Hypo- means “beneath” or “below” so hypothyroidism means you don’t have enough thyroid hormone. The thyroid itself produces mostly thyroxine, or T4 but also a little bit of triiodothyronine, or T3). T4 and free T4 is not very biologically active and has to be converted into T3 and then Free T3, the form of the hormone that does all the work.

Hypothyroidism is the most common hormone disorder. While not exclusively a women's health issue, it disproportionately affects women, with 4-10% of all women and nearly a quarter of women over 65 actively treated for it. That is 10 times more women than men. Additionally, about 60% of people with hypothyroidism, men and women, remain undiagnosed.

Thyroid hormone is responsible for numerous metabolic activities, with receptors for it in the brain, heart, kidney, intestines, bone and liver.

Common symptoms of hypothyroidism include constipation, fatigue, depression and brain fog, cold intolerance and feeling inappropriately cold, hair loss, dry skin, and unexplained weight gain not attributable to diet or lack of exercise. Remember, these symptoms can also stem from other health issues, and often more than one cause is involved so it is important to differentiate all the possible causes.

Hypothyroidism can be autoimmune (Hashimoto's thyroiditis) or non-autoimmune in nature.

First, Hashimoto’s. Autoimmune Hashimoto’s hypothyroidism is when your body mistakenly creates antibodies that attack parts of thyroid hormone function. These antibodies could attack thyroid peroxidase (TPO, the most common form of Hashimoto’s) or thyroglobulin (TG). Being positive for one or both of these antibodies is a diagnosis of Hashimoto’s.

But just because you have antibodies against your thyroid, it doesn’t mean that you immediately have low thyroid hormone. Often, the thyroid can still put out enough thyroid hormone while under attack. It should be monitored because eventually you won’t be able to and will require thyroid hormone replacement.

Second, sometimes thyroid hormone is low because the master gland, the pituitary or the part of the brain that controls it, the hypothalamus are not working properly to signal the thyroid to secrete thyroid hormone. This is rather rare.

Physiology and stress research identifies another type of hypothyroidism. Due to long term illness and/or mental and/or physical stressors, the feedback loop that controls hormone secretion between the thyroid, pituitary and hypothalamus in the brain gets dysregulated. This is also somewhat rare and would usually be accompanied by more globally low hormones throughout the body.

Hypothyroidism can also occur from damage to the thyroid such as thyroid surgery, thyroid cancer, or drugs such as lithium or steroids.

Regardless of the cause, conventional treatment is limited to prescription hormone replacement therapy. While this is literally a lifesaver, it does not fully attempt to understand or address the underlying causes and can often leave people with lingering health issues and fatigue.

That is where Functional medicine comes in, to help identify and rectify drivers of both autoimmunity (in the case of Hashimoto’s) and broader hormone dysregulation between the brain, pituitary and thyroid and other hormone secreting glands, including the adrenals (cortisol) and ovaries or testicles (sex hormone estrogen and progesterone and testosterone, respectively).

Functional Medicine (FM) seeks to identify the root causes of health conditions and symptoms, including both autoimmune Hashimoto’s and non-autoimmune hypothyroidism. While the conventional medical approach is to identify an established disease and prescribe a drug or procedure to target that disease, FM also looks to identify the drivers and root causes of the disease, remove them, and support the body in returning to full balance.

Thyroid health optimization usually begins with a thorough investigation of the gut, where ~75% of our immune system and a lot of our nervous system live. Treatment includes changing an inflammatory diet, eliminating food reactivities (allergies or intolerances) and in-depth gut microbiome testing and treatments.

We also test and address other sources of inflammation, nutrient levels and cellular health and other hormonal imbalances. Lifestyle factors are also important to restoring hormonal health and vitality, so we teach and support you to build healthy habits for sleep, exercise and stress management to restore you to full health.

Conventional medicine does not differentiate between the two, because there is no difference in treatment, there is only prescription thyroid hormone replacement. While treating low thyroid hormone from either cause is very important, if we don’t look deeper, we are often missing drivers of the condition, other causes of symptoms besides the thyroid and fail to help a person feel fully well.

For autoimmune Hashimoto’s hypothyroid, the Functional medicine (FM) approach can stabilize and may even be able to slow its progression through addressing triggers of autoimmunity, such as gut imbalances, stress, toxins and infections. Many with Hashimoto’s know that their medication dose is often increased or decreased at each appointment as the condition varies. While we can’t yet eliminate autoimmune antibodies, the FM approach may make it easier to stabilize on a dose and actually feel fully well.

For non-autoimmune hypothyroidism, it is perhaps even more important to use an FM approach, both because it may be possible to fully recover and get off prescription medication and because you probably have other issues leading to your symptoms other than hypothyroidism.

Non-autoimmune hypothyroidism, when not from hypothalamus or pituitary damage, is more often due to long term or severe mental or physical stressors, including illness, and nutrient deficiencies. Resolving these may allow our hormones to heal and get off thyroid medication. Failing to identify and address them usually means that we don’t really feel well on just a thyroid hormone prescription.

Conventional prescriptions, such as Synthroid and its generics, levothyroxine and tirosint, are T4 only prescriptions. They supply the body with T4 (thyroxine), which then needs to be converted into the active form of thyroid hormone, free T3 (triiodothyronine), at its target cells in the body.

There are also gland-derived thyroid prescriptions such as NP thyroid and Armour. These have both T4 and T3. Dosage of T4 and T3 should be standardized, but vary somewhat because they are natural products.

In natural medicine, glandular prescriptions including both T4 and T3 have become popular over T4-only prescriptions. At InHealthRVA, we prefer to treat on a case-by-case basis, and here’s why.

T4 is mostly an inactive and much more stable hormone in the body while T3 is more potent and immediately active. T4 has to convert to the active T3 at its target tissues and the body has numerous, intelligent controls over how much and when this happens.

Things like inflammation and other hormone imbalances (especially adrenal cortisol dysregulation) can block T4 to T3 conversion.

Giving T3 through glandular thyroid hormone prescriptions can be one way to overcome this block of T4 to T3 conversion and can be necessary if we can’t figure out or heal the reasons conversion is blocked.

But, wouldn’t it be better if we could address the inflammation and adrenal imbalances that limited this conversion, rather than trying to “micromanage” with medication? It is likely that if inflammation and other hormone balances are contributing to your thyroid issues, that you won’t feel fully well on thyroid prescription alone anyway.

Also, we often see T3 suppress your own production of T4, making you more dependent on the medicine.

Last, while hypothyroidism can be too often underdiagnosed, we also often see the opposite: people are put on thyroid medication to cover up all other sorts for fatigue, brain fog and metabolic issues. Incorrectly dosing on natural thyroid medicine to cover up these issues is not much different than taking any other form of stimulating hormone or treatment.

Let’s identify the reasons you are feeling unwell and work to optimize and balance your whole body.