From Fatigued to Fantastic!

by Jacob Teitelbaum

  TREATING AN UNDERACTIVE THYROID

  We are constantly learning powerful new tricks for treating hypothyroidism, and there are many reasonable treatment approaches. Our treatment protocol information checklist (see Appendix B) gives the “nuts and bolts” of some approaches.

  What treatment will work best often depends on what is causing your thyroid levels to be inadequate. Common causes of underactive thyroid hormone in CFS/fibromyalgia include:

  Hypothalamic dysfunction. Your thyroid gland may be fine, but it is not getting adequate stimulation from the hypothalamus and is basically “asleep.” In this situation, simply taking a mix of T4 and T3 (see below) at the dose that feels best may be adequate. As the CFS resolves and hypothalamic function recovers, it is often possible to wean oneself off the thyroid hormone.

  Hashimoto’s thyroiditis. In this autoimmune process, your body’s immune system attacks and damages the thyroid. This can be diagnosed by a blood test called an “anti-TPO antibody.” If the anti-TPO antibody is elevated, you likely have Hashimoto’s thyroiditis and may need to take thyroid supplementation for the rest of your life.

  Inadequate conversion of the T4thyroid hormone to active T3. In this situation, which is common in fibromyalgia, patients often respond best to treatment with pure T3 hormone.

  Receptor resistance. In this situation, your body is making adequate amounts of thyroid hormone but the areas that it stimulates are very slow to recognize the thyroid hormone’s presence. Because of this, it takes a very high level of pure T3 hormone to get a normal response. This problem often resolves over one to two years on the high-dose T3 treatment as the body heals from fibromyalgia and/or chronic fatigue syndrome.

  Given the multiple causes of thyroid insufficiency in CFS and fibromyalgia, let’s discuss how to best treat these problems.

  THYROID HORMONE

  Most doctors prescribe T4 (Synthroid) to treat an underactive thyroid. T4, though, is fairly inactive until the body converts it into T3, or activated thyroid hormone. If the problem is only with the thyroid gland itself, prescribing Synthroid will work just fine. However, during periods when the body wants to conserve energy (for example, during times of infection or with CFS/FMS), the body slows down its metabolism. It does this by decreasing the production of active T3 from T4, which is turned into inactive “reverse T3” instead. In some cases, the body may get “stuck” and become unable to make adequate T3. Because of this problem, many physicians prefer to use compounded or Armour Thyroid, which contains a mix of T4 and T3.

  If you suffer from chronic fatigue and have achy muscles and joints, heavy periods, constipation, easy weight gain, cold intolerance, dry skin, thin hair, a change in your ankle reflexes called a delayed relaxation of the deep tendon reflex (DTR), or a body temperature that tends to be on the low side of normal, you should consider asking your doctor to prescribe a low dose of Armour Thyroid. As long as you do not have underlying heart disease and you follow up with a blood test to make sure that your free T4 thyroid levels are in a safe range (going above the upper limit of normal may aggravate osteoporosis, a problem already common in CFS/FMS), a trial of low-dose thyroid hormone treatment is usually quite safe and may be dramatically beneficial.

  I prefer to start with a trial of compounded T3 plus T4 or with Armour Thyroid, in which both T3 and T4 are already present. I begin with 1/4 grain (15 milligrams) a day and increase it to 1/2 grain (30 milligrams) a day in one week. Then, I increase it by 1/2 grain each one to six weeks until the patient finds a dose that feels best. If this treatment does not bring about relief, a trial of Synthroid, which contains only T4, may help. One hundred micrograms (0.1 milligrams) of Synthroid “equals” 3/4–1 grain of Armour Thyroid. Often, one hormone treatment works when the other does not. Adjust the dose as above. You will know if the treatment is working within one to six weeks on a given dose.

  If you are shaky or hyper, or have a racing heart (for example, a pulse over ninety beats per minute), lower the dose. In addition, try taking the full dose of thyroid in the morning on an empty stomach or half the dose twice a day to see which feels best. Do not take thyroid hormone within several hours of taking iron or calcium supplements, or you won’t absorb the thyroid.70A

  Once you have found a dose that feels best, or once the 2-and 3-grain levels are reached, your doctor should check the free T4 blood levels. The first test should be administered about one month after you’ve reached the optimum level described above and then once every six to twelve months. You may need to slowly adjust the thyroid supplementation so that you remain within normal range for blood free T4 thyroid hormone levels.71 Do not allow your doctor to do a TSH test. It will be low (because of the hypothalamic dysfunction) and your doctor will incorrectly think you’re on too much thyroid—even if your blood T4 hormone levels are low normal. This will make you and your doctor crazy. Although many patients can stop taking thyroid hormone after twelve to twenty-four months, you can stay on Armour Thyroid or Synthroid for as long as it is needed.

  Another approach, used by John Lowe, DC, a researcher in Boulder, Colorado, is to use pure T3 hormone (Cytomel). He feels that FMS patients have “thyroid resistance”—that is, it takes a much higher level of thyroid to obtain the normal effect. Even though the body may only make about 25 to 30 micrograms of T3 a day, his studies found it took an average of 120 micrograms a day to make his FMS patients feel healthy.72, 73 We have found this approach to be helpful in many patients. For more information, see www.drlowe.com.

  All thyroid treatments must be prescribed and monitored by a physician. Holistic physicians are more likely to be familiar with and open to trying these new treatment approaches. Unfortunately, many doctors are (incorrectly) trained to stop increasing the dosage of thyroid hormone once an individual’s thyroid tests are in the “normal” range—even if the dose is inadequate for that person. Synthetic T4 (Synthroid) and pure T3 (Cytomel) are available at any pharmacy. Sustained-release T3, which works better for many patients, can be obtained from compounding pharmacies. There has been a significant problem with quality control for T3 hormone, so I recommend that you use ITC Pharmacy (see Appendix E: Resources). When you settle on an optimal dose, the compounding pharmacy can then make a single capsule of that dosage to be taken one or two times a day. This is less expensive because the cost tends to be based more on the number of capsules than the actual amount of T3 in them.

  POTENTIAL SIDE EFFECTS

  If someone has blockages in the arteries that feed the heart and is on the verge of a heart attack, taking thyroid hormone can trigger a heart attack or angina, just as exercise can. Thyroid treatment can trigger heart palpitations as well. These are usually benign, but if chest pain or increasing palpitations occur, stop the thyroid supplementation and call your doctor at once. Because of this concern, I often recommend that patients at significant risks of angina—people who smoke, have high blood pressure, are over age forty-five, have cholesterol levels over 260, or have a family history of heart attacks in individuals under sixty-five years old—have an exercise treadmill test done before treatment, even if they can’t complete the test.

  To put the risk in perspective, in the many thousands of my patients on a thyroid supplement, none experienced heart attacks or other major health issues from taking it. In the long run, I suspect that thyroid treatment is much more likely to decrease one’s risk of heart disease by lowering cholesterol.

  The other main concern is that excess thyroid hormone can cause osteoporosis. In my research, I have seen no studies showing any increase in osteoporosis in premenopausal women, or even in postmenopausal women if they are on estrogen, if one keeps the T4 thyroid blood level in the normal range. As noted earlier, TSH is simply not a reliable monitor of thyroid levels in CFS/FMS because of hypothalamic dysfunction. We don’t know for sure if keeping the T3 level above normal in FMS patients with thyroid resistance worsens the osteoporosis already commonly seen in CFS/FMS, but this has not been a problem in Dr. Lowe’s expe
rience with thousands of patients. If you need to keep the T3 or T4 above the upper limit of normal, you should have a DEXA (osteoporosis) scan every six to twenty-four months. If this scan shows osteoporosis, lower the thyroid dose. If this is not possible, consider other osteoporosis-prevention measures we discuss in this book (see Chapter 8) with your physician.

  The Reproductive Glands

  Many people going through midlife develop fatigue, poor libido, or depression.74 This includes men and women alike. Researchers have found that if the estrogen and testosterone levels in females or the testosterone level in males is low, a trial replacement of these hormones can bring about dramatic improvement and is therefore worth considering. Underactive adrenal glands can aggravate this problem.

  LOW TESTOSTERONE—NOT ONLY A MALE PROBLEM

  Low testosterone is associated with many problems, including fatigue, depression, poor stamina, osteoporosis, muscle wasting, diabetes, high cholesterol, weight gain, and poor libido. Low testosterone, classified as being in the lowest 20 percent of the normal range, is a major problem in 70 percent of my male patients with CFS/FMS. The severity of the problem has worsened, as men’s average testosterone levels have dropped by 16 percent over the last fifteen years.75 Although testosterone levels are normally much lower in females, deficiencies in women cause similar problems. Testosterone is critical in females as well as males, and I find low free testosterone levels in most female CFS/FMS patients as well. It is important, then, to check the free, or unbound, blood testosterone level in both men and women. This measures the active form of the hormone. A serum (or total) testosterone level measures mostly the inactive storage form of the hormone. Inactive (total) testosterone levels are often normal despite an inadequate level of the critical active (free) testosterone.

  Optimizing testosterone levels can result in many benefits in people with CFS and fibromyalgia. After six to eight weeks, the effect of treatment is often marked. Benefits include:

  In women with fibromyalgia, a study done by Professor Hilary White of Dartmouth University showed that giving natural testosterone decreased fatigue and pain.76

  Fibromyalgia and CFS are associated with decreased red blood cell levels. Testosterone supplementation is a highly effective way of increasing the red blood cell levels.

  Testosterone can improve libido, which is low in 73 percent of CFS and fibromyalgia patients.77–79

  Testosterone increases bone density, therefore decreasing the risk of osteoporosis.80

  Testosterone improves mood and decreases depression.81

  Testosterone increases muscle strength and decreases fat levels.

  Research has shown that men who have low testosterone are at greater risk of premature death. For example, one study that followed men over forty years old for five years found that the men with low testosterone levels were 88 percent more likely to die during that period.82, 83

  Low testosterone is associated with an increased risk of high cholesterol, angina84, 85 and diabetes.86

  Chronic fatigue syndrome has been associated with a possible decrease in the heart’s ability to pump blood, and testosterone improves heart function.87

  As is the case with most hormones, keeping testosterone levels optimal using bioidentical hormones seems to be very helpful in CFS and fibromyalgia and also appears to be associated with increased health and longevity. However, it is important that we not confuse giving safe levels of bioidentical natural testosterone with the high-dose, synthetic, and toxic testosterone that bodybuilders sometimes use.

  TESTING FOR LOW TESTOSTERONE

  Again, it is important to check the free (not just total) testosterone. Most laboratories can test free testosterone only if they also measure the total testosterone—this is a normal procedure.

  Be sure that the normal ranges for the lab results are broken down by ten-year age groups—thirty-one to forty years old, forty-one to fifty years old, and so on. It is meaningless to have a normal range that includes eighty-year-olds if you’re twenty-eight.

  Also, bizarrely, some labs even have a normal range for women’s testosterone levels that begins at zero. This would be like having a normal range for women’s heights that goes from 0 to 72 inches. If your result is below normal, or even in the lowest 25 percent of the normal range, I would consider a trial of natural, bioidentical testosterone therapy.

  TREATING LOW TESTOSTERONE

  For men, I recommend using topical testosterone creams or gels, applying 25 to 100 milligrams to the skin each day. This is available from regular pharmacies (Testim 1 percent gel), but the form made by compounding pharmacies is much less expensive for those without prescription insurance. Be aware that if the skin where it is applied comes in contact with a woman’s skin (e. g., after a hug or if you do not wash your hands after applying the cream), this can result in very high, undesirable, and unsafe levels in that woman’s body. Always be sure to wash your hands after applying the cream.

  I do not recommend taking testosterone by mouth in males, as it can dramatically worsen cholesterol levels since testosterone goes to the liver first when taken by mouth, which is where cholesterol is made. I also do not recommend injections because this results in very high levels for the first few days afterward and in very low levels a week later. Testosterone pellets that are injected under the abdominal fat each four to six months may well be the best approach, but it is difficult to find physicians trained in this technique.

  For women, testosterone treatment is easier. I recommend the natural testosterone creams made by compounding pharmacies. The usual dose is 2 to 5 milligrams a day. If you also need estrogen or progesterone (see Chapter 4), all three of the hormones can be combined in the same cream, resulting in increased simplicity and a lower cost. With this dosing, most women have more energy, thicker hair, younger skin, and improved libido.

  Adjust the testosterone level to the dose that feels best, checking blood levels to make sure they do not go above the upper limit of normal. Most people feel best with a blood level around the 70th percentile of the normal range.

  POTENTIAL SIDE EFFECTS

  In men, acne suggests the dose is too high. It is important to monitor levels because, as in bodybuilders who abuse testosterone by taking many times the recommended dose, elevated levels can cause elevated blood counts, liver inflammation, a decreased sperm count with resulting infertility (usually reversible), and elevated cholesterol with increased risk of heart disease. Because of this, in men, a testosterone level, PSA, complete blood count (CBC), cholesterol test, and liver enzyme test should be done occasionally. Testosterone supplementation can also cause elevated thyroid hormone levels in men taking thyroid supplements. In men who are on thyroid supplements, consider rechecking thyroid hormone levels after six weeks if you get a racing heart or anxious/hyper feelings.

  It is important to note that testosterone can be converted to two other hormones: estrogen and DHT (dihydrotestosterone). If the estrogen level rises too high in males, breast size may increase and erections may decrease. Because of this, it may be reasonable to also check total estrogen levels while on testosterone and, if they are elevated, to add a medication called Arimidex (0.5 milligrams every other day), which blocks the conversion to estrogen. DHT level can also become elevated, resulting in a higher risk of prostate enlargement.88

  As noted above, in men, most studies show that bringing low testosterone up to the normal level decreases angina and leg artery blockages, and decreases diabetes. If DHT goes too high, however, it can cause prostate enlargement and a worsening of male pattern baldness. If this occurs, these side effects can usually be blocked by taking the herb saw palmetto (160 milligrams twice daily) along with the testosterone. Fortunately, both of these problems have been fairly uncommon.

  Treatment with testosterone in men has not been shown to increase prostate size (if DHT is normal) or the blood test marker for prostate cancer (PSA).89 In addition, there is currently no evidence from studies of natural testosterone treatment s
howing that it increases the risk of prostate cancer.

  If acne, intense dreams, or darkening of facial hair occurs in women taking testosterone, the dose is too high and should be decreased. These effects, which can also occur with DHEA supplementation, are usually reversible. These side effects can also be caused by an estrogen level that is too low relative to testosterone, and may be avoided by supplementing both together. If you choose to take testosterone and estrogen separately, it may be best to use estrogen for four to eight weeks before starting testosterone. This often decreases side effects.

  For many patients with CFS and fibromyalgia, treating low testosterone levels has been critical in leading to dramatic improvements in stamina, energy, and overall sense of wellness.

  LOW ESTROGEN AND PROGESTERONE

  Although not likely to be a problem with men, deficiencies of estrogen and/ or progesterone can be major problems in women with CFS/FMS. A book by Dr. Elizabeth Lee Vliet, Screaming to Be Heard: Hormonal Connections Women Suspect…and Doctors Still Ignore, reviews the role of estrogen deficiency in causing fatigue, brain fog, disordered sleep, fibromyalgia, poor libido, PMS, low levels of serotonin and other neurotransmitters, interstitial cystitis, and other problems. She notes that the perimenopausal period (the period as you approach menopause) has a gradual onset, and symptoms of estrogen deficiency can occur five to twelve years before your blood tests and periods become abnormal. As previously noted, hypothalamic dysfunction can also cause estrogen deficiency.