Episode 37: Is It Your Thyroid? Hashimoto’s & Hypothyroidism Explained: What You Need to Know, with Dr. Kyle Rosenstein

Is your thyroid holding you back? Endocrinologist Dr. Kyle Rosenstein joins us to explain the signs of hypothyroidism, what Hashimoto’s really means, and why thyroid lab testing isn’t one-size-fits-all. We also dive into how and when to take thyroid medications  (hint: don’t take it with your morning coffee) and what to know if you’re dealing with multiple autoimmune conditions. If you’ve been wondering whether your symptoms are thyroid-related, this episode is for you. 

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specific individual’s medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis or treatment. This podcast does not create a physician- patient relationship and is not a substitute for professional medical advice, diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Transcript

[00:00:00] Before we start today's episode, I would like to quickly read you our podcast disclaimer. The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis, or treatment.

This podcast does not create a physician patient relationship and it's not a substitute for professional medical advice, diagnosis, or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different, so make sure you consult your own healthcare professional before seeking any new treatment.

And before you alter, suspend, or initiate a new change in your routine.

Welcome to the starting gate. We're your host, Dr. Kitty Dotson and Dr. Sarah Schuetz, two internal medicine doctors who spent years practicing traditional primary care. Over time, we realized something was missing from modern healthcare, a [00:01:00] real understanding of how everyday lifestyle choices impact overall health.

We will help you cut through the noise of the countless health influencers and their conflicting opinions because no matter who you follow, the basics of lifestyle medicine are at the heart of it all. 

Welcome to the starting gate. We're your host, Dr. Kitty Dotson and Dr. 

Sarah Shuetz. 

Hopefully you're making it through summer with your kids and leaning into all those tips that we got from Dr. Sarah O'Leary. But today we are gonna switch focus into a condition that affects millions of people, me included, and many of whom don't even know that they have it, and that is hypothyroidism.

Many women will experience vague symptoms like fatigue, weight gain, hair loss, and are unsure if it's their thyroid to blame. So this is a common question. I know Kitty and I both had this question so much in primary care because when we don't feel well, we're trying to find answers. And the thyroid is something that typically gets blamed a lot.

 So today we really want to talk about what do symptoms look like? What are other conditions [00:02:00] that can mimic these symptoms? Because many patients get frustrated once they have the workup and are found not to have hypothyroidism, but they still have all these symptoms and know where to turn talking about actual testing and what treatment can look like.

This is a very popular topic on social media. So this can get confusing for many patients as well because they're getting different advice from their doctor than what they may see from many popular social media accounts. So we brought an expert in today and I'm super excited to have a friend of mine.

come in and be our guest. We have Dr. Kyle Rosenstein, who is board certified in internal medicine and endocrinology and works here locally at Baptist Health. We are so excited to have you. Kyle, can you introduce yourself to our listeners and tell us why you ended up in endocrinology? 

Absolutely.

It's good to be with you y'all today. Like Sarah said, I'm Kyle Rosenstein. I work at Baptist here in Lexington. . Endocrinology was something that I started to think about probably halfway through my residency. , I gravitated towards it because it was primarily [00:03:00] outpatient based and a lot of these patients were having a lot of symptoms and it's nice to be able to get labs to evaluate them.

And then there's also good treatments for 'em. So I think there's not a. Ton of conditions where you have symptoms and labs and treatments that all line up together.

But yeah, that's what brought me into it. And thyroid is just one of the conditions that we treat. We also see a lot of diabetes adrenal disease other pituitary hormone diseases. And so it's a good mix 

and I wanted Kyle to do this show with us because I think he's a fabulous teacher still to this day.

I will text him with questions when I need help when it comes to the endocrine system. So we want to bring that knowledge to our listeners today. To get us started talking about thyroid disease, we wanna spend most of our time talking about hypothyroidism, but we think it would be best if you could define for our listeners what is hypothyroidism versus hyperthyroidism, just to get an understanding of what disease conditions can our thyroid cause.

Yeah. So hypothyroidism is a condition [00:04:00] of sustained low thyroid levels. Whereas hyperthyroidism. Or more generally speaking, is thyroid. Toxicosis would be a condition of elevated thyroid levels. These conditions can be transient or permanent depending on the cause. So that's one thing to, to keep in mind.

But when we're talking about hypothyroidism today, I assume we're talking about the more permanent form, not the thyroiditis that you can have thyroid toxicosis followed by lower levels that usually resolves itself.

And then when it comes to symptoms, what does a patient with hyperthyroidism. Present 

It's somewhat non-specific, I feel like more and more I'm catching people earlier. Maybe 20 years ago checking a TSH wasn't as common practice as it is now. But I feel like more commonly for many non-specific symptoms, people are checking thyroid labs.

Probably just as the prevalence of the disease has increased. And then as more and more people are talking about it, they sometimes request those labs. But anything from fatigue, cold intolerance, you can have some weight gain constipation, [00:05:00] dry skin, some menstrual irregularities depression, brain fog.

And then in the elderly, those symptoms can be a little bit more muted. As subtle as just mood change in depression and the elderly can be consistent with hypothyroidism 

and even we see it with mild cognitive impairment. Yeah. In, in that sense. Now, the flip side, what would someone that has an overactive.

Thyroid look like. 

Sure. Sometimes this also depends on the degree of elevation of thyroid hormone, but heat intolerance, tremor, palpitations, anxiety some people lose weight, not everybody. More frequent bowel movements. I would say one of the more common things I see is just exercise intolerance.

People say they're walking up a flight of stairs and their can't catch their breath, or they feel like their heart's pounding in their chest. That's pretty common. I think some of the more classic symptoms, I would say I rarely see just because people are detected so much sooner, but you certainly can see it.

Yeah. Palpitations and anxiety I think were what cued me in on, on most of the patients I saw with that. But. Just listening to you and, just hearing all of these symptoms are very [00:06:00] vague and all of these symptoms can be symptoms of other things as well. So that's why thyroid can be a little confusing because a lot of these symptoms can go with different disease states.

But the good thing is it is pretty easy to look into. And I agree. I think doctors are thinking about thyroid disease more often now and just going ahead and testing for it, 

 When it comes to hypothyroidism. And that's what we're gonna spend the rest of our time. So thinking about those symptoms that you had mentioned and how common they are, how many times we hear complaints of fatigue or weight gain, constipation mood symptoms.

That is so much of what we see in primary care, and I know that patients feel very frustrated, right? When they're like, I can check all these boxes of all the symptoms you just listed off, why is my thyroid normal? Is there something else going on? Are we not doing the right test? What kind of explanation do you usually give to patients that may fall in that [00:07:00] bucket?

Like you said, there's a lot of, I would say, things that it can mimic. There are other conditions that you need to rule out, whether it's iron deficiency, anemias that can cause fatigue menopause syndrome. Sleep apnea, that's undiagnosed, untreated is a big one. Depression. And so I think the first thing is you need to make sure you have the right diagnosis, and that's what the labs try to help find out.

So if your labs are persistently normal or your primary provider's telling you that they don't see any abnormalities, I think it would be a good idea to take a deeper dive into some of the other potential causes to, to see if there's something that's being missed or overlooked. A lot of the people I see with fatigue, weight gain brain fog, if you just start with some of the basics are you sleeping?

Are you actually getting good sleep? Do you have sleep apnea that's not been checked or tested for? Do you have risk factors for sleep apnea? Maybe a sleep study would be a good place to start. And then looking at diet and lifestyle, I see a lot of people that wake up in the morning, tired, have a bunch of caffeine to get going, don't really eat healthy during the day, [00:08:00] don't get a lot of structured physical activity.

They're on their phones late at night and go to bed late, and then they're wondering why they're tired, gaining weight, having brain fog, and unfortunately for a lot of those, or maybe fortunately it's not their thyroid but there's a lot of things that need to go into ruling that out once you have a consistent level of normal labs for your thyroid.

And that's definitely something I hate because many patients, they have these symptoms. Maybe their thyroid's checked, they may even not get an evaluation for some of these other concerns, or there's just not any tips on what to do with their lifestyle to see how they can feel better. So one thing we definitely want people to feel like is, even if it's not your thyroid, that doesn't mean you should stop looking for answers.

Yeah. Definitely. Don't stop. But don't be afraid to stop and look at. You know how you're living your life during the day. I can tell you I have had hypothyroidism for 20 years now, and. The fatigue and brain fog I was experiencing at the [00:09:00] time did not go away. When I started my medication and fixed my thyroid numbers.

Some of the muscle symptoms that I was having did go away, but that was because the fatigue I was having was due to residency, not sleeping, not eating well, and not taking care of myself. And so really what's helped more with those symptoms for me over these years has not been thyroid medicine, but has been taking better care of myself.

So whether or not you have thyroid disease , you definitely need to do these lifestyle things that we talk about so you can see how much is this and how much is this? 

And another patient population that I think we're finally doing better with that would come to the doctor worried about their thyroid.

A lot was women in that perimenopause state or in menopause or having all the symptoms of thyroid disease. and it actually was just the fact that they were in perimenopause. But we're getting better. And if you haven't listened to our show about that, be sure to check it out because we go into great detail about all those symptoms and how it can be appropriately [00:10:00] managed As we're going through all this, we just want to be sure that we touched on this as well, so you don't feel left hanging if it ends up not being your thyroid. We want you to continue pursuing additional things and working on lifestyle factors to see if you can reclaim your health. 

 if you do go to your doctor with most of these symptoms or any of these symptoms, what they may run is something called A TSH.

And so Kyle, can you take us through what is A TSH? Why is that the first test we run and what happens from there? 

Sure. I guess just to get started the thyroid has a pretty good feedback mechanism. And so the TSH is a thyroid stimulating hormone made by the pituitary gland. That hormone then goes and signals your thyroid to make more thyroid hormone, and as more thyroid hormone is made the TSH comes down to, to lower itself.

So one of the biggest questions I get is my TSH is high. I thought you said my thyroid levels are low. It's that inverse relationship there. It's a very good test. [00:11:00] I related to like my kids doing their chores. If the chores are getting done, I don't need to figure out who's doing what or not doing what, because I see they're getting done.

The TSH is good at looking at the additional tests like the T 4 and T 3. And so I think as much as I might get pushback from other people, I think that's probably one of the best screening tests that you can get for your thyroid levels. Now there are obviously additional tests that you can check for your thyroid.

The T four, T three and there are some other more exotic ones as well. But I think overall for someone with I would say some non-specific symptoms that is curious to know if their thyroid is working or not. Working A TSH is a great starting point. 

And how do you get your kids to do the chores?

It's a work in progress. 

So when it comes to TSH, let's say, and I think this is where it can get a little muddy, is you do come back with an abnormal TSH. Where do [00:12:00] you go from there in trying to figure out what's going on? 

So I would say a lot of it's the degree of abnormality. Depending on the lab assay that's used, there's various different lab assays that are available.

But the general normal range would probably be somewhere around 0.5 to 4.5 for the TSH. But I would say if it's pretty close to within that area I would look back at the symptoms that the patient's having. I would see if there's any other known pituitary conditions or any risk factors.

We see a lot of people on immunotherapy. And so that can have an impact on your thyroid. Or if they have other pituitary disease like you're doing workup for amenorrhea or something like that where you have suspicion that there could be other pituitary issues, then I might do some additional testing there.

If your TSH is completely suppressed and you have symptoms that are consistent with thyroid toxicosis, then I would certainly grab additional labs. The free T four and a total T three would be appropriate at that point, along with some antibody testing to look for [00:13:00] graves disease. If the TSH is very elevated and they have classic features of hypothyroidism, then I probably would also check a free T four.

And I would check a TPO antibody, although that's could potentially be up for debate 

and TPO antibody is to look at Hashimoto's thyroiditis, which is the most common form of having low thyroid function, right? 

Correct. So I guess it becomes a little bit academic. I, if you're going to treat it the same anyways.

Do you want to pay the extra money to get that test? If you have a persistent elevation of your TSH and low T four, you're probably gonna end up on treatment long term. Some people want a diagnosis. TPO antibodies, the most common antibody with Hashimoto's, although you can't have antibody negative.

So like I said, I like to get it just from an academic standpoint, but some people won't and that's probably okay. And I 

think it's important for patients to understand is the fact that depending on where you pick up their, [00:14:00] progression of their Hashimoto's, things just look different. And that's where the antibody can be helpful if you're catching it super early versus later.

Yeah. So I always I guess I'm very lucky to practice in a time with medical records. So I almost always see somebody after they've seen at least one, probably more than one provider. And so I have years worth of lab data that I can usually see the trend see what their TSH has done over the years.

And so that, that's very helpful. Now if I see someone early on there are some findings that are suggestive of Hashimoto's with a potentially normal TSH, so that would be managed differently depending on each patient. 

And so let's say somebody comes in, they do have an elevated TSH, meaning their thyroid function is low.

You do a TPO antibody and it is positive. And so you've diagnosed them with hypothyroidism secondary to Hashimoto's. Is there any benefit of continuing to monitor that TPO [00:15:00] antibody over time? Or at that point, are you just going by their thyroid levels and symptoms? 

Yeah, that's a question I get a lot.

I don't typically repeat it again. We know just like other autoimmune conditions, you can have flares in your symptoms and antibodies. Ultimately it doesn't really change management for Hashimoto's hypothyroidism. So I don't see a need to repeat it 

You're going to be treating the thyroid and make sure it's optimal regardless of what the antibody 

is cor correct. Yeah. And it's not like in another condition where suppressing the immune system to lower those antibodies is gonna be beneficial just because the risk of immunosuppression doesn't really outweigh the benefit when you can replace the thyroid hormone.

So if you have this positive number and you're worried what are my levels doing? Do I need to be worried about that? Basically we don't do anything about the antibody level specifically. It's really just treating the effect of having those, the effect that it has on the thyroid and that antibody level [00:16:00] could change day to day.

So it's not a linear relationship of how high your antibody level is and how low your thyroid function is. And so that's why your Dr. May not be checking it consistently like they are with checking your TSH. And your T four if needed. Yeah, and just 

to follow up on that, there are a lot of people that have their TPO antibodies checked with a normal TSH and a lot of the population is gonna have elevated TPO antibodies.

Those people are at risk for developing hypothyroidism but they could go a whole life without developing it. So for those patients, I would generally recommend just checking a TSH annually with like their annual set of labs or with other unexplained changes in their health. 

And there's another population that is a little bit unique with positive TPO antibodies, and that's pregnant patients who may have normal thyroids.

 What kind of difference? Do you actually use for interpretation of those patients? 

Yeah it increases the risk of miscarriage for having TPO [00:17:00] antibodies, particularly if your TSH is above 2.5. So for women who are in their childbearing age I do treat them with thyroid hormone replacement.

If their TSH is above 2.5 and they have TPO antibodies and treatment for that would be with T four monotherapy. 

And that's mostly just the difference in , what our body needs from, our thyroid when we're pregnant. 

 Thyroid hormone demand increases with pregnancy and having low thyroid levels maternal thyroid levels has poor outcomes with the fetus.

So 

Our body just doesn't tolerate the fluctuations as much. And it's also important for people who have hypothyroidism when they're pregnant to have very close monitoring of their thyroid as well. Because of that. 

Yes. 

 Then there is another antibody that sometimes people check with low thyroid.

Can you just touch on that and what is that and is that ever indicated? 

, Are you referring to thyroglobulin antibody, yeah. Yeah. So the only time I really monitor that is with people who have a history of thyroid [00:18:00] cancer. Generally speaking for risk stratification of the.

An otherwise healthy patient or a patient who has hyper or hypothyroidism? I don't see much utility in checking that. , It's on several panels, so it happens. I frequently see it. But from a practical standpoint I use it for thyroid cancer monitoring. 

Yeah, it is definitely on a lot of the , thyroid panels that people have.

And so I would see a lot of times people coming in that had normal thyroid, but it had one of these panels and had a thyroid globulin, positive antibody and no history of thyroid cancer. Does that person need to be concerned? Does that person need to continue to follow that level? 

No, I look at it from a standpoint of people who have had, a thyroidectomy or their thyroid removed for treatment of thyroid cancer.

If you start seeing antibodies directed towards the thyrogolbulin, then you would be more concerned that there are lingering cells that are producing thyroglobulin So from a monitoring of someone who has an otherwise healthy thyroid gland, I don't [00:19:00] see a utility in checking it or monitoring it.

Or if you find that you have an elevated thyroglobulin antibody. You don't need to get any additional testing 

because that is not associated with Hashimoto's. 

No, I think that's reassuring. 'cause a lot of people get really scared if they have had that tested and they see it positive and then , they look it up online and see this association with thyroid cancer and it can be really alarming for people.

So I think that's really reassuring to hear. 

Other things that can come on these panels that can be very confusing even for physicians is sometimes you'll see that there are multiple types of free T three testing. When is that ever helpful 

or total? It may, you may say total. Total or free. Free or reverse.

Can you explain those to us? Sure. 

Your thyroid hormone in the periphery is bound to a lot of different proteins that circulate, and , depending on the amount of protein that you have your total amount of thyroid hormone can vary quite a lot. So for instance, women who are pregnant have an [00:20:00] increased amount of binding proteins, and so their total thyroid hormone is going to be elevated.

Patients who have thyroid dysfunction can also have a different amount of total thyroid protein because of their binding globulins. And so the free the free T four, the free T three are newer. They've probably been around for decades now, but newer than the total assays that look at the more active form of the thyroid hormone.

And so typically speaking now the main labs that I would look at is a free T four over a total T four. The free T three you can use. It's not as, good of a lab assay. So I typically look at a total T three over that. I think as long as you're knowing what you're looking for, when you order them, you can interpret them correctly.

And I think that's part of the problem is sometimes these are just like a shotgun workup, all the labs are obtained and then one's off. But if you don't know why you got it to begin with, then it's really hard to interpret. 

Yeah, for people who have [00:21:00] hypothyroidism, we would look at the TSH.

If it's elevated, then we would look at the free or total T four preferred, the free T four for those types of people, we really don't get into looking at the T three unless it's for cases of hyperthyroidism with like T three toxicosis. But more and more people are having them monitored and checked, so I.

If you ever have questions you can talk to your primary care doctor or endocrinologist. 

Yes I agree with that, and I think. Maybe one thing that could help is understanding the relationship between T three and T four for our listeners, because I think that helps people understand why maybe you don't need both.

Yeah. So I guess starting from the basics, thyroid hormone is a life sustaining hormone. There's very few of these hormones that we have, cortisol, life sustaining hormone thyroid hormones, a life sustaining hormone. Many of the other hormones that we make. Are very important.

But if you were to remove them, say, testosterone in a man, , they're not going to die. And I think once you understand that the thyroid makes and stores a lot of thyroid [00:22:00] hormone and it predominantly makes T four hormone and it's based on the amount of iodine molecules that are bound to the protein.

 And so it predominantly makes T four, which is a less active form of the thyroid hormone because if you have too much thyroid hormone as we said from the introduction, you can have a lot of symptoms that can be dangerous. And so in the periphery, primarily the T four gets converted to the more active form of T three, which has the end organ effect.

And that's done through a series of enzymes in the periphery. 

And so basically your thyroid's got this large store of T four to use as it needs. And based on the stressors or different things going on throughout your day, it will convert however much it needs of the storage form to the active form.

And that could vary throughout the day and what you're doing. 

Correct. So you have, t four and T three, but primarily T four. That's circulating and on an as needed basis, you're able to pretty quickly shuttle that T four to T three to use. And so [00:23:00] you have a very tightly regulated system to ensure that you don't have too much T three, which could lead to dangerous things like cardiac arrhythmias.

And you wanna make sure that, you have abundant supply of it as needed to prevent from the more hypothyroid symptoms. 

So really trying to make sure T four, you're looking at what you got in the bank and letting your body do its work of deciding how much to use. And we know that depending on what's going on in our body, if we're sick, it's gonna need a different amount versus when we're well, or if there's other processes or conditions going on in our body is going to need to fluctuate between that T four, T three.

And that's why it's really ideal to pay attention to the T four storage because day-to-day it's going to be changing. 

Yeah, 

Okay, so you told us earlier that a normal TSH on a lab value usually comes back somewhere between 0.5 and four or 4.5 depending on the lab. So if somebody [00:24:00] does have.

 symptoms of hypothyroidism, but their TSH is 4.1. And so technically let's say this lab said normal was up to 4.5, I hear difference between what's a normal lab and what's an optimal lab if that person has symptoms and they're technically normal but not optimal.

What do you think about that? 

It's a tricky question. So first of all, I would want to repeat it and make sure that it's still there within six months or so. But if they're persistently in that area of four and they have symptoms that could be consistent with hypothyroidism and they've added a pretty exhaustive workup for other things that could be mimicking it, I personally would consider looking at their TPO antibody to see if it's elevated and see if this is a trend towards more hypothyroidism or if they have a history of many labs in the system. And they said, five years ago I felt great. And you see their TSH going from 0.9 to one, to two, [00:25:00] to now four.

I think that's different than say an otherwise healthy 70-year-old who comes in and their TSH is four and they have, some fatigue that's maybe expected with aging and other medical conditions. Their TPO antibodies are negative and or they haven't had an extensive workup to rule out other causes for their symptoms.

So I think you get in a little bit of a tricky situation with that question. But I would say. The most important thing is not to overreact on a single lab. The TSH is going to fluctuate. It even fluctuates during the day. You have a slight rise of it in the middle of the night around, two to 4:00 AM and then it trickles down throughout the afternoon.

And so what you wanna look for is you wanna see is it persistently elevated and was there a period of time where they didn't have symptoms and it was different for a prolonged period. 

Yeah I always loved the trends I felt. I felt like that's so helpful when trying to actually see what's going on because of these fluctuations.

What is the harm of treating someone who does not [00:26:00] have Hashimoto's? No antibodies present, so unlikely that they will reach overt hypothyroidism and treating them to make them optimal. Is there harm to that?

Potentially. If their symptoms aren't due to their thyroid and you give them thyroid hormone, then you're masking another untreated condition. So say they have sleep apnea and they're tired and you don't treat 'em with a CPAP, but you give 'em thyroid hormone. I think that's a huge disservice.

Additionally, you're gonna get some atrophy of the thyroid gland. It's a life sustaining hormone. I would always like for those hormones to be made and regulated by the body. It's really good at it. And so I frequently see, slight abnormalities and thyroid hormones, especially like after a significant medical event or, someone had COVID or some significant infection.

They're still having a little bit of brain fog and fatigue and they have a thyroid level, A TSH check that's borderline abnormal and they think that thyroid hormone is going to, I. To help them get back to normal. But it's probably just an appropriate response of the system, the thyroid [00:27:00] system, to slightly upregulate.

The TSH. I 

love hearing that answer 'cause I think it is important to realize it's always best if we can get our body to do what it's supposed to do instead of trying to replace it. And then when you replace it inappropriately, you're downregulating your own body to do it, and it is going to function better and fluctuate better with what's going on in your life than you adjusting doses yourself.

It's always better to let it be dynamic and not depending on medicine if you do not need the medicine. 

And I think it's important to know that it is dynamic. You are gonna see changes. Throughout the day, throughout different periods of your life with different illness and stress if you check somebody who's in a heart failure exacerbation, their thyroid hormones may be slightly off.

Obviously you wanna make sure that they don't have true hypothyroidism that's causing that, but if they don't, I don't think there's a strong indication to treat it 

because essentially it can come back to normal on its own as you heal from the other processes going ex. 

Exactly. Especially also, thyroiditis, which is one of the more common causes for abnormal thyroid function [00:28:00] tests.

In most people as a self-limiting and resolving issue you can get TSHs that are very abnormal. Typically, your thyroid levels start very high and then will get very low and then recover on their own. If you interfere with this, you may be taking medication inappropriately or you may just missed the diagnosis.

And what would make someone realize that they have a thyroiditis then? 

There's a couple different causes. There's the painful one, which is where you get some sort of viral infection or something, and then the anterior portion of your neck hurts really badly, and that's inflammation of the thyroid gland.

If you go to your doctor immediately, you might see that your thyroid levels are very high. Your TSH is very low. And then by the time I get the referral in my office, usually their thyroid levels are very low and their TSH is very high. I think provided, the TSH isn't, crazy high.

We usually just let it. Resolve on its own repeat labs in three to four months. And generally speaking, those people do just fine. There's a painless form of thyroiditis. Again, [00:29:00] most people just don't feel themselves, feel off. There's no anterior neck pain with that. But again, it's generally a very predictable set of lab patterns and you don't need to intervene on it.

So there's also something that, it took me a while as an attending to learn this, but once I did it made a big difference is understanding there is , an impact on biotin supplementation and lab values. Can you please explain that? Because I know , it's very common in many vitamins and so individuals don't realize.

 , It can mess up these assays. 

Yeah. And I would say also, most commonly found in the hair, skin, and nail products for people who take things for their hair, skin, or nails. And I, the question I always get asked is it dangerous for my thyroid? No, you can take it, it's totally fine. I just recommend holding it for about a week before your labs.

And that's just because the biotin interferes with some of the test assays that are used. Depending on the type of test assay, it can actually make the lab read falsely low or falsely high. So generally [00:30:00] speaking, we would see the TSH lower than it truly is and the T four higher than it truly is. For your multivitamin that has like less than 20 micrograms of biotin, it's probably not a huge deal.

You could probably hold it a day or two before. For some of the hair, skin and nail products, which are loaded with like hundreds or sometimes even thousands of micrograms of biotin you should hold that for a week before. And then another thing that I found it in is, a lot of energy drinks now have it.

Oh, I 

didn't realize that neither. 

Yeah. So Celsius energy drinks have a lot of it. I had a patient who kept having abnormal thyroid labs and some fatigue and , they're in my office actually drinking this can of Celsius and I was just like looking at the back label and they're like, yeah, I have three a day.

I'm always tired. And I look at it and there's, I wanna say 300 micrograms of biotin in it. I don't know why. I don't know if they , want you to have better hair, skin, or nails with it, or of course, why would you not? Yeah. So I would say there's nothing wrong taking it. If you find that it's helpful for your health or for your hair, skin or nails, feel free to do so.

[00:31:00] but just hold it for, to be safe about a week before your labs. 

 in summary about the labs, we just all need to realize that it. Is needed to have someone that is able to understand the actual thyroid and all the labs interpreting your labs because it's not as black and white as sometimes social media presents these labs.

And it is important to understand trends. It's important to understand symptoms associated with these labs. just really want our listeners to understand that this can be more complicated than it's presented sometimes in social media. 

Yeah, and just to reiterate I think the TSH is a very good test for the vast majority of patients.

Unless you've had a history of head trauma or pituitary tumor or radiation to your head or have multiple hormone abnormalities the TSH performs very well over time by itself. 

So once we have labs, and let's say you're someone that's diagnosed with Hashimoto's, your lab values are all [00:32:00] consistent with that, how do you treat that person?

 I would say the first step would be thyroid hormone replacement. And the general consensus for that would be with T four monotherapy, which would be medications like Levothyroxin, Synthroid, Unithroid, euthyrox or tirosint. And the vast majority of patients do quite well with that medication.

Now you just rattled off a bunch of different names, but they're all a form of T four replacement. Can patients have different responses to different formulations of that T four? 

Yes. So I would say, there's a lot that goes into that question. . I think it really depends on different patient characteristics. The most important thing for thyroid hormone is that it'd be absorbed properly. So the biggest issue I see with thyroid hormone replacement is that patients are taking it with food or hot beverages or other medications that prevent its consistent absorption.

So I frequently see people with thyroid levels that are all over [00:33:00] the place. And for those that have hypothyroidism, you'll know that the dosing is not very far apart. You have 25 50. 75, 88, a hundred, 112, et cetera, it goes on up to 200. But there is a difference in the 88 and a hundred and it's only 12 micrograms, but if you are taking it with food or you're taking it with other hot beverages or supplements that may not get optimal absorption, you're gonna have a varying level of your thyroid labs.

And so the first thing I want to just, emphasize is the importance of taking your thyroid hormone correctly. Should be on an empty stomach, should be with like room temperature or cold water. The big things that are problematic are calcium supplements, iron supplements, proton pump inhibitors, which reduce stomach acid and impair the absorption 

If you are taking iron supplement, just be sure that you're taking it at least three to six hours separate from your thyroid hormone.

That's one of the big things that blocks absorption of thyroid hormone. 

How far away should someone separate their. [00:34:00] Antacid, whether that's Zantac or Nexium or Pantoprazole or any of those. How can someone that takes levothyroxine separate that? Because we also 

give them the advice to take that on an empty stomach.

So what do you do? 

Yeah, so tirosint is a good option for those patients. That's the liquid gel, cap based thyroid hormone replacement. And it does better with patients that take a PPI. So people have really bad reflux or gerd, they gotta take their PPI like right in the morning on an empty stomach I'll sometimes try to get away with tirosint so they can take it.

Otherwise, I'd like it to be separated by, again, three to six hours. I usually have them take the PPI on an empty stomach before their largest meal of the day. Very few of my patients have breakfast as their largest meal of the day, so it works out and then again, if they have to take their PPI in the morning, then we'll go to the nighttime dosing of the thyroid hormone.

Another thing that's very common for a lot of my patients is they'll get a little pill tray for their, Monday through Monday pill box, and they'll put it on their bedside table. They wake up in the middle of the night, they'll take it, and they wake up in the morning. They don't see the pill [00:35:00] there, they just assume they took it in the middle of the night.

That works pretty well. 

I tried that at one point too. Does insurance cover that? 

Tirosint Tirosint? Sometimes. Yeah, that, that would be what I would think 

would be the, so

sometimes you can make a case that they require it. It has an FDA approval for patients who take a PPI. And so if you use that, sometimes you can get a authorization for it.

If not, you can buy it directly from the manufacturer. And I want to say it's. 30 or $60 a month? 

No, not as bad as some of 'em out there. 

Yes, and so I think if you are consistently taking it correctly and still have varying levels of thyroid. Levels, then there can be other considerations. 

And usually insurance is what's driving to the cheapest form of Yes. Of Synthroid. And that's usually where everyone has to start no matter what.

Yeah. So when it comes to picking one, so Levothyroxine, which is the generic form is covered by I would say, every insurance and probably first line preferred.

And it's cheap without insurance. Yeah, it's cheap. Yeah. 

It's do a couple of dollars. I don't think it [00:36:00] is, it's much at all the issue with levothyroxine for kids that chew it or for other people that chew it, it doesn't taste as good as some of the other ones.

There have been a couple of recalls at least that I can think of in the last couple months. And it's not for dangerous things other than the fact that the doses are off a little bit. So a little bit of quality control issues with them. I would say those are the two main things. 

Okay. Before we leave the topic of how to take your levothyroxine.

In an ideal world, yes. You take it what? First thing when you wake up, you don't drink coffee for how long? An hour. 

I think that's just unrealistic. If I could get people to do 30 minutes, I would feel really good about myself. Yeah. Yeah, ideally an hour. You can also do it at night before bed if it's been three hours since you last ate.

I'm a lot, that's 

what I do nowadays, just. For any of you struggling to find a time to take your Yeah. Levothyroxin, because I don't like to delay my coffee, as you may know from some of our other episodes. So I would rather take it at night [00:37:00] and I do try to stop eating three hours before bed, so that's probably good on both for me.

Yeah, 

on both cases that's a good thing. But 

I think the other thing I had a lot of patients struggle with was they know these rules and so let's say they got up and they went ahead and ate breakfast and drank their coffee, and then they're like, crap, I forgot to take my medicine. And then they would be oftentimes like I guess I can't take it now.

'cause they told me to take it on empty stomach. Yeah. And then they wait and the next day, oh no, it happened again. And so then sometimes they would be concerned to take it because it wasn't on an empty stomach, and then they might go a few days without taking it. And so I would usually say. Just take it anyways.

Yeah. You may not be getting as much bang for your buck from that pill as you would if you were on an empty stomach, but still take it. 

So a few things just to touch on that some is better than none. It's really hard though to have your doctor adjust your dose if you are missing a dose or not taking it consistently.

Like I said, the doses are pretty close [00:38:00] together. Especially in the 75 to 150. So if you miss a dose once a week, that's a big difference in your dose that your doctor, if they don't know, that may end up moving your dose down or up based on that. If you are taking it consistently with hot beverages and food, I.

You may not be absorbing all of the dose that you should be. And so you may have a dose adjustment but it's still better to take it than not to take it. And the other thing for Levothyroxine alone, or I guess all of the T four monotherapies, I just wanna make sure I'm clear that it's not anything that contains T three or the desiccated thyroid.

You can't do this, but for T four, you can double up. If you miss a dose, you can take two the next morning. It has a really long half-life. Like we said earlier in this, the T four is pretty stable. It's not super active. Your body can handle a pretty good reservoir of it. And so in a euthyroid patient, like the half life's probably five to seven days.

So I have people who take care of their elderly parents and they may give them three pills one morning and four [00:39:00] the next. They see 'em twice a week. Not ideal, but it's better than missing all of their doses. 

Just think if you're someone that takes thyroid medicine, but you have trouble being consistent in taking it with the ideal setting, just figure out when you can take it consistently.

Let your doctor know and they can adjust the dose. Yeah, depending on how you're gonna do it, as long as you're consistent. I think

just be honest with your doctor and say, like I oftentimes get people with a TSH of eight and they're like I missed three doses the last two weeks and I know that I don't need to necessarily change their dose.

'cause what I frequently see is the yo-yo where their TSH is low, they're. Provider increases the dose and then they feel bad and they're more consistent with taking it. And then their thyroid levels end up high and then they de And so once you start getting out outta sort, it just propagates itself and you don't 

feel well when you're yo-yoing either.

No, for sure. And so that, that does not make anyone feel good. So just being open with your doctor. The other form of supplementation that is out there and is not always used is T three, which we [00:40:00] talked about TT three and from the lab perspective, but T three from the supplementation or medication side, what does that look like?

Who may need that? I know that is a hot topic. 

Yeah, this could be a two hour discussion probably longer, but so I would say the vast majority of people do fine with. T four monotherapy, that being the levothyroxine or Synthroid or tirosint.

There are a subset of patients that still have symptoms of hypothyroidism despite a normal TSH. And for those patients, you can consider on a patient to patient basis, a trial of T three therapy or combination therapy with T four and T three. The most common one's gonna be cytomel or liothyronine or your desiccated thyroid extracts like armor, thyroid, np, thyroid or Adthyza.

But again, the biggest issue I see with this is people come in, their TSH has never been normal. It's either high or [00:41:00] low, and then they're wanting to jump to T three combination therapy. And so in a subset of patients who have normal thyroid levels and are still symptomatic. Then it's reasonable to consider trying it.

It's much more short acting, so I think of it like a little burst of caffeine. So you still get some spikes. The desiccated thyroid is an animal product thyroid gland, so like armor thyroid's gonna be desiccated pig thyroid extract. It has a high percentage of T three compared to T four. And so generally I would try the levothyroxine with liothyronine first to see if they perceive any benefit from the combination therapy.

If they have some benefit, but not total improvement in symptoms that I might consider increasing the dose while maintaining a normal TSH. And then if they have no benefit from that there is the desiccated thyroid products that you can consider. 

And in those. The reason they're not a first line therapy is because of [00:42:00] the high ratio of T three, correct.

Yeah. So it's much more heavily weighted towards T three, so people initially can feel better on it because they have higher thyroid levels and that can cause a little bit more energy. A little bit improved metabolism, but over time you don't want the sustained high levels. It's a little bit harder to titrate 'cause the doses aren't as close together as the levothyroxine.

But in some patients they do very well long term on those. And I typically, if as long as their thyroid levels are normal, they feel well on it. I typically don't. Mind keeping them on it.

I know sometimes when individuals are taking T three supplementation, just like you mentioned, it's hard to titrate, it's hard to get right.

It's hard to get your TSH appropriate because sometimes it will push you more towards that hyperthyroid state. What is the risk of being in that hyperthyroid state over long term? From this, because I think that's what many doctors are concerned about when it comes to that because we have seen some of the negative things that can occur.

[00:43:00] transiently people do feel a little bit better. But if you have sustained high thyroid levels, you're just putting yourself at risk for issues like osteoporosis, cardiac arrhythmias, that can cause heart failure. Over time people tend to lose that effect because they're in overdrive all of the time.

So after several years, they feel like they need to go up on their dose because they don't quite feel the same. And that's when you start getting even more suppression of the TSH and more risk of side effects. And like I said, if your TSH is well controlled on desiccated thyroid products and you've been on it for a while and you feel like your euthyroid.

 While taking it. That's fine. But if you feel like you need to continue to increase your dose and your TSH is low then you're gonna really put yourself at risk from taking that. 

And I think that's what's important is like in all this, when it comes to treatment and taking medication for it, is you have to also pay attention to monitoring your levels once you're on it because you can cause harm.

Absolutely.

 , When you're treating someone, is there a [00:44:00] specific TSH that you're aiming to try to get them to or do you go more on symptoms? 

 I would say it's a combination. Like I said, we already talked about women who are that childbearing age.

I try to keep them around one to 2.5 and just counsel them that as soon as you get a pregnancy test that's positive, you're gonna need more thyroid hormone. Usually I tell them just to double up their dose and call me for that day. And then I would say other patients it's more based on symptoms.

If I can pinpoint a point in their life where they felt well, and I see that their TSH was, 1.4, I'll try to shoot for that. But again, the TSH is a fluid level in the patient with a normal thyroid gland. It doesn't stay fixed at one. It goes up and down with time of day and stressors and things like that.

Generally speaking, I try to keep people around maybe one to two and a half if they don't have otherwise a preference. But also, people that age can have a TSH that drifts up to 10 and that can be normal. And that doesn't necessarily require treatment. They can otherwise feel well.

So I don't think we need to be overly aggressive, especially later in life with our thyroid [00:45:00] dose. 'Cause even levothyroxine or T four monotherapy can also cause some degree of harm if it's over replaced. 

There was an article that came out last month that they did age matched patients on levothyroxine versus euthyroid patients. And for age and TSH match patients on levothyroxine had an increased risk of osteoporosis. So I think that as we age, we're probably too aggressive at trying to target that TSH of, 0.5 or 1.5 or two.

And I also think that flat profile of feeling like we have to have a TSH, that's just. Flat all the time is potentially causing some harm. 

 So again, just more of that fact that we have to realize our thyroid is dynamic and we are so many times trying to make it not dynamic. And we have to remember that in our testing specifically that there will be fluctuations depending on what's going on in our life, how we're aging, and we need to keep that as part of our thought process and algorithm when we are treating and diagnosing as well as monitoring.

. So how [00:46:00] about things like nutrition, what we eat? You usually hear about iodine with thyroid disease and so is that something people need to worry about?

Does someone with Hashimoto's need to try to specifically increase iodine in their diet? 

So if you have Hashimoto's and you're on. Levothyroxine or thyroid hormone replacement, you really don't 'cause there's iodine that you're taking every day in your pill. As we talked earlier, the thyroid hormone is made of iodine molecules.

So I think having a reasonable diet that contains normal trace minerals and vitamins is good for thyroid health. I don't think you need to go overboard. I think with as much iodine as added to salt, if you eat out maybe once a week, you're probably sufficient on your iodine intake.

If you're already on thyroid hormone replacement, you're already getting enough iodine for your thyroid, even though your thyroid's probably not doing a whole lot. Other things that I hear, selenium and zinc those are necessary for converting some of the thyroid hormones and manufacturing some of the thyroid hormones.

So again, I think if you have a. [00:47:00] A well-balanced diet. You should be getting enough of the selenium and zinc. But if not, if you're worried, I think a multivitamin that contains that is sufficient. I don't think you need to have excess. 

And one thing from a diet standpoint if you are concerned about your selenium, Brazil nuts are loaded with selenium.

So many people, instead of taking a multivitamin will have Brazil nuts in order to get enough selenium. 

a couple a week is just a couple. It's not a lot. They 

are loaded. Because that is also something to be noted is I've heard of people just like eating tons of Brazil nuts, making sure they have a healthy thyroid, but it really doesn't take a whole lot because they are so loaded.

Yeah. And also helps with cardiovascular risk. Yes. So one other thing you may wanna think about is just avoiding too many ultra processed foods. We talk about that a lot, but there's some question, and I don't know that this has really been well studied, but some question that having a lot of ultra processed foods is gonna increase inflammation, which could fuel underlying autoimmune [00:48:00] Hashimoto's, if you have it.

Yeah. I think that's just good for all health conditions. To be honest. I think the ultra processed foods are. Far too over-consumed and have a host of detrimental effects. I tell all my patients, treatment with thyroid hormone, there's risks, there's benefits especially if you have the borderline TSH and you're not sure, I think eating a healthy diet has virtually no risk and only benefits other than maybe some people would see cost as a, as an issue with that.

But if you're looking at ways to improve your health I still think sticking with the foundation of healthy eating, regular exercise, good sleep, and then removing detrimental things like excessive alcohol and things like that are gonna be way more bang for your buck than, considering a low dose thyroid hormone supplement or replacement when you may or may not actually need it, 

just like we had talked about on our previous show, when we talk about autoimmune conditions, understanding things that flare them, makes them worse, et cetera. So when you are on this borderline aspect, if you're trying to make your body as [00:49:00] healthy as possible , that is a key in all disease forms is we're going to feel better and our body's gonna respond better and decrease chronic conditions when we're avoiding ultra processed foods on a regular basis.

Touching on the autoimmune conditions I know there's a lot of talk of celiac disease with Hashimoto's.

And so for patients that I see that have Hashimoto's, they frequently ask if they need to be checked for celiac or if they need to avoid gluten.

I would say if you have one autoimmune condition, you're at more risk for additional. And so celiac and autoimmune hypothyroidism, or both autoimmune conditions. So you can have both concomitantly if you have virtually no GI symptoms. You don't need to be checked for celiac disease with a new diagnosis of autoimmune hypothyroidism.

If you have some GI issues, I'm pretty liberal on this. Usually screen my new patients and just go over a. Okay. Brief, GI questionnaire. 

So bloating. Yeah, diarrhea, that kind of stuff. Yeah. 

Blow like bloating, diarrhea, intermittent [00:50:00] constipation. Also talk about like rashes that can be seen.

Then I'll screen for celiac disease. If you don't have celiac disease, you don't need to avoid gluten. If you do have it, you should, because that's just gonna cause more inflammation, which can worsen your Hashimoto's or your thyroid disease. But as a rule of thumb, if you have hypothyroidism. You can eat gluten as long as you don't have celiac disease.

And so I think that's where some of that, we hear that a lot and it's just important talking to your doctor about your specific symptoms and see if that needs to be assessed. Because the other thing is many times people will go gluten-free on their own and then if you've been gluten-free for a long period of time and then try to scream for celiac disease, you're gonna get a false negative because you have removed that trigger for it.

So keeping that in mind, always bring up these symptoms if you have a diagnosis of hypothyroidism, Hashimoto's, talking to your doctor about those GI symptoms because of that prevalence, having a screening test [00:51:00] before. Removing all the gluten would be very helpful. It is a diagnosis that you want to actually know if you have. 

Yeah, absolutely.

So when it comes to patients who have hypothyroidism and they have been able to take their medicine appropriately, like we've talked about, they've finally have been able to manage their TSH and they're just wanting to know what else do they need to be doing to feel their best.

Is there any other specific advice for this chronic condition that you recommend for patients in order to optimize their treatment? 

 I think just with a lot of different chronic diseases, if you can hit on the core principles for health, stress reduction, getting adequate quality sleep getting regular physical activity, trying to keep somewhat of a schedule.

I think those will also translate well to patients with hypothyroidism. I don't have a specific exercise or regimen of exercises to do that can help improve your thyroid function if you have a longstanding diagnosis of [00:52:00] hypothyroidism. 

So we don't have to get in the weeds there, right? I don't, we can keep it simple.

I think 

so. I don't see 

we, we prefer simple here. Yes, I will 

say for patients who do make changes in their health with hypothyroidism, the thyroid hormone replacement dose does need to be adjusted based on your lean mass. So for patients who start working out losing weight it's not uncommon to see a dose adjustment required.

For their thyroid hormone replacement. So 

if you are out there making those big lifestyle changes and living a healthier life, don't forget to be sure that you're going to your doctor and having your TSH checked to make sure you're not needing adjustment because you've changed your body composition from doing all these things.

And congratulations if that is you. Kyle, you have really given us a lot of good insight about thyroid today and just to summarize what we've learned, hypothyroidism is a problem with a sustained low thyroid function, and you may have symptoms of fatigue or feeling [00:53:00] cold, constipation, weight gain, brain fog, and these symptoms could mimic a lot of other things, if you had anemia or sleep apnea or having bad symptoms from perimenopause.

So don't forget to look at everything and even if you find a thyroid diagnosis, don't forget to address those other potential problems that could be contributing to how you feel as well. And then when it comes to labs, there are a lot of labs out there, and there are a lot of labs now being marketed directly to you as the consumer where you're not really discussing them with the doctor.

So if you get labs and you see some abnormality, make sure you really talk to someone who understands what those are and can help you interpret if it's something you need to worry about or not. And then. Remember to try your best to take your thyroid hormone away from your other meals. If you're like me and you wanna take it in the morning and you can't hold your coffee back, either be consistent and let your doctor adjust your dose to how you're [00:54:00] taking it or try taking it at night or another time during the day where you can be consistent on an empty stomach.

Remember biotin, if you're taking that, especially for hair, skin, and nails, or now we know energy drinks, that could affect how your TSH is coming back in the labs as well. And so we want to make sure you're being treated with the best medication to help your symptoms, but also we wanna make sure that we're not.

Overtreating you, because if we do that, that can lead to some atrophy, meaning some kind of destruction or weakening of the thyroid gland and can lead to other things like osteoporosis or abnormal heart rhythms. So we wanna treat you to feeling better but not overtreat you because we can get ourself into problems with that as well.

And then don't forget to just. Think about all the things that we always talk about on here with managing your stress, prioritizing your sleep, really thinking about your nutrition, because all of those things are gonna act together with your thyroid gland and help you to feel the [00:55:00] best that you can. And I apologize, I'm still recovering from some laryngitis.

If I'm sounding a little bit like a frog by the end of this show. 

 And if. If you've enjoyed this show and felt like you've learned something, don't forget to like it.

Share it. Let others know if they're struggling with understanding what's going on with their thyroid, this may be a great way to help them educate themselves. 'cause I know there's just a lot of crazy information out there on social media today, and it can make people feel very confused on what might be happening with their body.

And if you are struggling and feel like you may have an issue here, be sure you take time. We always love to encourage listeners to reflect on their symptoms. Write them down. Bring all that information when you meet with your physician that way. You both can problem solve together and have a good idea of what may be going on with your health.

And if there's any other concerns beyond that once the thyroid's checked [00:56:00] don't feel like you have to stop there. There are many other things that can be causing similar symptoms to your thyroid and make sure that these are all , appropriately addressed. We've enjoyed having Dr.

Kyle Rosenstein on here and really appreciate his time and we will be looking forward to next week's episode. When we have Dr. Sweeney who's going to talk about all things related to metabolic health. And we are gonna take a deep dive into what that actually means.

How you can have a check on your metabolic health and what you need to be doing with your lifestyle to make sure that it is optimized. See you next time.