Hashimoto’s is usually diagnosed through either blood tests, thyroid ultrasounds, or biopsies of the thyroid gland. Blood tests are typically the most accessible option, and the right ones can often uncover autoimmune thyroid disease.
Most of these tests will be covered by health insurance if ordered by a licensed physician. If your doctor will not order these tests for you, you can get them through direct-to-consumer lab services and pay out of pocket, and in some cases submit the claim for insurance reimbursement.
Blood Tests
TSH (Thyroid-Stimulating Hormone)
TSH is a pituitary hormone that responds to the level of circulating thyroid hormones. The TSH test is used as a screening test for thyroid function and is likely what your doctor would suggest if you reported thyroid symptoms.
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THE MANY SYMPTOMS OF HASHIMOTO’S
Hashimoto’s thyroiditis has a unique set of symptoms when compared to nonautoimmune hypothyroidism. If you have Hashimoto’s, your symptoms may fluctuate between those of hypothyroidism and those of hyperthyroidism, or you may even experience symptoms of both conditions simultaneously. You may also have symptoms related to autoimmune inflammation. Here are some of the symptoms of each:
HYPOTHYROIDISM
Cold intolerance
Constipation
Depression
Dry skin
Fatigue
Forgetfulness
Hair loss
Joint pain
Loss of ambition
Menstrual irregularities
Muscle cramps
Stiffness
HYPERTHYROIDISM
Anxiety
Eye protrusion
Fatigue
Hair loss
Heart palpitations
Heat intolerance
Increased appetite
Irritability
Menstrual disturbances
Tremors
Weight loss
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Additional symptoms, which can be seen in other autoimmune conditions, include: acid reflux, adrenal fatigue, allergies, balance disorders, bloating, constipation, diarrhea, feelings of disconnection, gum disorders, irritability, irritable bowel syndrome, loss of ambition, mood swings, panic attacks, rashes, vertigo, weakness, and numerous other inflammatory symptoms.
A comprehensive approach is needed to resolve all of your symptoms and to get to the root cause of the condition!
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In advanced cases of Hashimoto’s and primary hypothyroidism, TSH will be elevated. In advanced cases of Graves’ disease and hyperthyroidism, TSH will be low. Unfortunately, the TSH test does not always catch Hashimoto’s in earlier stages. During these stages, you can have either high or low TSH or lab work that reveals “normal” readings even while you are experiencing unpleasant thyroid symptoms. I was told that my thyroid was “normal” when I was exhausted, forgetful, losing hair by the handfuls, and sleeping for twelve hours each night under two blankets in southern California.
At the time my TSH was 4.5 mIU/L, and this was considered normal based on the reference range of 0.2–8.0 mIU/L, which most labs still use. The problem is that when this original “normal” range of TSH was created, scientists included elderly patients and others with compromised thyroid function in the calculations, leading to an overly wide reference range. Based on this skewed range, many doctors may miss identifying patients with an elevated TSH (this is one reason why you should always ask your physician for a copy of any lab results).
Thankfully, the accepted TSH reference range is on the path toward change. In recent years, the National Academy of Clinical Biochemists indicated that 95 percent of individuals without thyroid disease have TSH concentrations below 2.5 mIU/L, and a new normal reference range was defined by the American College of Clinical Endocrinologists to be between 0.3 and 3.0 mIU/L. Functional-medicine practitioners have further defined normal reference ranges as being between 1 and 2 mIU/L for a healthy person not taking thyroid medications.
Thyroid Antibodies
The best blood tests for Hashimoto’s are those that measure thyroid antibodies, because these will indicate an autoimmune response to the thyroid gland. The two antibodies that are usually elevated in those with Hashimoto’s are:
Thyroid peroxidase antibodies (TPO antibodies)
Thyroglobulin antibodies (TG antibodies)
If you have Hashimoto’s, you may have an elevated level of one or both of these antibodies. In general, the greater the number of antibodies, the more aggressive the attack on the thyroid gland.
Current medical reports state that 80 to 90 percent of people with Hashimoto’s will have TPO antibodies. That said, researchers at the University of Wisconsin Thyroid Multidisciplinary Clinic found that only half of the patients who came up positive for Hashimoto’s through cytology (when thyroid cells are withdrawn through a thin needle and then evaluated under a microscope; see more on this type of test below) had TPO antibodies. Even if your thyroid antibody test is negative, you could have a less aggressive variant of Hashimoto’s known as seronegative, or antibody-negative, Hashimoto’s, which does not present with elevated levels of either of the above mentioned antibodies, but may be seen on ultrasound or when running more invasive tests such as the fine needle aspiration.
Free T3 and Free T4
Blood tests can also measure levels of the two most active forms of thyroid hormone, triiodothyronine (T3) and thyroxine (T4). These levels will be low when Hashimoto’s progresses to hypothyroidism. These hormone tests are sometimes helpful for diagnosis and can be useful too in determining a correct dosage of thyroid medications. I recommend utilizing the free T3 and free T4 tests instead of the total T3 and T4 tests, as they reveal the thyroid hormone that is unbound, or “free,” to interact with thyroid hormone receptors.
Thyroid Ultrasound
Some individuals may have Hashimoto’s despite no detectable alterations in their blood work. In these cases, a thyroid ultrasound may need to be used to help determine a diagnosis. Clinicians have found that the changes consistent with Hashimoto’s may be visualized on thyroid ultrasounds even when a person does not test positive for antibodies.
Fine-Needle Aspiration Cytology
In a fine-needle aspiration cytology test, cells are extracted from the thyroid gland through a very thin needle and then studied under a microscope for signs of Hashimoto’s. Due to its invasive nature, this type of test is usually reserved for determining whether thyroid nodules are benign or cancerous. In some cases, patients will learn they have Hashimoto’s when they have suspicious nodules examined this way.
Although I don’t recommend this test as the first test for a diagnosis of Hashimoto’s, I’m mentioning it here, because this test is more likely to pick up additional cases of Hashimoto’s when other advanced tests may miss it. As my friend Dr. Alan Christianson, world-renowned thyroid doctor, always says, “Test results can be negative, and it’s really important to listen to the patient. You can’t completely rule out Hashimoto’s unless you look at every cell inside of the thyroid gland under a microscope.” I share this because some people who have thyroid symptoms and will likely benefit from lifestyle interventions for Hashimoto’s are often told that they don’t have Hashimoto’s based on blood tests and even ultrasounds and unfortunately delay taking part in strategies that could help.
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TESTING, TESTING, ONE-TWO-THREE
Most conventionally trained doctors will say that once you test positive for thyroid antibodies, you will never need to test for them again. “You will always test positive, so it doesn’t matter,” they say. I disagree! Testing thyroid antibodies is helpful to determine a baseline for the aggressiveness of your condition (the higher the number, the more aggressive the condition) as well as to track the progress of your interventions. I generally recommend testing antibodies every one to three months when doing active interventions to improve your thyroid health. You will see
the full effect of your interventions within a time span of three months to two years; however, you may be able to see a trend within one month. Reduction in thyroid antibody levels by at least 10 percent should be considered a positive change, an indication that your interventions are helping.
In general, antibody levels over 500 IU/mL are considered aggressive, while levels under 100 IU/mL are considered “in remission” for Hashimoto’s. That said, there is no standard definition of remission, and I consider any reduction in antibodies (when correlated with improved symptoms) a positive step on the remission journey! Antibody levels under 35 IU/mL are considered “negative” for Hashimoto’s according to some tests, while other tests consider levels under 9 IU/mL to be negative. However, as I already mentioned, a negative antibody test does not rule out Hashimoto’s, so I encourage you not to get too hung up on having perfect numbers and focus on feeling better!
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Although these tests can reveal to us a diagnosis of Hashimoto’s, they don’t offer any insight into root causes of the disease, something that can be even more helpful when it comes to understanding solutions. For that, we need to look to the origins of autoimmunity, since all autoimmune disease requires the same factors to be present.
THE ORIGINS OF AUTOIMMUNITY
We know that Hashimoto’s is an autoimmune condition. This means that understanding how autoimmunity works can give us important clues about how Hashimoto’s happens—and how we might heal from it.
There are at least eighty known autoimmune conditions, including Hashimoto’s, type 1 diabetes, rheumatoid arthritis, lupus, and celiac disease (an autoimmune reaction to gluten). Although these are all different conditions, research has shown that all autoimmunity requires the presence of the same factors. Dr. Alessio Fasano, Director of the Center for Celiac Research and Treatment at Massachusetts General Hospital, found that three things must be present for autoimmunity to develop:
The genetic predisposition
Triggers that turn on genes
Intestinal permeability (gaps in the intestinal barrier that can let inflammatory pathogens pass into the bloodstream; otherwise known as “leaky gut”)
There was a time when it was believed that once these factors had combined to activate the immune system, there was no going back; autoimmunity was thought to be irreversible. Thankfully, we are no longer living in that time.
Researchers have shown that autoimmune expression is much like a “three-legged stool.” All three factors need to be present in order for autoimmunity to find expression. Although we can’t choose or change our genes, we can impact the expression of both our genes and autoimmunity. We have two potential options to address with autoimmune disease: the triggers—finding and eliminating autoimmune triggers, such as infections or toxins; and intestinal permeability—looking for the root causes of why the gut may be permeable.
The amazing thing is, when we address triggers and/or the health of our gut, we can see significant improvements in autoimmune disease and, in some cases, even get the condition into remission! I’ve spent the last several years researching Hashimoto’s triggers and developing strategies to address and eliminate them. I’d like to take you into what’s going on in Hashimoto’s to deepen your understanding of my approach.
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THE FIVE STAGES OF HASHIMOTO’S
Hashimoto’s is a progressive autoimmune condition that can lead to the development of other autoimmune conditions if not addressed properly. The five stages are:
In Stage 1 a person discovers a genetic predisposition to develop Hashimoto’s. The thyroid function is normal, and there’s no attack on the thyroid. For all intents and purposes, the person does not have thyroid or autoimmune disease at this stage.
In Stage 2 of Hashimoto’s, the attack on the thyroid gland starts, but the thyroid can still make enough thyroid hormone. Although most thyroid tests may be normal at this stage, many people will test positive for thyroid antibodies and may have changes consistent with Hashimoto’s on a thyroid ultrasound, but will have normal TSH levels according to the TSH screening test. This is the stage when symptoms begin, yet many people are misdiagnosed with another condition, such as depression, anxiety, or hypochondria, because most doctors don’t do the right tests. This stage is also the optimal stage when lifestyle changes and a Root Cause Approach to the condition should be started, because it’s much easier to prevent damage than try to fix it later.
In Stage 3, the thyroid gland starts to lose its ability to make enough thyroid hormone for the body, and a person will have a slightly elevated TSH with normal T4/T3. More symptoms will be seen at this stage, and there is a higher likelihood of a diagnosis, though some doctors may miss or dismiss the slight TSH elevation and many doctors will recommend a “wait and watch approach.” At this stage, in addition to lifestyle changes, a thyroid hormone–supporting medication may also be extremely helpful and in my opinion warranted, though many conventionally trained doctors will refuse to prescribe thyroid hormones until Stage 4.
In Stage 4 of Hashimoto’s the thyroid gland has fully lost its ability to compensate, and the person becomes hypothyroid. Hashimoto’s is relatively easy to diagnose at this stage with the current “standard of care tests,” which will reveal that the person has elevated TSH and lowered T3/T4. This is the stage in which a person will be even more symptomatic and will finally be offered a thyroid-hormone prescription by most traditionally trained doctors.
Stage 5 is when other types of autoimmune conditions develop. We know that autoimmune conditions can be progressive, and taking thyroid hormones or surgical removal of the thyroid gland will not stop the progression of autoimmunity. People with one autoimmune condition may find themselves diagnosed with other types of conditions such as lupus, psoriasis, or Sjogren’s syndrome. The good news is that addressing lifestyle, nutrition, and the root causes of autoimmune conditions can help not just autoimmune thyroid disease, but also the symptoms and progression of other types of autoimmune issues.
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WHAT’S GOING ON IN HASHIMOTO’S?
In Hashimoto’s, in addition to the issue of intestinal permeability there are six potential types of triggers: food sensitivities, nutrient depletions, an impaired ability to handle stress, an impaired ability to handle toxins, digestive issues, and chronic infections. Each person with Hashimoto’s will have his or her own combination of triggers, which means that creating a universal approach to healing can be challenging. However, I’ve found that nearly every person with autoimmune thyroid disease has underlying root-cause commonalities—the same factors and imbalances are present—and many of these imbalances can be reliably addressed with proper nutrition.
Although triggers and stressors for the condition can vary from person to person, the body usually responds to them in a very predictable fashion by moving us away from a “thriving state” toward a “surviving state.” In just about every person with Hashimoto’s, I see the same recurring patterns.
I’ve called these patterns the “Vicious Cycle of Hashimoto’s.” This cycle is interrelated and simply adding thyroid supplement to the mix will not result in full recovery for most thyroid patients. But although the triggers of Hashimoto’s can break the body down, nutrition can build it back up.
HEALING HASHIMOTO’S PATTERNS WITH NUTRITION
The recognizable patterns in Hashimoto’s that lend themselves to nutritional healing include the following.
1. Micronutrient deficiencies. Most people with Hashimoto’s have numerous micronutrient deficiencies. These micronutrient deficiencies can occur as a result of eating the Western diet, eating nutrient-poor foods, following a calorie-restricted diet, digestive enzyme deficiencies, inflammation from infections or food sensitivities, medications, or an imbalance of gut bacteria. Lack of sufficient thyroid hormones can also lead to nutrient deficiencies, as it makes nutrient extraction from food more difficult and less efficient.
These nutrient deficiencies contribute to the d
evelopment of Hashimoto’s as well as many of its symptoms. Restoring the nutrients through nutrient-dense foods, supplementation, and optimizing digestion are some of the fastest ways to feel better with Hashimoto’s and begin to build the body back up!
2. Macronutrient deficiencies. Oftentimes people with Hashimoto’s have diets that are deficient in protein and fat, two essential macronutrients that support the body’s growth and repair processes. These deficiencies can develop as a result of our carb-heavy Western diet, fat phobia, and vegetarian/vegan diets as well as impaired protein or fat digestion.
Impaired protein digestion can also lead to deficiencies in the amino acids L-tyrosine and L-glutamine, both of which may play an important role in healing from Hashimoto’s. L-tyrosine is necessary for production of thyroid hormones, while L-glutamine is essential to proper gut lining and immune function. Both amino acids are often depleted in people with Hashimoto’s. Improving protein digestion can help restore levels of these important amino acids and promote an anabolic (building up), instead of a catabolic (breaking down) state within the body.
3. Deficiencies in digestive enzymes. Studies have found that people with Hashimoto’s and hypothyroidism often have a deficiency in the digestive enzyme hydrochloric acid, resulting in low levels of stomach acid (hypochlorhydria) or a complete absence of it (achlorhydria). Low stomach acid can make it more difficult to digest proteins, which in turn can lead to deficiencies in the amino acids mentioned above.
Hashimoto’s Food Pharmacology Page 3