Understanding and Diagnosing Hashimoto’s and Hypothyroidism
A lot of us at goop have thyroids that are on the fritz. And a lot of us have found navigating treatment for the autoimmune disease Hashimoto’s thyroiditis, the most common cause of hypothyroidism in the US, to be a fairly complex challenge—despite the disease being relatively simple to diagnose.
LA-based endocrinologist Theodore Friedman, MD, PhD, has a private practice in Beverly Hills, where he takes forty-five-minute appointments with patients one night a week. (The rest of his time is spent researching and working at an LA County clinic for patients with diabetes and thyroid disease who need care.)
About a third of Dr. Friedman’s new patients every week have Hashimoto’s. “Patients with more challenging endocrine problems come to see me from across the country. They’ve usually been to their local endocrinologist, who often blows off their symptoms,” he says. “I try to dig a little deeper into what’s going on with them, and I try to come up with both diagnoses and treatments that really get them to feel better.”
A Q&A with Theodore Friedman, MD, PhD
Hashimoto was a Japanese endocrinologist who first described the disorder in the early twentieth century: It’s an autoimmune disease where you have antibodies attacking your thyroid gland.
Hashimoto’s hypothyroidism is when the thyroid gland, as it’s attacked over time, becomes hypothyroid—meaning the thyroid is underactive and can’t make enough thyroid hormone. That’s not always the result; the antibodies can be sort of mild, so you can have Hashimoto’s without having hypothyroidism.
I see about seven patients a week in my private practice. About two or three have hypothyroidism. Of those patients who were told they have hypothyroidism, and I find that they don’t have Hashimoto’s, I usually question whether they have been correctly diagnosed with hypothyroidism. Most hypothyroidism, if it’s properly diagnosed, is Hashimoto’s hypothyroidism.
I always say: I spend half my time putting people on thyroid medicine because they are not on it and should be. The other half of my time is taking people off thyroid medicine because they’ve been put on it inappropriately and shouldn’t be on it. The trick is to not assume that everyone has a thyroid problem—because not everyone does—and get the right person on the right treatment.
A Hashimoto’s diagnosis is currently based on the presence of an antibody called the thyroid peroxidase antibody. When you get a TPO blood test, the level of antibodies present can vary significantly. Looking at how high the TPO antibodies are is somewhat helpful in determining diagnosis and treatment.
About 10 percent of the people who have hypothyroidism and Hashimoto’s test negative for antibodies. They are harder to figure out, but they often have an ultrasound characteristic of Hashimoto’s, where the gland looks hypervascular and heterogeneous. Often I get an ultrasound to confirm the case if I’m very suspicious of Hashimoto’s and the antibody test is negative.
Certainly, an elevated level of thyroid stimulating hormone causes me to be suspicious that the patient is hypothyroid. The TPO test is especially useful for those with borderline elevated TSH. Somebody who has a TSH of 10 certainly has hypothyroidism and needs to be on thyroid medication, regardless. Somebody who has a TSH of 1.5 is not hypothyroid, and it might not be that important to measure the antibodies, although you might. But for someone who has a TSH around 5, measuring the antibody can help determine whether or not to put someone on thyroid medication. In that case, I’d put them on medication if the antibody test is positive and not put them on the medicine if the antibody is negative.
Symptoms of hypothyroidism can include fatigue, weight gain or inability to lose weight, dry skin, dry hair, irritability, poor sleep. There’s a concept that’s very interesting to consider: Do people with Hashimoto’s and hypothyroidism have more symptoms or different types of symptoms than people who just have hypothyroidism that’s not caused by Hashimoto’s? I believe that’s the case. A very interesting article came out a few months ago: They did thyroidectomies on patients that had Hashimoto’s. These were people who were properly treated with levothyroxine, and they were doing okay biochemically, but they weren’t feeling well. The thyroidectomy—removing the thyroid—actually improved their symptoms. That gave an indication that there’s something about the thyroid of people with Hashimoto’s that even if their blood tests are normalized, they still have symptoms.
We start by treating the underlying hypothyroidism. The majority of Americans who are hypothyroid are prescribed levothyroxine, a drug that provides thyroid hormone to treat the underactive thyroid. I’d say in 80 percent of people it works well. In about 15 to 20 percent of people it doesn’t work well.
The thyroid gland makes both T4 and T3, and levothyroxine is just T4. The thyroid gland makes about 85 percent T4 and about 15 percent T3, which it converts from T4. You’re hoping that by prescribing levothyroxine, by giving 100 percent T4, you’re going to get the extra conversion of T3 in the body. And some people don’t do the conversion properly.
People often come to me on T4 and are not feeling well. I either put them on a T4/T3 combination prescription or put them on a brand of desiccated thyroid. Those medications have both T4 and T3, and people often do better on that than on the straight T4. In my experience, people with Hashimoto’s may need the desiccated thyroid in the T4/T3 combination, and hypothyroid people without Hashimoto’s may not.
Yes, I do. In medicine, the better your lifestyle, the more likely you are to do well. I think stress reduction is crucial, along with a clean diet with not many preservatives and processed foods. Get away from things that have whiteness in them—white flour, sugar, cakes, cookies, candy. Try to eat mostly vegetables and fruit.
I encourage exercise. Everyone needs exercise, but for people with thyroid disease it is crucial.
Can you change the Hashimoto’s with lifestyle changes? Can you decrease the antibodies? It’s interesting, and I don’t have an answer, but an absence of answers is my answer. There are providers who claim they can reverse it with lifestyle changes, but there are no studies on reversing Hashimoto’s with lifestyle changes, so I am sort of dubious about whether it works. Having a clean lifestyle helps you, but I don’t know if it reverses the disease or is a substitute for thyroid medicine. Certainly having a clean, healthy diet; exercising; and reducing stress are all good factors that allow your body to work the best it can.
Some of them I put on thyroid medicine anyway. It depends how many symptoms they have, where their TSH is, and whether they have already tried lifestyle changes and those haven’t helped. If their TSH is like 2.5 or 3, and they have a lot of symptoms that aren’t getting better, I would try thyroid medicine.
Doctors sometimes see patients who come in and are sluggish and can’t lose weight, and they’ll jump and put them on thyroid medicine, maybe without testing for that TPO antibody. If the patient does better on it, I’m reluctant to take them off.
But if they’re not doing better, or maybe they’re doing worse, I usually try to take them off. A healthy thyroid gland makes the correct ratio of T4 and T3, at the correct time of day. So it’s better for a patient to be off thyroid medicine if their own thyroid is working. If when I test them for TPO antibody, it’s negative, and they’re not doing better on thyroid medicine, I taper them off the thyroid medicine and see how they do off of it. I try to find the true underlying cause.
There is that 80 or 85 percent of people on levothyroxine who are doing fine and going to their primary doctor. In my job taking care of underserved patients, I see a lot of people who are doing pretty well on levothyroxine. The 15 or 20 percent of people who are not doing very well are the patients you specifically need to make the extra effort to try to help. Those people often need very fine adjustments to their dose. Patients don’t do well on either too much or too little of the thyroid medicine—you have to find the sweet spot where the levels look good and their symptoms look good. You need to find a dose where they don’t have the hypo symptoms of fatigue and sluggishness and slow reflexes and hair loss—things like that. It often requires a little bit of trial and error, substituting one medicine for another one until you find one that’s helpful.
Patients often need to be vocal and be their own advocates. I say: Push for getting your TPO antibodies measured, push for nontraditional treatments if you aren’t doing well on your traditional treatment. Talk to doctors about TPO antibodies, especially if you are that borderline case. Bring the journal article that shows the efficacy of desiccated thyroid medication. Sometimes doctors just don’t like to treat with desiccated thyroid, or they don’t like to treat until the patient has severe disease. All of those things make it difficult for the patient to be a good advocate, and sometimes, they may have to find a different doctor.
Theodore C. Friedman, MD, PhD, is a professor of medicine at Charles R. Drew University of Medicine and Science and at UCLA. He is the lead physician in endocrinology at the Martin Luther King, Jr. Outpatient Center in Los Angeles. He has a private practice in Los Angeles, specializing in treating patients with adrenal, pituitary, thyroid, and fatigue disorders. His practice includes detecting and treating hormone imbalances, including hormone replacement therapy. Dr. Friedman is also an expert in diagnosing and treating pituitary disorders, including Cushing’s disease and syndrome. You can find out more about Dr. Friedman and schedule an appointment here.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.