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Episode 3 | Two Roads Diverged, Part 2: Integrative Doctors and Hypothyroidism

Two of the nation's leading integrative and naturopathic physicians explore their approach to diagnosis and management of hypothyroidism.


Two roads diverged in a yellow wood,

And sorry I could not travel both

And be one traveler, long I stood

And looked down one as far as I could

To where it bent in the undergrowth;

Then took the other, as just as fair…

~ From “The Road Not Taken,” by Robert Frost

(Podcast audio excerpt features poet Robert Frost reading his poem)

MARY SHOMON: Do you want to finally live and feel well with a thyroid condition? Then I want to welcome you to the Thyroid Deep Dive podcast. It’s time to dive in!

How do you get properly diagnosed with and optimized treatment for your hypothyroidism? Should you see an endocrinologist, or an integrative or holistic physician? And, how do their treatment approaches differ? This is part 2 of a special episode diving in to the diagnosis and treatment of hypothyroidism from different perspectives.

In Part One, we heard from endocrinologists, who laid out the conventional approach to hypothyroidism. In this part, we get an overview of the integrative and naturopathic perspective on hypothyroidism diagnosis and treatment from bestselling author and renowned physician, Dr. Jacob Teitelbaum, talking to us from Hawaii.

“This is not a one-size-fits-all condition.” ~ Jacob Teitelbaum, MD

You’ll also hear from one of the Washington, DC area’s leading naturopathic physicians, Dr. Kevin Passero.

“The more you’re trying to control the situation through educating yourself and really advocating for yourself, usually the better outcomes you have." ~ Kevin Passero, ND

Both doctors have decades of experience treating hypothyroidism, and what they have to say is eye-opening, to say the least!

This is Part 2 of “Two Roads Diverged,” episode 3 of the Thyroid Deep Dive podcast.

The TSH "Normal" Range

MARY SHOMON: When it comes to the thyroid, many doctors rely almost exclusively on the thyroid stimulating hormone test, known as the TSH test. The TSH test poses some challenges. First, TSH measures a secondary pituitary messenger hormone, NOT the actual levels of thyroid hormones like T4 and T3. And second, some doctors consider ANY TSH test result that falls within the reference range to be “normal.” Dr. Teitelbaum has simply the best analogy to explain why relying solely on the so-called “normal” test results may not make sense.

DR. TEITELBAUM: Mary, this is a really critical thing for so many millions of people. Thyroid problems, along with other autoimmune problems, nutritional deficiencies, stress-related hypothalamic dysfunction--there are so many things that trigger inadequate thyroid function. The doctors are relying predominantly just on blood testing, which is miserable. So, let me give you an example of a key problem with thyroid testing. The normal range is what most doctors rely on. And the vast majority of doctors have no idea where the normal range comes from. And that creates a problem.

All that normal means is that they take 100 people, and the 95 in the middle are defined as normal. It's called two standard deviations. So, if I wanted a normal range for shoe sizes, I check 100 people, and the normal range for shoe sizes would be size 5 to 13. Now, that doesn't mean that if you put my size 12 foot in a size 6 shoe it’s going to fit. But as far as most doctors are concerned, if I have a size 6 as my shoe size, they're going to say it's in the normal range, there's nothing wrong with that. And that is, simply put, utterly insane. And say you even are lucky enough to fall in the lowest 2% instead of the lowest 3% of the population, so that you do become abnormal on the test. They’ll give you just enough. So, if I have a size 4 shoe, they’ll go, “oh that’s small” and give me a size 6 because it's in the normal range. Utter, utter horrible nonsense.

What you need to do is you need to adjust the thyroid using the form that's best for each individual, to the dose that feels best to the person. Once you find that dose, you check the free T4 to make sure it's not elevated, for safety. And that's how the testing should be used. The TSH, in many illnesses including fibromyalgia -- because that hormone control center called the hypothalamus is not working -- is often a meaningless test, and often needs to be low for the person to have optimal thyroid hormone levels.

MARY SHOMON: Dr. Passero has a similar approach to the TSH test and to the “normal range,” and how TSH levels relate to optimal thyroid treatment.

DR. PASSERO: Normal levels are going to be a very broad perspective based on the laboratory range, which is set quite wide. Now, doctors like to come up with narrower guidelines as far as what's normal and what's not normal. That exists in the conventional endocrinology world, where they use just typically the reference range on the lab. But even in the integrative and holistic world, a lot of more natural doctors will say, “well, the optimal level is, let's say between, or the normal level for thyroid patients should be a TSH between 1 and 2.” In my experience, optimization isn't necessarily about the lab values, although the lab values are important. An optimized thyroid patient is somebody that's sitting across the desk from you who is feeling good.

And in addition to feeling good, we've got some handle on some laboratory values that are a little bit more focused than what just the general reference ranges show. Because the general reference ranges are really for a very broad age group and doesn't differentiate sex or different stages of life that people are in. So, it's very difficult to just stick people somewhere in that normal range until you feel fine.

There are some people that walk in my door and they have a TSH, let's say that is above what would be the optimal functional range, but they feel fantastic. And it wouldn't make sense to raise or lower their medication just for the point of normalizing their lab values, when they're doing really well where they are. Optimization, ultimately, is the patient experience.

A lot of patients do come in and they've been told that their thyroid has been normalized, they maybe had an elevated TSH when they're first diagnosed with their thyroid issue, they saw their doctor, they were put on some form of thyroid hormone replacement that often normalizes the lab values, but the patient still experiences all of the symptoms of hypothyroidism. The low energy, they have difficulty losing weight, low body temperature, skin is dry, hair is either falling out or very dry, nails are brittle, there could be constipation, brain fog, all of the most classic symptoms. Yet the doctor is saying, “well, your numbers are normal.” And that's somebody where the lab may look optimized, but the patient clearly is not.

Typically a TSH approaching over 3, and definitely over 3.5, in the vast majority of people, you're not going to see people feeling all that good with the TSH that elevated, even though it's well within the reference range and some traditional doctors won't even address until the TSH is 6 or 7. I've even heard endocrinologists say they won't start treatment until the TSH is up to 10. That's double the high end of the normal reference range, whereas most people don't feel good as soon as their TSH starts creeping up over around 3 ½. That's a huge red flag to me.

T4 and T3

MARY SHOMON: In diagnosing and managing hypothyroidism, holistic and integrative physicians tend to emphasize levels of the actual thyroid hormones, T4 and T3, rather than TSH. Dr. Passero explains how he uses testing for T4 and T3 to help identify and treat hypothyroidism in his patients.

DR. PASSERO: The TSH is just a hormone from the pituitary gland, that's triggering the thyroid to make hormone. The TSH up or down doesn't necessarily dictate really how you feel, it's the level of T4 and T3 that's interacting with your cells and actually interacting with the nucleus, specifically T3 and stimulating increased production of ATP, which is what gives your body energy. That's why thyroid hormone is the main regulator for all metabolic processes in your cells, because of that effect on metabolism.

Free T4 and free T3 levels are definitely a more ideal way to assess what the thyroid hormone levels in the blood are doing than the total T4 and total T3. Although I like to look at all the numbers when I'm doing the thyroid evaluation.

The free T4 and free T3 have their own reference ranges. The free T4 reference range is about .8 up to about 1.6 or so, depending on the lab. And T4 is less of a bioactive hormone, so that one can be a little bit more off, or not quite as tightly regulated in the reference range, and not affect how people feel as much. The low end of the reference range, let's say on a major lab like LabCorp for free T4 is .82. You don't want to see it at .8 or a little bit below that. It's clearly telling you that the amount of hormone in the bloodstream is less than what is ideal for the body. Same with the T3. T3 is far more bioactive than T4. T4 is often times considered a pro-hormone, which is kind of like a pre-hormone, it circulates in the bloodstream, but it's not that bioactive. It's when your body converts it into T3. T3 is far more active as far as stimulating metabolic activity. So, a big red flag is if you see those free T3 levels on that very low end and the free T3 level bottoms out at about 2.0 on most major labs and tops out at about 4.3 or 4.4, depending on which laboratory you're using. So, if you see those free T3 levels at 2.1 or below the low end of the reference range, and you have symptoms associated that fit a hypothyroid picture, that needs to be looked at, regardless of what the TSH shows or regardless of what medication you're on. So that's a huge red flag.

Thyroid Antibodies

MARY SHOMON: Another test that some doctors consider important is the thyroid antibody test. Some endocrinologists include it in an initial workup, but conventional medicine does NOT use this test as a basis for hypothyroidism treatment. Dr. Passero outlines the approach that’s more commonly used by integrative physicians.

What I would like you to address is the issue of thyroid antibodies, and in particular, the TPO antibody test that helps us identify Hashimoto’s and why it's important to know if your hypothyroidism is autoimmune and the situation of patients that have normalized or normal range or even optimal thyroid levels from the TSH, T4, T3 level, but have elevated TPO antibodies, and what that can mean.

DR. PASSERO: This is such a huge issue for so many people. Thyroid antibodies are oftentimes not measured in thyroid screening tests, even when a person has an elevated TSH. That's a whole different story because it is very important to know if the nature of your thyroid disorder is autoimmune-related, because it opens up an entirely different window of treatment options if you're working particularly in the functional medicine naturopathic medicine world. Because there are very effective ways that you can help to modulate the immune activity, calm it down, bring antibodies levels down and reduce the inflammation and the stress on the thyroid gland, which greatly improves symptom management.

Secondly, the most important issue and one of the things that gets missed so many times is that people have symptoms of hypothyroidism, exact symptoms. And a lot of these people also, if they start querying a lot of people in their direct family lineage, they'll find that other family members also have hypothyroid issues. Now, they are presenting with the symptoms, they go to their doctor and they get this cursory test done and TSH is normal, maybe it's perfect -- even in an ideal functional range-- maybe a TSH between 1 and 2. Their free T4 is in an optimal functional range at 1.3 or 1.4. And even their free T3 is totally optimal, even according to a more stringent naturopathic functional medicine standard of 3.3 or 3.5. But they don't feel good. And their doctor just says, “Well, it's not your thyroid, that's not the issue.” But they're having all of the symptoms.

There is a very high prevalence of people that have completely normal laboratory tests for all of the standard ones, TSH, free T3 and free T4, but have elevated antibodies and elevated antibodies causing the chronic inflammation in the thyroid can present with the exact symptoms of hypothyroidism. And if a patient walks in my door and they have the clinical symptoms of hypothyroidism, and their thyroid antibodies are elevated, even if everything else is normal, I treat them with the same therapies I would treat somebody with if they were totally diagnoseable hypothyroid from their TSH being elevated. And it completely changes their world.

Research does show if you start some treatment before the TSH elevates in patients that have positive antibodies, you can prevent further down-the-road significant thyroid crashes and other major thyroid abnormalities down the road if you treat earlier on and that has been validated in the clinical research.

Generally speaking, I would say over 95% of people that I've worked with who have normal TSH but elevated antibodies, not only do we reduce their risk of developing worse over hypothyroidism in the future, but it completely changes their quality of life, in real time, as in in the now.

Reverse T3

MARY SHOMON: There’s also another test, one that many endocrinologists refuse to do, but many integrative physicians find useful. It’s called the Reverse T3 test. Dr. Passero explains it for us.

DR. PASSERO: The concept of reverse T3 is a little bit of a difficult one for people to understand. Reverse T3 is a protection mechanism for the body is how we see it. I explained earlier that T3 is the most metabolically active thyroid hormone in the body, reverse T3 is kind of like the brakes on T3. It's what's called a stereoisomer. The stereoisomer in chemistry, I can explain it really easy. Hold up your left hand and your right hand across from each other. Your thumbs match in the same position and all your fingers match in the same position if you put your two hands together, but they're exactly opposite. You can't fit a right-handed glove on your left hand. They're the same exact structure but is what's called a mirror image. And that is what reverse T3 is versus regular T3. A T3 is a tyrosine with three iodines attached to it, and it comes from a T4, which is a tyrosine with 4 iodines. And reverse T3, the body removes an iodine on the opposite side of regular T3. As a stereoisomer, it has the same conformational shape, so it fits into the T3 receptor, but with reverse T3, it doesn't activate it. So, it acts almost as like a block to slow down metabolism, because if that receptor site is bound, the T3 actually can't access it.

People then say “Oh, well that's really interesting, but why in the world would my body want to shut down its own metabolism?” And it's because when stress levels get high, or in a situation of T4 production somehow elevates above what the body can handle, the body will start, instead of making T3, it will make reverse T3 to try and deal with all the T4 that's in the system. So, it's almost like a protection mechanism in case the thyroid becomes overactive.

Measuring reverse T3 is an important thing to do because if reverse T3 levels are elevated, somebody could have a normal TSH, normal T4 levels and normal free T3 levels. But if the reverse T3 is elevated, they can still present with the clinical symptoms of hypothyroidism, because that reverse T3 is blocking the receptor sites, preventing the T3 from activating metabolism. Functionally at the cellular level, things aren't working right. But if you don't measure that reverse T3, all of the blood hormone levels look absolutely normal.

The most important instances when I see reverse T3 elevated and why this is such an important test to measure is for the patients that walk in my door who have been managed by traditional approaches to hypothyroidism. So basically, they've been put on a synthetic T4 thyroid hormone, and they have had a normalization of their TSH, their T4 levels look normal, but they still have every single clinical symptom of hypothyroidism. And they're incredibly frustrated, because they feel awful. But their doctor has told them, “You're on the appropriate medication, your lab values have normalized, and you should feel fine. So, if you're still having symptoms, it's not your thyroid. Exercise more, eat less, or maybe you're depressed and you should go see your primary and get on an antidepressant.” Which is complete and absolute negligence and ridiculous, in my opinion, because that is not actually what's happening.

And the reason why the reverse T3 is so important in that situation is because the synthetic T4 medications like Synthroid, and levothyroxine, they normalize the TSH, but oftentimes you start to see the free T4 levels approaching the very high end of the reference range 1.6, 1.7, getting very elevated, sometimes above the high end of the reference range. And like I talked about earlier, reverse T3 is a protection mechanism that the body has for dealing with too much T4. And so, if the doctor is giving more T4 therapy to try and bring the TSH down or the TSH is normalized, but the patient says “I'm still tired,” they say, “Take more T4.” It's natural that the body would be converting that T4 into reverse T3.

And it is a pattern that I can predict as soon as a patient sits down in front of me if they tell me, “I'm on all this thyroid medication, we keep upping the dose, but I still feel awful.” I say “I'm telling you; I can already tell you what your labs are going to look like. Your Free T4 is going to be on the elevated end, and your TSH is going to be normal or even maybe a little bit mildly suppressed, and your reverse T3 is going to be elevated. And so, the T3, the main metabolically active thyroid hormone that you have, can't do its job. So even though everything looks perfectly normal, at a cellular level, you are functionally hypothyroid.” Switching thyroid medication to a form that works with their body changes everything for those people…everything!

Treatment: Natural Desiccated Thyroid

MARY SHOMON: Getting the right diagnosis is an important first step. After that comes the critical business of treatment. Both Dr. Passero and Dr. Teitelbaum prescribe any thyroid medication that can safely help their patients. Most endocrinologists and conventional physicians start with levothyroxine, the synthetic T4 drug. But, in a departure from that approach, our doctors report their best results with natural desiccated thyroid drugs, like Nature-throid, WP Thyroid, Armour, and NP Thyroid. Here’s Dr. Teitelbaum, outlining his treatment approach.

DR. TEITELBAUM: Generally, I'm going to start with the desiccated thyroid, just because it tends to be safer than just using the Cytomel or pure T3, and legally it's a little more safe as well. So, I'm going to start with the desiccated thyroid, I will start with 30, half a grain or 30+ milligrams. And I will go ahead and have them every week or two march the dose up, and as they start getting to the place where they feel -- and I'll go slower as the dose goes higher, it depends on how much they think they need -- but if they're starting to feel like they have shakiness, too much coffee, palpitations, stuff like that, I'm going to back them back down. If they're crashing later in the afternoon, and they have their afternoon lull, first I'll have them drink 12 ounces of water and see if that takes care of it. But if it doesn't, then I'm going to split the thyroid and give part of the dose later in the day. And some people even find that they sleep better if they take part of the thyroid at night.

If they're not responding to that, and they still are very suspicious for having a low thyroid, I will go ahead and go with a pure Cytomel, often leaving out the T4 entirely and just going with a T3, either compounded or the Cytomel form.

And there's different groups. Some groups are simply having trouble converting the T4 to the active T3, and they'll usually need between 5 and 25 micrograms a day, sometimes 30. Then there are those who have receptor resistance, the cells are deaf to the T3, and they may need as high as 120. You're literally making them hyperthyroid to have a normal thyroid effect. And each person is different and it needs to be tailored to their individual case.

MARY SHOMON: That makes a lot of sense. What about your patients that are on a T4-only preparation, and who are doing pretty well, but need a little bit of extra support? Have you found adding in some Cytomel or a sustained release T3 helpful for some of those patients?

DR. TEITELBAUM: In some cases, I will. And it's also important to realize there's a subset of people who are overtly hypothyroid and really need it, but if you give them 5 micrograms of T3, it’s too stimulating. There are two things in those kind of settings that can be very helpful. One, giving vitamin B1, thiamine, 500 milligrams three times a day. After six weeks of being on it, and they should continue it, then they often, one, cognitive function often improves. So, it's a whole different metabolic issue going on in that subgroup. But also, they're able to tolerate the thyroid in many cases without feeling shaky. Then they can tolerate the thyroid they need. There's another subset of people, and especially people who had a history of say Graves’ disease that burnt out. They feel tired, they feel like their dimmer switch is on low and they feel just kind of sluggish and dull. And if you give them 1 microgram sublingual of T3, maybe 2, the lights go on, everything works well. You give them 5, they’re jittery and it’s uncomfortable. So, there's some that need very tiny dosing. It’s very individual and needs to be tailored from person to person. This is not a one-size-fits-all condition.

MARY SHOMON: Absolutely. That's one of my mottos. And I agree with you 100%.

Dr. Passero also has had the most success with natural desiccated thyroid drugs, as he explains.

DR. PASSERO: In my opinion, the natural desiccated thyroid extracts are the most consistent thyroid hormone replacement option in regards to creating symptom resolution for patients. Now, that doesn't mean that blanketly I say they're the best, because every person has to be addressed as an individual and I don't have any dogmatic approach to what people should do. It has to do with what each patient needs. But in my experience, it's the simplest solution to oftentimes getting people to feel better, and that's because the natural desiccated thyroid extracts are a combination of T4 and T3 in a ratio very similar to how your own thyroid would produce T4 and T3. So, we're getting as close to that biological mimicry with an oral supplementation hormone as we possibly can by using that combination.

Now, some people would say, well, you can do the same thing with, let's say you use Tirosint and T3. You could still create a four to one ratio and do the same exact dosing ratio that you would use in a natural desiccated thyroid extract, and you should get the same result. And the result is, that the reality is that that doesn't always happen. And I know that because there are times when some of these natural desiccated thyroid extracts -- because they can't just be easily made in a lab, they have to be extracted from the thyroid gland of an animal, a pig -- there can be some issues with the supply chain, and that's come up over the years. And so, we've had to switch people to our best bioequivalent. And even though on paper, it's in exactly the same as far as the amount of T4 and T3 as a natural desiccated thyroid extract. When we were using a T4 and T3 combo, patients say “I don't feel as good, something isn't right.”

And there are other factors in the natural desiccated thyroid extract, there's pre- hormones, there's T2 in there. There's other nutrients in there that naturally occur in the thyroid, like iodine and other trace nutrients. Those may be factors that make it have a better clinical outcome.

Treatment with Levothyroxine

MARY SHOMON: As I mentioned, most doctors prescribe levothyroxine drugs, and that’s what the majority of hypothyroid patients are taking, and they work fine… for many patients. These synthetic T4 drugs include levothyroxine tablets – like Synthroid, Levoxyl, and a long list of generics – as well as a liquid form of levothyroxine called Tirosint that comes in a gel cap and oral solution. In some cases, a synthetic T3 like Cytomel is added. Dr. Passero walks us through these treatment options.

DR. PASSERO: We can start with the generic synthetic T4s, the levothyroxines like you spoke about, and the raw material is basically the same, and that’s the case even in the range of the Tirosint. It is synthetic T4, so it is bioidentical T4, meaning that it is meant to match the same structure as T4 in our body. But it is made in a laboratory. Each pharmaceutical company is going to make their product a little bit differently, they're going to have their own little recipe. You can go to the store and buy five brands of chocolate chip cookies, but if you look on the label, it's all going to be a little bit different. They're all chocolate chip cookies, but the recipes are not the same.

And it's the same thing for all of these different forms of thyroid hormone replacements, specifically, the T4s. And it's important to note because some of the companies, their recipes contain that people don't react well to.

Excipients are things that they mix with the raw material, that synthetic T4 powder, to get it to flow through the tableting machines, or to get things to stick together, the binding agents because you actually just have to get the tablet to stick together. And then there's coatings that they put over tablets. So, there's all these different things that go on in the manufacturing process that can create problems.

MARY SHOMON: Dr. Passero raised the issue of excipients in tablets, and that’s an issue I also discussed with Dr. Teitelbaum, who had some thoughts about a patient story I shared with him.

I'm hearing more and more from thyroid patients who are taking various thyroid tablets usually in the T4 category, the levothyroxine tablets, who have said, “You know, I'm having all sorts of problems all sorts of symptoms that are suggesting that they are sensitive to some of the ingredients in those tablets, some of the excipients. And it was interesting because I talked with one woman who had started on Synthroid and she said, ”Literally within two days, I started getting migraines. And I told my doctor and he said, “No, there's no way they're not related,” and tried to send her to a neurologist. And I spoke with her. And I said, “Are you by any chance sensitive to lactose?” And she said, “Yeah, I'm really lactose intolerant.” And I said, “What about pollen allergies or seasonal allergies?” And she said, “Yeah, I have terrible hay fever.” And I said, “well, the Synthroid has lactose and acacia in it. And both of those are sensitivity-provoking ingredients for your particular conditions.” And she said, “Oh, the doctor never told me.” I mentioned to her if she was going to stay with a levothyroxine drug that she could try Tirosint which has almost no excipients in it because it's the liquid capsule and the straight liquid. Well, she said “I'm going to talk to the doctor immediately,” she got off the phone called the doctor, and switched to the Tirosint, and called me back a week later and said,” the day after I started the Tirosint, I didn't have a migraine.” And she had had been having a daily debilitating had to lay in a dark room for three-hour migraine ever since she started her tablets. And the minute she stopped, the migraines went away. And about two months later, she said “I haven't had another migraine since.”

DR. TEITELBAUM: The reason I was laughing a bit when you’re talking about that is that I never cease to be amazed how you go in to a doctor and you say, ”I do this, it caused this. I stopped it, it went away. I did it again. It caused this.” “Well, it couldn’t be that!” Of course it can be that. This is what's happening. It's one thing if you just do it once, but if you challenge and rechallenge and challenge the third time and each it does that, then that is a very real thing for you. You put it very well, Mary, you really covered it well. Very often, the excipients, the other things that are in the pills, can trigger sensitivities. But the thing to be aware of is these are common to many different kinds of pills and other things we take. So, it gives us a good breadcrumb trail to follow. “Okay, so what else am I taking that has these excipients?” So, one, using a good compounding pharmacist is a really good way to bypass the whole excipient and additive and filler issue. The Tirosint can do that too. But these simple things of playing your own Sherlock Holmes.

And in my book, the new edition of From Fatigued to Fantastic, there’s a whole large section on “sensitive to everything.” So, if you're always sensitive to the same things, you take that levothyroxine every time. Now you're not going to be allergic to levothyroxine, because your body is making it every day. So, you know you're not allergic to that, you're allergic to the other stuff in the pill, in the Synthroid. But if it's the same thing, then it's food or additive sensitivities. There's a technique called NAET, the acupressure allergy elimination technique. When I first heard it, I said, “voodoo, it’s nonsense.” Until the woman doing it knocked out my hay fever with one 20-minute treatment, my lifelong hay fever went away. And then I was faced with either looking at what was, or falling back on my old medical beliefs with this couldn't work because we don't understand it. I actually flew to California, met the woman who developed the technique who is an MD, PhD, acupuncturist. Came back home and married the woman who had done it on me, I was that impressed. So NAET is a very good way to test for and eliminate the different sensitivities.

MARY SHOMON: There’s also another challenge with generic levothyroxine, as Dr. Passero explains.

DR. PASSERO: Thyroid hormone is very finicky with gastrointestinal absorption. Iron, calcium, certain types of minerals can really bind up the thyroid hormone and prevent it from getting absorbed properly.

Tirosint is still a synthetic T4. It's the same active ingredient that's in Synthroid and that's in every other kind of levothyroxine but it's in a liquid gel cap, so there's no binders, no fillers, no coating agents. Once that gel cap is dissolved, which happens very quickly, there's very little to inhibit the absorption of the T4 that’s in there. So, you get more stable blood levels. You get less variability with allergens like gluten and dairy products and other things that are in there that can actually make people have reactions that they think the medication is not working right. But basically, they're having a reaction to something in the medication that's not making them feel well. So, it kind of levels the playing field a little bit, and simplifies all those other variables that can create problems with thyroid hormone replacement, by putting it in this ultra-pure gel cap that doesn't have any of those ingredients. It's just pure T4. So, it can work a lot better for people.

Levothyroxine is a generic. So, there's going to be all sorts of different companies that make levothyroxine. Synthroid is a brand. So Synthroid is going to be the same every time in regards to its ingredient mixture. It's the same kind of chocolate chip cookie every single time, from the same exact company. They've got their recipe, and they duplicate it every time they produce a batch.

Levothyroxine, it may be different. That's just like going to the store and buying any chocolate chip cookie, and then the next time going and saying, “I want some, I'm going to buy this brand.” Well, if you're always buying them for your kid, you may bring one batch home and your kid says, “Oh, I like this one, Mommy, this one doesn't taste as good as the other one.” And you say, “Well, it's a chocolate chip cookie, so just eat it.” That's the same thing with levothyroxine. You're not being brand-specific. So sometimes people get on levothyroxine and they're feeling good and they're doing well on it, it's important to talk to the pharmacy and ask the pharmacy, “Hey, listen, what brand am I on? And when I asked for my refill, can you make sure that I get the same brand?” Because what the pharmacies do is, they have different distributors, they use all different distributors. And every week or every month when they do their inventory, they just have to order a bunch of drugs in. So, you're getting these different things batch to batch and it can really throw people off. So, it's important with the generics to be consistent.

Adding T3

MARY SHOMON: Doctor Teitelbaum mentioned adding T3 to the traditional levothyroxine as a treatment option, and this is also an approach that Dr. Passero uses, as he explains here.

DR. PASSERO: There are some people that don't get the metabolic stimulus just from taking a synthetic T4. Some people seem to have some issues with conversion. Their enzymes don't seem to convert T4 into T3 very readily. The traditional endocrinology model assumes that T4 hormone replacement is all anybody ever needs, because the body has the enzymatic capabilities to convert that T4 into T3, which theoretically is true. Your thyroid makes four times more T4 than it does T3. But don't forget about that quarter. Your thyroid is still making some natural and some endogenous T3 on a very regular basis. When you switch over to just T4 therapy, you're not paying attention to the fact that there was some endogenous T3 production from your own thyroid. This becomes more of an issue for patients that are looking for thyroid hormone replacement that have had a thyroidectomy or have had radioactive iodine or are very advanced in their thyroid disease, and there's been a long history of autoimmune thyroiditis that can create damage. Those patients have less endogenous thyroid function, so only relying on the T4 therapy misses an important part of basic human physiology: that your thyroid does produce some endogenous T3.

Now in addition, I found that the younger you are as a human being, the better you tolerate standalone T4 therapy, and that's a pretty simple explanation. Enzymes slow down as we get older. So, when we're young and our enzyme activity is very active, it's very easy for the body to convert ample amounts of T4 into T3. Sometimes as you get older, and the enzyme starts slowing down, the T4 therapy isn't as effective at creating at a biological balance of T4 and T3 in your bloodstream and for yourselves.

So, this now introduces the option of using some T3 therapy, because now we're using a combination to try and mimic a little bit more what the natural biological activity of the thyroid does, which is produces some T4, and some T3.

So, adding that T3 in can be helpful and there are several different ways to do it. Cytomel is probably the most common one and that is just T3. So Cytomel works pretty well. The issue with using T3 therapy is that when you take a dose of T3, you get a spike in your bloodstream of the T3 hormone. And if you spike that level too high, too quickly, it can be a little bit overstimulating for people and you have to be careful. So T3 therapy sometimes has to be spaced out through the day. You might take a little dose in the morning, you may take a little dose later in the afternoon, and even some people may take another little dose in the evening. You can't load all your micrograms of T3, all at one time in the day, you can if the dose is pretty low, but if you're somebody that needs a higher dose of T3 for symptom resolution, it becomes a little bit problematic, in my opinion to stack all of your microgram dosage of T3, just at one time of day in the morning for most people. Because you can get this really large spike of T3 in the bloodstream. And then it sort of levels all throughout the day and people can feel good, but that spike can be dangerous.

One way that some doctors try and get around this is they work with a compounding pharmacy and they make something called slow release T3, which is the pharmacy takes that same ingredient T3, but they mix it with slow release compound that that the body takes a while to digest. So theoretically, it mirrors a little bit more what the body does physiologically, where the body gets T3 from the little teeny bit that's trickling out of the thyroid throughout the day, but also it can convert the T4 on demand throughout the day.

The Adrenals

MARY SHOMON: Any discussion of integrative approaches to hypothyroidism is not complete without at least mentioning the adrenals. I discussed this with Dr. Teitelbaum.

Let's talk a little bit about the adrenals. Because we have a lot of thyroid patients that go to see doctors who “get it,” and they get to a place where they're feeling better. Their levels are looking good in terms of optimized, versus just somewhere in the reference range. But they still are finding that they're crashing in the afternoon or they have a difficult time getting up in the morning. Or, one of my favorites is, they are tired during the day, but at about 10 or 11 o'clock at night, it's like time to go party, or they're waking up at 2 and 3 in the morning and can't go back to sleep. It's like their schedule is upside down and the body doesn't know when it's supposed to be energized and when it's supposed to be at rest. And my sense with those patients is we may be talking about some adrenal issues that are complicating their thyroid issue. And this is one of your areas of expertise. So, can you explain a little bit to us what might be going on?

DR. TEITELBAUM: The adrenals are like the body's stress handler. And the very simple way to tell if you have inadequate adrenal function, and again, for that, it's not enough to be in the lowest 2 1/2 % of the population to be abnormal. It has to be so low on the blood test that it is life-threatening. It's funny, most people run a cortisol of 18 in the morning, and anything under 6 is considered adrenal insufficiency, potentially. Now, the funny thing with the test is I've had a number of people who accidentally had the lab run the cortisol level twice on the same tube of blood on the same person, and they are routinely about 4 points apart on the two tests. It’s not that accurate. 6.1: totally healthy, no problem even if you're bedridden, and 5.9, life threatening. It's insane. So, I'm going to give you a very high-tech way to tell if you need adrenal support. Ask the people around you, “Do you get irritable when hungry?” The term has been coined “hangry.” Irritable when hungry. If you do, you need adrenal support, period. It's that simple. You'll also see things like low blood pressure, recurrent infections that take forever to go away. If you’re in marriage counseling or a divorce lawyer, there's a very good chance that one of the two of you has adrenal fatigue, which causes that irritability and creates havoc in the relationship

I’ll tell you, treating the adrenal is very, very easy. I like a mix called Adrenaplex, which smooths out the adrenals very nicely. There's another wonderful thing for those of you who have low energy is especially with thyroid or adrenal, there's a mix of six nutrients, combined in something called the Smart Energy System, and that supports adrenals, but also improves production and conversion of thyroid hormone. So, the Smart Energy System…very, very helpful. And you talk about people who are wide awake at bedtime because their day-night cycles have shifted. Morning cortisol is normally 18. Normally less than 2 at bedtime, so you can sleep. So, you may find that during the daytime, it's down at 8 in the morning and up at 3 at nighttime. And the way that you tell if that’s going on is that your mind is wide awake, and racing at bedtime. Tired all day, tired all day, tired all day and then wide awake. And like you say, for some people, it’s the only four hours a day of function they have is at 10 pm to 2 am. So, you can either roll with up and keep your day-night cycle and use that time, which for some people I just have them do that. But for those who need to be on a same schedule as the rest of the planet, taking phosphatidyl serine. Easy to find on Amazon, 100 to 200 milligrams, 60 to 90 minutes before bedtime, will bring down the cortisol level. So, you can fall asleep, get to sleep and start shifting your day-night cycle back to the rest of your friends and family.

MARY SHOMON: Here's a question about adrenals, because you mentioned Adrenaplex, the Smart Energy System, phosphatidyl serine. And in the past, a lot of the functional medicine and integrative physicians would say to us, “Hey, adrenal management is not a do-it-yourself project. This is something you really should do with a knowledgeable practitioner.” Do you feel like with guidance of a book or information from you, can we do this ourselves or is it really something we should be doing with a practitioner?

DR. TEITELBAUM: If you can afford and find a good holistic practitioner -- the Institute of Functional Medicine is one way -- because we go to regular doctor and say “adrenal fatigue,” they'll look at you like you're wearing a little aluminum foil hat or something, you know? Of course you can begin this on our own. And the things like the Adrenaplex, the Smart Energy System, those two together can dramatically help adrenal function. Increasing salt, cutting back sugar can dramatically help adrenal function. So, it's not a matter of can you do it on your own. Of course, you can begin it that way. But what do you do then, if it's not enough? There are some people who will need the prescription bioidentical cortisone, not prednisone, but cortisone. And in those cases of a prescription, you do need to be working with somebody else. So, if the simple answer to that is if you could do it on your own, and it works, that's great. And if it doesn't, then find somebody to help you just like anything else.

Finding the Right Doctor

MARY SHOMON: There are about a dozen integrative and naturopathic doctors I can name off the top of my head who have consistently been at the forefront in treating hypothyroidism. Both Dr. Teitelbaum and Dr. Passero are among them. But since they can’t treat everyone, I asked them for their recommendations for all the thyroid patients who are struggling to feel well, and who are trying to find the right practitioner to help them manage their thyroid condition. Here’s Dr. Teitelbaum’s advice:

DR. TEITELBAUM: Look for somebody who does complementary medicine, and that’s the bottom line. I treat people from all over the world and often by phone. But if you simply go to the IFM website, or in states where naturopathy is allowed,, to find a naturopath, decent ones who are much, much, much more likely that they know what to do instead of you're going in with my book, From Fatigued to Fantastic and saying, “Would you do this?” And the doctor’s looking at you cross-eyed. Most non-holistically trained doctors just don't know this stuff. They've been misinformed. They've been miseducated. So, do you want to go find somebody that you can train to do your heart surgery or do you want to go to somebody who knows what they're doing? Go to a holistic physician.

The problem is most holistic physicians -- because insurance will not pay for holistic medicine or time -- can't participate with insurance and that's a problem. So, in that situation, then, a doctor you’ve known for a long time, if you ask him for just one thing at a time, they may do it. But then if they won't, then make an appointment with a holistic doctor. You may need to focus them, because being holistic, we're going to want to treat the whole thing. And that could get more expensive. So, you may just say, “Well, I just want to treat the thyroid.” And can we just focus on that, and hopefully get the cost down.

MARY SHOMON: I have interviewed a number of patients in the last two weeks and at least two of them said to me, “If I knew what I know now, after in some cases, 15, 20 years of running around to different doctors, different approaches, different treatments, I would have realized that it was worth it to jump out of my HMO or my health insurance and pay to see someone who had an integrative, functional medicine approach and get this under control at the start. Because honestly, both of them said, “I would have saved myself thousands of dollars -- and years of fatigue and exhaustion and not getting the right treatment -- had I just gone ahead and seen someone that knew what they were doing right from the start.”

DR. TEITELBAUM: If your transmission dies, you're not going to wait for your HMO to pay for it. You’re going to go to the car shop and go ahead and take care of it. People will do that for the car, but they won't do it for themselves.

MARY SHOMON: Dr. Passero also has guidance on some next steps that patients can take in getting on track to feeling and living well.

In a perfect world, you'd be able to treat all of the frustrated thyroid patients out there. And they would be getting that sort of personalized attention and listening and compassion. But everybody can't come to see Dr. Kevin Passero. So what would you advise to those patients out there who do feel like they're being gas lit by the medical world or being told “It's in your head and your problem’s not your thyroid, and this has nothing to do with anything, and go take an antidepressant and an anti-cholesterol drug and get off the couch and eat less and exercise more, and everything is going to be fine then and come back in a year?” What do you tell those patients? And can you give them some guidance on some next steps that they can take in their own area?

DR. PASSERO: Certainly, being educated and being your own advocate, that's where I think patients do the best. So that's the work that you've committed your life's work to is really educating people. And if you're really educated on the matters, you can really direct and dictate the terms of your care in a much better way. Patients that are better educated are always better advocates for themselves and usually always have better outcomes in their care.

If you're still really struggling with finding somebody that can actually regulate that whole medication side of it, and that only a doctor can do, you have a huge amount of tools that you can use, that don't require any doctors and that has to do with lifestyle. There are wonderful websites and books and everything that is all about advocacy for thyroid patients that doesn't even necessarily talk about just the hormone replacement component of it. It talks about low inflammatory diets, low-sugar diets, how to get your GI system balanced out, how to reduce some inflammation associated with the autoimmune condition, different nutrients that are important for the thyroid, different ways to help regulate your sleep and regulate your stress. And if you start pulling the levers on all these other aspects of your health and wellness, you can significantly improve some of your symptoms. Now, you may only get 50% better and I agree that that's not acceptable, but at least it's a step in the right direction to start reclaiming your health for yourself while you're trying to find other solutions to get you the rest of your way.

Closing Advice

MARY SHOMON: To wrap up, here is some advice from both doctors that you’ll want to take away from their interviews, starting with Dr. Teitelbaum:

DR. TEITELBAUM: I'm going to go back to saying a very simple statement: Listen to your body. How is that working out for you? How does it feel when you take it? If you're taking these things and you feel better, your body is saying “Thank you, I want this.” If it feels worse, it’s saying, “No thank you. I don't want that.” So, it's just like trying on shoes. Say you had to figure out a shoe size on your own. Say I’m a 12, and I put on a size 10, it would feel tight, 11 better, but still tight. 12 feels just fine, a 13 is falling off my foot. I'm listening to what my body is saying and I get a size 12 shoe. You can do the same here.

MARY SHOMON: And Dr. Passero leaves us with a call to action.

DR. PASSERO: People, once they start diving into this world, it's very empowering. And oftentimes, Mary, as you know, being an advocate and educating people. that patients end up actually driving their own care in many of these situations in educating their doctors about this is what I need. And through that process, they actually get an amazing improved quality of life. Being passive and waiting for the right solution to find you in life doesn't really work for any area of life. Everything in life, if you want to be successful at it takes some drive, some passion, some digging. It's very rare that the best things in life just land in your lap. A lot of times you have to work at it, and it's going to be the same thing in this situation. The more actively you're engaged, the more you're trying to control the situation through educating yourself and really advocating for yourself usually the better outcomes you have.

MARY SHOMON: I want to thank my guests, Dr. Jacob Teitelbaum and Dr. Kevin Passero, for sharing their thoughts on integrative and naturopathic approaches to hypothyroidism diagnosis and treatment in this episode. You'll hear much more from both doctors in upcoming episodes of The Thyroid Deep Dive, where we dive into nutrition, lifestyle, sleep, and other factors that affect your hypothyroidism.

If you listened to Part One of this two-part episode, you heard a rather different perspective, from the conventional endocrinology world. As you can see, these two roads DO diverge, and in the end, it's up to you to choose which road to travel.

Here's my perspective: The BEST road is truly the road that safely and rapidly gets you where you want to go. Keep listening to the Thyroid Deep Dive podcast, because my goal is to help you to finally find YOUR road to living and feeling well with hypothyroidism. You can subscribe at all your favorite podcast platforms.

More information, a complete transcript of this episode, and helpful resources and links, are all available at the website,

This is Mary Shomon, and I want to thank you for listening to the Thyroid Deep Dive. Today, and every day, may you feel well and live well.


Resources and Links

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