was doing the best thing that it felt was the right thing to do at the time. I think that’s a great point.

 

Treating underlying causes of autoimmunity during pregnancy

DrMR: So we’ve talked about how we want to manage the hypothyroidism during pregnancy. What about the other side of this, which is treating the autoimmunity? I think we’ve kind of hinted that the first priority is going to be making sure that the thyroid hormone levels are where they should be during pregnancy. What about wanting to treat the underlying cause of autoimmunity? What I see in this dialogue is there are some treatments that we can definitely do during pregnancy, and there are others that, as you mentioned earlier, we have less research on and/or may be better to come back to after pregnancy or after nursing. So how do you address the issue of autoimmunity during pregnancy? What do you do during pregnancy, what do you wait on, and what’s your rationale behind that?

DrJB: Well, I think that’s a great distinction to make. You and I both treat SIBO, and I’ll get pregnant patients who will come to me or they’re postpartum and they’re positive for SIBO, and it’s always something where it’s like, “Well, we have to wait. We can only manage symptoms because we can’t use these antimicrobials.” The majority of your immune system is sitting in your gut. That’s the home. If it’s unorganized and dysregulated, then that’s going to be a starting point. We have to clean that up. But you can’t do a whole lot of that during pregnancy. You can’t be treating with antimicrobial herbs, and even the pharmaceuticals I’d really be cautious with.

The beautiful thing about what we can do in pregnancy is that it all really benefits baby as well. Vitamin D status, I think, is absolutely essential to monitor preconception through pregnancy. If you didn’t get your vitamin D levels tested before you became pregnant, you want that done in the first trimester, and you want to know where you’re at.

Let me just back up a little bit. What you were talking about before about the modulation and what’s happening with the immune system, in pregnancy a lot of people will think that your immune system is suppressed or it gets shut down, and that’s not really what happens. To very oversimplify the immune system, you have Th1 and you have Th2. Now, Th1 is about bacteria and viruses. Like, when you get a cold or the flu, your Th1 system is going to battle that. Th2, that’s great for parasites, but we see it more commonly for asthma, allergies, and eczema. So what your body does because your body is really smart at saying, “OK, we’re pregnant. We want to maintain this pregnancy,” is it will actually downregulate your Th1 because Th1’s job is to go out and destroy anything that is not you. Baby is genetically unique. Baby’s not you. So your body is really smart. It brings down that Th1, and it brings up your Th2. So once you get past that first trimester, there’s more of what we call a Th2 dominance. At that point, the majority of autoimmune conditions are actually going to go in suppression. My Hashimoto’s patients will say the best they’ve ever felt is their second and third trimester. If they have a Th1-dominant autoimmune condition, they’re going to be feeling better because that Th2 is rising up, and so that part of their immune system that’s been making them feel so awful is being suppressed.

But if we can start to look at some of these things—I’m going to go in a little bit deeper about things that I do—that influence the regulation between Th1 and Th2, there’s another part of the immune system, which is the Th3. I like to think about Th1 and Th2 being on scales, and that Th3 is really the fulcrum in the middle. It’s helping balance both of those out. So if we can help modulate the Th3, we’re going to be at a better state come postpartum because what happens postpartum is your immune system comes back online, so Th1 flips back on. The moment you deliver that placenta, you essentially enter into a state of menopause. Your hormones hit rock bottom. Hormones are part of the speculation of why women are so much more susceptible to autoimmunity, and your baby is not going to be letting you sleep, and your adrenals are going to take a really big hit, and as I said before, you’re going to be in a state of inflammation, which is going to drive autoimmunity further.

So what I’m doing in the pregnancy period, I’m looking at the vitamin D3. Vitamin D3 helps modulate Th1 and Th2. Depending on what your levels are during pregnancy, we’re going to have you on vitamin D3 anywhere from 2000 to 5000 IU. Your levels should definitely be monitored. I usually like to pair it with a K2 depending on the prenatal a woman is taking. A lot of prenatals will have some K2 in them, but you want to monitor that. I’m sure you get the same thing, but I’ll have patients come in to me with autoimmune conditions and they’re taking as much vitamin D as they can because they heard it’s really good for them, but we want to monitor that because that can actually put calcium into the arterial walls. That’s not a good thing. You don’t want your blood vessels becoming rigid. After a woman gives birth, we want to see vitamin D3 up at about 6000 IU daily. That’s going to be great for the autoimmunity, but it’s going to be fantastic for baby because 6000 is where the research has shown us that’s the sweet spot for making sure baby is getting enough vitamin D3 through the breastmilk as well.

DrMR: Gotcha.

DrJB: It’s going to regulate the immune system. As you know, it influences the microbiome. It’s important to have in the postpartum period as well because when you get to 12 months you’re going to really ramp up your bone remineralization, so we have the opportunity to put minerals back in our bones, which is really important. And deficiency in vitamin D3 is actually associated with postpartum thyroiditis. We see that women who are deficient have a higher risk of developing that.

Some of the other things that are fantastic for baby and mom are omega-3’s. EPA, which is one form of omega-3, that’s about inflammation, so that’s really important for the inflammation part. But I recommend during pregnancy that women are having an EPA and DHA combo. DHA is going to be what’s fueling baby’s nervous system, helping with brain development, and it’s going to save your brain as a mom because your brain, it’s going to start shrinking in the third trimester, and you don’t get it back until several months postpartum. You need that DHA.

And I should say from an evolutionary perspective, this is absolutely brilliant. When I tell women this, they kind of get freaked out, but what’s awesome is that it’s actually your body’s way of saying you’re going to solely focus on this baby. Multitasking is gone. Your job is to completely focus on this baby and make sure baby survives, and you really get wired in. So those omega-3’s are really beneficial. If you can eat coldwater fish, getting two to three servings a week is fantastic. But usually women are supplementing then, so you can take it in supplement form. If you’re a vegan, you’re going to want to take an algae form, but you’re going to have to take a lot more is the only issue. We don’t convert that as well.

The other thing that we need to look at is also selenium. There’s great research that 200 mcg a day is fantastic for helping with the autoimmunity, but selenium is going to also be important for baby, and it’s something that most prenatals are going to have about 50 to 100 mcg in there, but you really want to be hitting the 200 mcg.

Something that’s really controversial in autoimmune thyroid is iodine. There are a lot of clinicians who are like, “Don’t take iodine because if you have TPO antibodies, that can really flare that,” and that’s true. If you’re deficient in selenium, that can really be an issue, and I have seen this clinically, patients flaring after other clinicians have put them on really high iodine doses, which I just can’t get behind. But what I want to say is that your need for iodine goes up by about 50 percent while you’re pregnant, so you want to make sure that you have the selenium, you want to monitor the TPO antibodies, but you need to have iodine coming in. Your prenatal should have iodine. Usually there’s about 150 mcg in there, but women typically need a little closer to 300 mcg. That’s essential for your thyroid, but it’s absolutely essential for baby as well. I’ve had patients who are like, “Well, I don’t want to take this prenatal because it has iodine.” You have to get iodine in for baby because baby needs that as well.

Then, looking at the other aspect of what supports thyroid health and thyroid conversion, so looking at B12 levels and folate. Your prenatal should have folate. I really like to make a point that I really don’t like folic acid or anyone taking that if they don’t know their MTHFR status. A lot of prenatals out there are switching to methylated forms of folate and B12. Sometimes women need a little more B vitamins. If their adrenals were kind of struggling ahead of time, or for instance, if we know they have SIBO and they’re pregnant, we’re going to know they have absorption issues. Those are some of the things we need to look at.

Something that’s really unique to pregnancy is the propensity towards iron deficiency anemia. It’s really easy to become anemic during pregnancy. Of course, we’d love to fix the gut before you even become pregnant and help with your absorption, but if you don’t have adequate iron, you can develop anemia, and that’s going to weigh in on a lot of things but also your thyroid health overall.

And then in terms of just some other anti-inflammatories and things that actually help with preconception and during pregnancy are things like n-acetylcysteine. There was a research study that showed 600 mg twice a day reduced inflammatory cytokines and the risk of miscarriage, and so continuing that at least through the first trimester. It’s a precursor to glutathione. I find most of my patients just like being on it. One caveat is that you ladies who are pregnant, you must take it with food because heartburn is bad enough in pregnancy, but if you take this on an empty stomach, it can be really bad.

And then also turmeric. I love to get my patients on a ritual of a turmeric-ginger tea. It’s really great in the first trimester. You can be doing that or juicing fresh turmeric. It’s fantastic for autoimmunity, but there are even cultures who use turmeric to enhance breast milk supply as well.

It’s an important thing to note that sometimes postpartum thyroiditis, the first way it starts to show up is a decline in breast milk. I’ve had numerous patients come to me because their lactation consultant is like, “Well, maybe see the naturopathic doctor and see if she can help you increase your milk supply.” It’s like, well, the underlying cause is that you don’t have adequate thyroid hormone. Your adrenals and thyroid, if they are not on point and you’re not taking care of them, you’re going to really see a decline in your breast milk.

In my book, which is called Healing Your Body Naturally After Childbirth: The New Mom’s Guide to Navigating the Fourth Trimester, I talk a lot about thyroid and adrenal health, but I’m also talking about breast milk supply and all of these other things that you have to consider because it’s not just about taking fenugreek, which is a great herb and it works well, but when it’s not working, you need to look further. I can’t even tell you how many times I have a woman come to me on fenugreek and really the result is that she’s only drinking 20 ounces of water a day and we need to increase the amount of water!

DrMR: Sure, yeah!

DrJB: Sometimes it’s really simple! It’s really simple, but people are so quick to jump on, like, “Well, this is the next greatest thing in natural medicine coming out!” which can be really fantastic if it’s used judiciously. You have to really stand back and really look at it. I know you and I have had these conversations before, but sometimes clinicians get this idea of what will work and they try to fit every patient into that keyhole, and that’s just not the way it works. You have to stand back and look at the patient as an individual and figure out what works for them.

Yeah, I know I just rattled off a whole lot of stuff! Those are some of the things that I do during pregnancy.

DrMR: No, that’s great. There are a few things I just want to touch on, and if you disagree with any of these, please feel free to let me know.

 

Fish, seafood, mercury and pregnancy

DrMR: One of the things moms or moms-to-be may be concerned about when eating fish is mercury. It’s been fairly well documented that as long as a woman is not eating solely types of fish like swordfish that are known to have a high mercury content, that there are really no problems with mercury accumulation or any negative impact on the baby’s neurological outcome. In fact, several studies have shown that mothers that eat fish tend to have children with slightly higher IQs than mothers that avoid fish. So I think eating fish, as long as it’s not one at the top of the food chain, like whale, shark, and swordfish, that would make fish permissible.

And to your point about iodine, which I think is a great point, and it’s important to clarify—and I’m so glad that you gave a specific dose—that we want to have adequate iodine intake, yes, but we don’t want to be going excessive. 300 mcg is still a far cry from the 60 mg that will sometimes be recommended to aid thyroid health, so that seems very reasonable and definitely a good idea, I would think, for moms to make sure they’re getting adequate iodine but not excessive iodine. We’ve done a few podcasts on the iodine issue if people want to learn where the line between adequate intake and excessive intake is.

Also, regarding selenium, there have been a few studies with pregnant mothers taking selenium that show a favorable benefit on thyroid autoimmunity and no deleterious effect on the baby. So that’s definitely something I think we can say that is safe.

Those are just a few of my notes from the nice list that you just provided us. Anything you wanted to mention about that?

DrJB: Yeah, I actually meant to touch on that whole mercury issue, so I love that you brought it back to that. A great resource that I send patients to is actually the Monterey Bay Aquarium. They have a whole seafood watch, and they keep it well updated . You can actually see mercury levels. If you’re concerned, you can take a look at that.

Nordic Naturals is a supplement company that you can actually ask them to send you little cards and you can actually have little pocket cards you keep with you and they’ll tell you what has the highest amount of mercury and some of the things that you noted.

What’s interesting about the studies with the improved cognition in babies of moms who ate seafood is that when you’re eating seafood, you’re getting iodine, selenium, and omega-3’s, when you’re eating those fish. You’re covering all your bases! When you’re eating that way and getting your iodine that way, you’re getting the selenium as well, and then you’re getting the omega-3’s. Yeah, I absolutely love that you came back to that as well. And it’s going to be better for you as well, the way you’re fueling your body. Yeah, it’s something that I don’t ask patients to shy away from fish. I think it’s definitely important to be including in your diet.

DrMR: Definitely. It’s a nice opportunity for me to maybe echo a principle that I’m hoping has been threaded throughout many of our podcasts, which is it’s one thing to have a theory, and then it’s another thing to actually have clinical science. The theory here would be that mercury is bad for your brain, which, yes, it is, but we can’t take from a theory and then create human recommendations unless we have better data. The theory that mercury is bad is true, but when we then filter that through looking at clinical trials or observational studies, we then see that women that eat a source of mercury that might be deleterious, which is fish, they don’t tend to have any real problems with neurodevelopment of their children.

So again, if we look at the issue of mercury in isolation, yes, mercury can be bad from the brain, yes, fish contain mercury, but we can’t over-extrapolate that to say we should stop eating all fish because to really firm up that hypothesis and use that information to generate a recommendation for humans, we have to look at what happens when people consume fish compared to people not consuming fish and seeing what the outcome there is. And again, the outcome here, with a few minor exceptions for types of fish, seems to fairly routinely show that fish consumption definitely helps with brain development.

DrJB: Absolutely.

 

Treating gastrointestinal problems during pregnancy

DrMR: Now, you touched on GI conditions, and I just want to echo this. I don’t want to go too deep into this because we’re getting near the end, but when someone has SIBO or a gut infection or what have you—and it seems like we’re in general agreement on this—there are a couple of treatments that may be viable and may be safe while pregnant, but it’s really my preference to wait until after the pregnancy to come back and address these things. I think you agree with that, but there are maybe a couple of things that can be helpful. These two are somewhat obvious, but I just want to make sure that we mention these.

Of course, cleaning up your diet can be hugely helpful for gut conditions, so going on a paleo-type diet may help quite a bit with SIBO-type or IBS-type symptoms. A low-FODMAP diet may also help. And I remember reading a study a while back that when mothers with colicky babies went on a low-FODMAP diet, it had an extremely high ability to resolve the colic in the baby. That’s maybe something else to consider for mom with IBS-type symptoms or a colicky baby.

Do you have anything that you’ve seen in that regard, Jolene?

DrJB: Yeah, I love that you say that about that FODMAP study because for a long time it’s been—I’m doing air quotes right now—but an “old wives’ tale” that eating garlic, onions, or brassica family, which is broccoli and cabbage, women have observed for a very long time that those foods could make a colicky baby worse and then forever were given the brush-off of, like, “No, no, no, no, no. There’s nothing on that.” Well, if you look at the FODMAP foods and you look at the things that are issues for SIBO, those are the same foods that can be problematic in a colicky baby. I love that you brought that up.

Yeah, so definitely diet is absolutely crucial. If you have any gut issues going on, I love the idea of doing a paleo diet—of course, making sure that you’re getting adequate carbohydrates. I always like to make the point that when we say “paleo” it doesn’t mean “ketogenic.” Those are two different things. We’re talking about high-quality protein and still maintaining your carbohydrate intake. That doesn’t mean that you’re going to be eating tons of grains, and I think this is an important point to make because in the first trimester it’s a time when I say all bets are off. Sometimes you just have to eat what you have to eat because you can’t even get food in because you’re so nauseous. And it’s something that it’s harder for you to break down protein sometimes in that first trimester because progesterone levels are so high your gut motility is going to be slow. Ladies, you will have gas and bloating in the first trimester. That’s going to happen because your gut motility is slow. All that progesterone is relaxing your intestines. Things are not moving the same.

So in that period, sometimes I’m using things like magnesium. You can use magnesium to help move the digestive tract. I like to use something like magnesium citrate. I should just say never magnesium sulfate, nothing like epsom salts, nothing like that. I like to be really clear on that. But using magnesium is a nice way to help with muscle aches and pains, and it can help sometimes if there’s a gut motility issue and help keep you regular.

The other thing is ginger, 2000 mg. Usually if it’s someone with SIBO and maybe we know they have SIBO or IBS symptoms and there are constipation issues plus there’s nausea, you can take 1000 mg of ginger in the morning and 1000 mg at bedtime, and that can be really helpful as well. If it’s not helpful, it doesn’t mean anything’s wrong with you. Every time I would throw up in my pregnancy, it was because I had ginger tea. It just did not agree with me! That’s just your body! It doesn’t mean something’s wrong with you. It’s just that that’s not working for you.

Garlic is safe during pregnancy. You can take garlic. If it’s really bad, I might use Allimax. It’s a really strong allicin, which is a derivative of garlic, to help with the antimicrobial.

I mean, the biggest thing—and this comes back to the mercury and anything else that you’d be taking into your body—is if you’re supporting the emunctories—and the emunctories are the ways that we move waste out—so we’re supporting bowels and we’re supporting urination and you’re doing deep breathing to the best that you can and you’re moving your body and you’re doing all of these things to really help your body eliminate waste, you’re going to be a lot better off.

Yeah, when you have a gut condition, it’s a lot of symptom management sometimes because you can’t go in and treat the underlying cause, but you can certainly support the gut health with diet and then making sure that if you know you have food sensitivities that you’re not consuming those. I don’t know if it’s an issue in other cultures, but it’s definitely an issue in the US that women think right away if they’re pregnant, they’re eating for two and they can eat whatever they want, and that’s usually when we start to see high refined carbohydrates coming in, lots of sugar. If you are someone who maybe had a little bit something going on in your gut and you start eating that way and you combine it with the slow gut motility, it’s a recipe for disaster. So just because you’re eating for two—I have to back up and say you’re not really eating for two. During your pregnancy, your increased caloric needs go up to about 300 calories. Now, when you’re breastfeeding, it’s like 500 to 600 calories. That’s your time to start eating! That’s great!

If you’re using this paleo diet, the other thing about eating in that way is it’s going to help lower the risk of gestational diabetes. We’re going to see lower risk of preeclampsia and things along those lines that women with Hashimoto’s are at higher risk for.

DrMR: Right.

DrJB: And even not overt Hashimoto’s, even that low-grade, you know, we’re looking at it, thinking something’s a little bit off with this thyroid, but we don’t have the clinical symptoms, we don’t have absolutes in the labs, what we call euthyroid state or subclinical thyroid, you can be at an increased risk for developing and having these complications in pregnancy. Yeah, it goes back to you can do a whole lot with your diet to prevent all of that.

DrMR: Absolutely. Yeah, and I just want to echo that because sometimes we get so fixated on the “treatments” that we forget about some of the basics that maybe appear a little bit less clinical, but they’re still very helpful.

 

Probiotics during pregnancy

DrMR: Along those same lines, there are also probiotics. Probiotics can be very helpful for digestive conditions, and there’s also a wealth of literature showing how probiotics can have a positive impact on the child. One of the sections of my coming book that I’m really excited about is all of the early-life interventions that mom while pregnant or while nursing can undergo to help increase the microbiotal, the gut, and the immune health of her child, and probiotics are definitely one of those.

You make me think of another important thing maybe to point out—a little offtopic, but just worth a quick mention—is the impact that female hormones have on motility. There was a patient in the clinic, I believe it was last Friday, who didn’t have any digestive issues until she hit menopause, and now she’s been diagnosed with SIBO. All of the IBS/SIBO-type symptoms started after menopause, and her female hormone symptoms are fairly pronounced. In this particular case, I think it’s going to be a two-pronged approach of needing to get the female hormones balanced and also to eradicate the SIBO.

I know people always want the protocol, but the challenge with just following a protocol blindly is that a protocol will do one thing: kill bacteria, but there’s more to a successful clinical outcome than just a protocol. I was talking with Allison Siebecker about this the other day, and she said if protocols were so effective, we wouldn’t need doctors because you would just have X condition and then just follow the protocol and then you’d be healed! Of course, it doesn’t work that way because there’s more to it than just a protocol.

DrJB: Yeah. How did I not even mention probiotics?! Yeah, all my ladies that are pregnant are on probiotics exactly for everything that you stated. It’s the immune modulation and also the effects on baby. I mean, what’s in your gut is going to be in baby’s gut, so it’s so important and it’s such a great place to go.

And to touch on the menopausal symptoms, I absolutely see the same thing. It’s a very chicken-and-the-egg situation, and I feel like sometimes people get a little too hyper-focused on which came first, but I see the exact same thing. What’s important to note is that—and it’s especially important to bring this full circle to what we’re talking about today with having adequate estrogen and progesterone levels—you need that progesterone hormone, which can be such an issue in thyroid patients. But if your gut isn’t functioning optimally and you aren’t moving out your hormones—because that’s where you’re moving out all that estrogen—those bacteria can actually re-conjugate your estrogen and send it back into circulation. We can see issues with estrogen dominance, and it’s not an issue that you need to be put on progesterone or that you need some kind of herb for progesterone. Sometimes it is, but a lot of times it can come down just to the gut, and when you’re getting that re-conjugation of estrogen and then the rest of the hormones start to come up, we’re going to see further shifts in the microbiome.

Yeah, I love that you bring that up because if you are seeing a doctor for infertility issues or you’re trying to get ready preconception and they’re not looking at your gut, you need to find someone who will because that’s a huge part of not only your health—and I’m really excited to read your book! Then I’m probably going to give it to all my patients because it’s so important that you have your gut health really dialed in before you become pregnant because that’s going to affect baby!

Now, let’s not freak out, everyone out there who is already pregnant or has had a baby. There are a lot of things we can do, and I’m sure your book is going to address a lot of that. Yeah, I kind of did not talk about probiotics, which I use all the time!

DrMR: That’s why we have two minds on this call, to make sure that we don’t forget anything!

 

Dr. Brighten’s least healthy habit

DrMR: The final question I’d like to bring us to is one I try to ask most guests unless I forget. We talk about all this stuff to become healthy, and sometimes what I see in my patients is this neuroticism about being healthy, and so I think it’s very important for us as different health practitioners, doctors, researchers, authors—whatever it is—to show the human side and show that we’re not these robots that never stay up past 10:30, never eat any rice, never whatever it is. So what is the least healthy, but maybe most soul-nourishing or most fun thing that you’ve done recently?

DrJB: Oh, gosh, that’s a really good question. Someone who has autoimmunity can become very neurotic about things. I tend not to be that way because the thing is there is nothing that will drive autoimmunity more than stress, so you have to just kind of chill out sometimes, but I think anyone who knows me, anyone listening to this who knows me, knows I’m really transparent about my imperfections. I really love a good whiskey or a good bourbon. And people will say to me, “Oh, my gosh. I cannot believe you drink that! Don’t you know what it does to your microbiome?! Don’t you know what it does—” and people will rattle off, and it’s like, “Well, of course, I know!” But I love the way it tastes. It makes me happy sometimes to go and have a drink and to have a conversation. Yeah, I totally out myself in that! But I think people who know me, anyone who gets on my Instagram account or anywhere, they know. I came out a few weeks and was like, “Guess what? I did eat a gluten-free donut, and it was delicious!”

DrMR: Nice.

DrJB: Yeah, I think the worst thing that we can do, especially as mothers, is try to achieve this idea of perfection. Our job as mothers—and as people in society, because we’re all having an influence on the children that we’re raising—I mean, I don’t want to teach my son perfection; I want to teach my son fluidity and to be flexible. The most adaptive species are the ones that survive, so if we’re getting hung up on every little detail in our life and really—I mean, I have patients that they will write down everything and they keep logs of everything, and I get that sometimes they need that, sometimes that’s part of their healing journey, but there is this part of being human and being OK with that and being very forgiving of yourself for that. I don’t think I’ve ever met an autoimmune patient that doesn’t participate or hasn’t at some point participated in negative self-talk. That is, on some degree, like an A-type personality that’s really hard on themselves. And again, stress and perfectionism. I have a motto in my clinic: Dogma equals death.

DrMR: I like it.

DrJB: That is the last thing I want to see for my patients.

DrMR: I like it, and I love the point you made point there about autoimmunity. There’s one section of the book where I talk about autoimmunity, and I really kind of reframe it as something that you may want to actually thank yourself for and something that you can almost, in a way, be proud of. It has to do with the immune system and immune system evolution, and I, of course, won’t go into that now, but it just reminds me of that. Sometimes you look at something as a bad thing, and if we reframe it, it can be looked at as a good thing. Just that simple process of reframing could be the difference between someone beating themselves up about it every day for the rest of their life or smiling to themselves about it. The way we frame things is sometimes really, really important because it affects, of course, your whole outlook.

DrJB: Yeah. I love that you say that. My autoimmunity is the biggest gift that I’ve been given. As you know, it’s not just Hashimoto’s. I have autobodies to my adrenal glands, phospholipid antibodies. I have a good mixed bag going, but it was something that made me get really real about my life, and it’s definitely one of the best things that’s ever happened to me because I have reframed everything. When I think about things, it’s a lot less of, like, “I should do this and I have to do this,” and a lot more of, like, “Is this what I want? Does this make me happy? At the end of the day, will I be proud of this? Was this worth time away from my son?” I reframe so many things. So I love that you say that. I hear so few clinicians say that, so I really just appreciate it, and I just want to honor that.

DrMR: Well, I think it’s really important because you made an earlier point about stress being a strong provoker of autoimmunity, and I think sometimes, especially in autoimmunity—and this is something I think we’ll do more about with the podcast or with articles in the future—sometimes we have diagnostic capacity that exceeds our treatment capacity. Patients may go do these really robust autoimmunity assays, and then all that does is just scare the crap out of them, and they are just in constant fear. We come back to, well, what do we do with that information? There’s a handful of great treatments for autoimmunity, and then after you’ve addressed all the modifiable factors, there’s really nothing else you can do, and fretting over these results and creating all this internal stress and fear and losing the ability to sometimes eat off plan or have fun or be up late or have a bourbon or what have you, that is going to be so much more stressful and clinically detrimental, in my opinion.

I think it’s just important to mention that because just like you were saying, there are so few clinicians that say that, and that’s why I am again echoing this maybe the fourth time now as we’re wrapping up this dialogue! I think it’s really important for both patients and for clinicians to hear, so thank you, Jolene, for being so great in that regard, I guess!

DrJB: Yeah, well, thank you!

 

Episode wrap-up

DrMR: Well, I think we’ve pretty much picked that issue apart, and hopefully this dialogue will be really helpful for people. Tell people about where they can track you down. I know you have a book and also an eBook, so tell people where you’re at, how they can find you, and what kind of gift you have waiting for them if they want more information.

DrJB: Yeah. You can find me at DrBrighten.com. My last name’s a little bit tricky, so the website URL is going to be D-R-B-R-I-G-H-T-E-N—a little part that’s tricky there.

For your listeners, because I think that we talk so much about screening before you become pregnant and what should be tested in the first trimester, they can go to DrBrighten.com/Labs, and they can actually download my recommended labs that I have all women who are wishing to become pregnant engage in, but also, more specifically, those who know they have Hashimoto’s or other autoimmune conditions.

I’ll be rolling out a program here in the future, which is going to be directed towards Hashimoto’s patients who would like to become pregnant. We’re focusing on the fertility in Hashimoto’s patients because this is something very overlooked, and I think we could save a heartache if we help women get on track before they ever become pregnant.

And I have an eBook. If you go to my website, you’ll see it there, but I also have my book, which is called Healing Your Body Naturally After Childbirth: The New Mom’s Guide to Navigating the Fourth Trimester. As I talked about before, basically actually what I should say is it’s the book I wish I had when I had a baby, and so I wrote it for all the moms out there. It’s a lot of, like, “This is what’s going to happen, and this is what you’re going to do about it.”

DrMR: Gotcha.

DrJB: Yeah.

DrMR: Cool. All right, folks. Well, there you have it. Jolene, thank you so much, and let’s try to get a whiskey or a bourbon in sometime soon, huh?

DrJB: Absolutely. I would love that. Thank you for having me!

DrMR: My pleasure. All right, thanks, guys.

Thank you for listening to Dr. Ruscio Radio today. Check us out on iTunes and leave a review. Visit DrRuscio.com to ask a question for an upcoming podcast, post comments for today’s show, and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.com.

If you need help with your thyroid, click here.

What do you think? I would like to hear your thoughts or experience with this.

Discussion

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!

24 thoughts on “Thyroid Autoimmunity and Pregnancy with Dr. Jolene Brighten – Episode 45

  1. Thanks for this very timely podcast. My husband and I are about to start trying for baby #1. Could you clarify how to determine if you have Hashimoto’s? For example, my TPO antibodies are 11 IU/mL. My lab results indicate that anything less than 34 is normal. But I believe Dr. Jolene said that the presence of any antibodies indicates Hashimoto’s. So does this mean that even a tiny amount, like my 11 IU/mL, means you have Hashimoto’s? Thanks!

    1. Hi Julie,
      Glad it was helpful. I agree with the traditional range for antibodies, so no at 11 you are not positive. But, you should keep an eye on your levels once you become pregnant. You should also have Thyroglobulin antibodies tested if you have not yet because they can be positive in Hashimoto’s also. Hope this helps.

      1. Thanks Dr. Ruscio – you are so helpful! Thanks for all the great work you’re doing. Looking forward to meeting you at Paleo F(x).

  2. I’m really disappointed that this was all about hypothyroid & Hashimotos and didn’t mention anything about Graves’ disease. Everyone seems to ignore this condition and because of that I haven’t been able to move forward with trying to conceive (for over three years now) because doctors don’t know anything or deal with it. It’s very frustrating that this topic wasn’t as inclusive as I thought it would be. Graves is still the red headed step child of the thyroid community I guess!

      1. I have, but there is no mention of how to manage Graves well enough in order to get pregnant (according to all my conventional doctors it’s impossible) nothing about managing Graves during pregnancy if you’re lucky enough to have that happen, nothing about the likelihood of coming out of remission during or after pregnancy… it doesn’t mention pregnancy at all! Before fertility testing I had no symptoms of Graves other than infertility and now I feel miserable and
        I can’t find anyone who who will even TALK about Graves and pregnancy other than when my fertility doctor told me to “get my thyroid fixed and come back” who clearly doesnt understand that there is no “fixing” autoimmune disease. Super discouraging all around.

        1. OK Sarah. Graves’ and pregnancy is a different animal. This is challenging because the amount of studies in this area are sparse. I would listen to/contact Dr. Brightnen who recently came on the podcast and specializes in thyroid conditions and pregnancy. Yes, we discusses Hashimoto’s but she should be able to help you with Graves’ also. One thing I can tell you is your fertility doctor is not wrong. As a general rule you should focus on just treating the thyroid hormone imbalances until after your done nursing. This will allow the best chance for a healthy pregnancy. THEN you return to treating the underlying cause of autoimmunity after nursing. We discussed this in the recent podcast also. There is nothing wrong with managing symptoms in the short term and then treating the autoimmunity later. Be careful not to fall to deeply into all the ‘internet fear mongering regarding autoimmunity’. I really hope this helps Sarah. Good luck 🙂

  3. Hey Dr. Ruscio! I am a big fan! I’m a OB RN and I’m also living hashimotos. I share a similar story with Jolene. My midwife palpated a goiter at 14 weeks gestation and gave me a consultation with an endocrinologist where my TSH was discovered to be 6.8 and my TPO antibodies were over 3,000. I was very symptomatic but being my first child (and working third shift) I thought it was normal to be sleepwalking through life. I was started on synthroid then. After delivery my TSH dropped to 0.4 and I felt mostly amazing aside from some anxiety. My endo told me my thyroid was healed, the goiter was gone and I didn’t need synthroid anymore! 6 months later I became depressed and was a mess. I asked my midwife to recheck my TSH and it was 26! I felt my endo was so reckless to not even plan a follow up lab when instead of being healed I had postpartum thyroiditis on top of my hashimotos! Believe it or not I stayed with that endo for another year and a half. My TSH was all over the map and I got tired of constantly upping my meds so I started looking for alternatives. I found a functional medicine Dr who took a hard look at my gut which needed some serious attention. He also found my TPO to now be over 5000! He started me on vit D, a probiotic, prebiotic and a healing smoothly. All from the brand orthomelecular. He changed me to a compounded T3/T4 and told me to go gluten and casing free.
    So here’s my question. I’ve been listening to your podcasts for a while now and have been waiting to hear what you have found about low dose naltrexone. But it doesn’t seem to be anywhere on your radar. I love how you take such an evidenced based approach in your practice and I’m hoping you could shed some light on the drug? I’m especially curious because we are trying to conceive again and I’m nervous about the lack of research in pregnancy. My dr wanted me to heal my gut some before he started me on LDN but thinks it would be beneficial with my antibodies being SO high.

    1. Hi April,
      Glad you like the info 🙂 I am open to LDN but admittedly have not got around to doing a comprehensive lit review/investigation on it. That being said I get the sense the benefits of LDN have been over stated. I would try the Mg, Se, CoQ10 protocol for AIT that we reviewed a few weeks ago with vitamin D and see what type of effect this has on your antibodies. Se has been shown safe to use during pregnancy. Also remember that maternal iodine status is very important for the fetus so even though most of the time AIT pts. do better on a lower amount of iodine intake this would be one exception. Also, have you rechecked your antibodies after your FM work? There is a good chance they are lower now 🙂 but if not see the advice above.
      Hope this helps!

      1. Thanks for the response! I have not had my TPO rechecked yet but will soon. I’m on MG and SE already, I initiated that before I started my FM work. I will discuss CoQ10 with my Dr. Have you ever treated a woman with it in pregnancy or would you consider that a pre-pregnancy treatment?

  4. Thanks for this very timely podcast. My husband and I are about to start trying for baby #1. Could you clarify how to determine if you have Hashimoto’s? For example, my TPO antibodies are 11 IU/mL. My lab results indicate that anything less than 34 is normal. But I believe Dr. Jolene said that the presence of any antibodies indicates Hashimoto’s. So does this mean that even a tiny amount, like my 11 IU/mL, means you have Hashimoto’s? Thanks!

    1. Hi Julie,
      Glad it was helpful. I agree with the traditional range for antibodies, so no at 11 you are not positive. But, you should keep an eye on your levels once you become pregnant. You should also have Thyroglobulin antibodies tested if you have not yet because they can be positive in Hashimoto’s also. Hope this helps.

      1. Thanks Dr. Ruscio – you are so helpful! Thanks for all the great work you’re doing. Looking forward to meeting you at Paleo F(x).

  5. Hey Dr. Ruscio! I am a big fan! I’m a OB RN and I’m also living hashimotos. I share a similar story with Jolene. My midwife palpated a goiter at 14 weeks gestation and gave me a consultation with an endocrinologist where my TSH was discovered to be 6.8 and my TPO antibodies were over 3,000. I was very symptomatic but being my first child (and working third shift) I thought it was normal to be sleepwalking through life. I was started on synthroid then. After delivery my TSH dropped to 0.4 and I felt mostly amazing aside from some anxiety. My endo told me my thyroid was healed, the goiter was gone and I didn’t need synthroid anymore! 6 months later I became depressed and was a mess. I asked my midwife to recheck my TSH and it was 26! I felt my endo was so reckless to not even plan a follow up lab when instead of being healed I had postpartum thyroiditis on top of my hashimotos! Believe it or not I stayed with that endo for another year and a half. My TSH was all over the map and I got tired of constantly upping my meds so I started looking for alternatives. I found a functional medicine Dr who took a hard look at my gut which needed some serious attention. He also found my TPO to now be over 5000! He started me on vit D, a probiotic, prebiotic and a healing smoothly. All from the brand orthomelecular. He changed me to a compounded T3/T4 and told me to go gluten and casing free.
    So here’s my question. I’ve been listening to your podcasts for a while now and have been waiting to hear what you have found about low dose naltrexone. But it doesn’t seem to be anywhere on your radar. I love how you take such an evidenced based approach in your practice and I’m hoping you could shed some light on the drug? I’m especially curious because we are trying to conceive again and I’m nervous about the lack of research in pregnancy. My dr wanted me to heal my gut some before he started me on LDN but thinks it would be beneficial with my antibodies being SO high.

    1. Hi April,
      Glad you like the info 🙂 I am open to LDN but admittedly have not got around to doing a comprehensive lit review/investigation on it. That being said I get the sense the benefits of LDN have been over stated. I would try the Mg, Se, CoQ10 protocol for AIT that we reviewed a few weeks ago with vitamin D and see what type of effect this has on your antibodies. Se has been shown safe to use during pregnancy. Also remember that maternal iodine status is very important for the fetus so even though most of the time AIT pts. do better on a lower amount of iodine intake this would be one exception. Also, have you rechecked your antibodies after your FM work? There is a good chance they are lower now 🙂 but if not see the advice above.
      Hope this helps!

      1. Thanks for the response! I have not had my TPO rechecked yet but will soon. I’m on MG and SE already, I initiated that before I started my FM work. I will discuss CoQ10 with my Dr. Have you ever treated a woman with it in pregnancy or would you consider that a pre-pregnancy treatment?

  6. I’m really disappointed that this was all about hypothyroid & Hashimotos and didn’t mention anything about Graves’ disease. Everyone seems to ignore this condition and because of that I haven’t been able to move forward with trying to conceive (for over three years now) because doctors don’t know anything or deal with it. It’s very frustrating that this topic wasn’t as inclusive as I thought it would be. Graves is still the red headed step child of the thyroid community I guess!

      1. I have, but there is no mention of how to manage Graves well enough in order to get pregnant (according to all my conventional doctors it’s impossible) nothing about managing Graves during pregnancy if you’re lucky enough to have that happen, nothing about the likelihood of coming out of remission during or after pregnancy… it doesn’t mention pregnancy at all! Before fertility testing I had no symptoms of Graves other than infertility and now I feel miserable and
        I can’t find anyone who who will even TALK about Graves and pregnancy other than when my fertility doctor told me to “get my thyroid fixed and come back” who clearly doesnt understand that there is no “fixing” autoimmune disease. Super discouraging all around.

        1. OK Sarah. Graves’ and pregnancy is a different animal. This is challenging because the amount of studies in this area are sparse. I would listen to/contact Dr. Brightnen who recently came on the podcast and specializes in thyroid conditions and pregnancy. Yes, we discusses Hashimoto’s but she should be able to help you with Graves’ also. One thing I can tell you is your fertility doctor is not wrong. As a general rule you should focus on just treating the thyroid hormone imbalances until after your done nursing. This will allow the best chance for a healthy pregnancy. THEN you return to treating the underlying cause of autoimmunity after nursing. We discussed this in the recent podcast also. There is nothing wrong with managing symptoms in the short term and then treating the autoimmunity later. Be careful not to fall to deeply into all the ‘internet fear mongering regarding autoimmunity’. I really hope this helps Sarah. Good luck 🙂

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