Fatigued? Poor sleep? Constipation? Dry skin and hair? Menstrual changes? Change in your libido? Hair loss? All of these are possible symptoms of a #thyroid issue. However, these same symptoms can also be attributable to other #hormonal imbalances as well, or the interplay between other hormone issues, such as #adrenaldysfunction, and thyroid problems. Why? Because your hormones are all connected, and are highly interdependent on each other.
I totally understand how this feels too; part of my history pre-functional medicine included being misdiagnosed and mistreated for my hypothyroidism, Hashimoto's disease and severe adrenal fatigue. I suffered for years with hair loss, profound fatigue, and brain fog. Once I sought out support from the functional medicine community, I finally was diagnosed with adrenal dysregulation, Hashimoto's and subclinical hypothyroidism, none of which my PCP had even bothered to test for or knew anything about, frankly. The best news is that with the right treatment, I overcame these issues. My Hashimoto's is now in remission and although I am sensitive to stress like all people, I have recovered well. I have a particular passion for assessing and addressing these issues in patients, because I remember what it felt like to not be heard and to not have answers.
So how we can dig in to figure out what is causing your #fatigue? Or hair loss? I start with listening: I can get a ton of information about your hormones based on your symptoms. Next, TEST. And test properly. Too may providers take shortcuts with thyroid and only measure a TSH (thyroid stimulating hormone) and MAYBE a T4 (thyroxine). But this will only show you a fraction of what is occurring hormonally. And remember how I said the hormones are highly interdependent? This means that when we test for a hormone imbalance such as hypothyroidism, we also need to assess the full endocrine system. A proper lab evaluation would include at least:
Thyroid: TSH, Free T4, Free T3, total T3, Reverse T3, and thyroid antibodies (BOTH anti-TPO antibody and thyroglobulin antibody). Also assessed is reverse T3/T3 ratio when the results come back.
Sex hormones: in women: estradiol progesterone, testosterone free and total, prolactin and FSH/LH measurements along with sex hormone binding globulin levels, all drawn at the correct points in your cycle if you have them. In men: FSH/LH, prolactin, testosterone free and total, estradiol and progesterone, along with sex hormone binding globulin, drawn as early in the morning as possible. In women, also assessed is estradiol to progesterone ratio when the results come back.
Adrenal: AM cortisol (before 9 am ideally) and DHEA-sulfate levels.
Based on the above evaluation, I may also order additional hormone studies to better understand the physiology of what might be the root cause of your symptoms. A few additional tests I may consider include:
DUTCH testing: a dried urine test to assess metabolites of hormones as well as an organic acids assessment. https://dutchtest.com/
Adrenal salivary cortisol: A 6 point test that measures CAR (cortisol Awakening Response) followed by 4 point salivary cortisol measurements throughout a full typical day, as well as salivary DHEA-sulfate measurements. https://www.gdx.net/product/adrenocortex-stress-hormone-test-saliva
Salivary hormone panel: there are some cases where assessing the full hormone system and cortisol secretion together are most helpful, so a salivary hormone panel can also be done, which includes a 4 point cortisol test with DHEA-sulfate as above, but also measures estradiol, estrone, estriol, testosterone, androstenedione, DHT, melatonin, progesterone and a 17-OH progesterone.
Once we have the above information collected, we can dig in to the root cause of your symptoms. One of the most common patterns I see is subclinical hypothyroidism that is caused by stress hormone imbalances. This means that thanks to stressors, be they immediate or chronic, cortisol and DHEA-sulfate may be too high, too low or abnormal in their pattern of secretion, and this indirectly affects the thyroid hormone production and utilization. It does this often by decreasing T3 production and increasing Reverse T3 production. Additionally, a patient can have cellular resistance to thyroid hormone that is produced, creating a state of hypothyroidism due to the cells not taking up thyroid hormone properly. Think of T3 as the gas pedal of the thyroid hormones: T3 helps increase metabolism, increases hair growth, increases the speed of cognitive processing; while Reverse T3 is exactly the opposite; Reverse T3 is the brake pedal of thyroid hormones, slowing everything down. This slows down your GI system, metabolism, brain processing and more. Symptoms are common and include fatigue, brain fog, abdominal weight gain, insomnia or disrupted sleep, depression and/or anxiety, and more.
The most important thing to mention here is that the above issues are extremely treatable! Meaning that you don't have to suffer with ongoing fatigue and brain fog, despite having "normal" traditional lab assessments. Sometimes we have to dig deeper to get to the root cause, but once we understand it together, the root can typically be treated.
So, how do we address some of the common causes of subclinical thyroid issues and fatigue? Since, as I said earlier, stress can be a huge contributor, addressing the stress in your life is one of the most critical points of treatment. While supplements and medications may help you feel better, they won't correct a stress system that is out of whack in the face of chronic ongoing stress. That must be addressed with lifestyle, which occasionally, can be pretty challenging. A few suggestions I make for clients include:
Prioritize sleep. Making sure to get at least 8 hours a night of quality sleep, using good sleep hygiene practices and ensuring a good sleep pattern is essential to healing the adrenal system.
Exercise, not to much, but just enough. Sometimes people are overexercising in the setting of fatigue; some people are not exercising at all because they are too exhausted. We figure out where your body is now, and what we think it can handle and can make specific recommendations tailored to your lifestyle and body. Generally speaking though, walking and yoga are a great place to start. And yoga has been proven to help down regulate your nervous system. Science!!
Make time for self care. See my previous blog post about self care; or my advice is to make a list of activities that help calm and soothe you. Then, schedule time for the activities and focus on 1 hour daily to do your favorite self care activity.
Make changes. This is sometimes the tough love part of our conversations together. Maybe it is changing a job that you hate, engaging in counseling to process a stressful event, or making changes within a relationship; if the stress in your life is continual, you will be limited in what symptom relief you can achieve. Some stressors we can't change (i.e. the illness of a loved one), in which case we must engage support systems, counseling and active self care strategies to cope. But you have to look at this for best results.
Meditate. Again, Science! Even sitting quietly for 3-5 minutes a day can be helpful. Or, seek out more info in books on the subject. My favorite? How To Meditate by Pema Chodron.
Eat a whole foods, nutritious diet. Your system cannot function well in the setting of fatigue on a less than optimal diet. Eat more whole unprocessed foods, eliminate or minimize caffeine which can be hard on the adrenals, and eliminate sugar as a few initial steps.
Additional therapies also might include supplements or even bioidentical hormone replacement therapies, or other medications to improve adrenal or thyroid function, or to address other hormone imbalance found in your testing. A few strategies I employ includes maximizing thyroid function with supportive nutrients (zinc, selenemethionone), replacing thyroid hormone when appropriate, using herbal adaptogens to support the adrenal system to rebalance, or using BHRT for the adrenals in rare cases. Each of these approaches is customized to the client and their body and goals.
Most importantly, don't suffer. Get tested properly, understand the problem and get support from a Functional Medicine provider.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415184/; Health Impacts of Yoga and Pranayama: A State-of-the-Art Review, by Pellav Sengupta
https://www.sciencedirect.com/science/article/abs/pii/S0306453018308977; Exploration of psychological mechanisms of the reduced stress response in long-term meditation practitioners, by Luidmila Gamaiunova, Pierre Yves-Brandt, Guido Bondolfi and Matthias Kliegel.