Your Hormones in Harmony | Part 4

Thyroid: The Conductor of Your Hormone Symphony

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Dr. Aaron Hartman

February 20, 2024


    The Conductor

    For all your hormones to play in harmony, they need to pay attention to the conductor of the symphony. That conductor is your thyroid.

    Technically, your thyroid isn’t a hormone. Your thyroid is a butterfly-shaped gland located just below your Adam’s Apple.

    The thyroid gland produces three hormones:

    • Triiodothyronine (T3)
    • Thyroxine (T4)
    • Calcitonin

    Collectively referred to as “thyroid hormones,” T3 & T4 are nearly identical in chemical composition and made largely of iodine.

    This, by the way, is why iodine is often added to our salt. Before iodized salt was introduced in 1924, people with insufficient iodine in their diet often developed Goiter, an enlarged thyroid.

    Much like cortisol, the production of your thyroid hormones begins in your brain — your hypothalamus, to be exact. T3 & T4 are regulated by “Thyroid Stimulating Hormone” (TSH) which is produced in the pituitary gland, which in turn is regulated by “Thyrotropin-Releasing Hormone” (TRH) produced by the hypothalamus. Or, arranged sequentially, we can view the process in the figure below:

    That’s a lot of T’s! This touches on some of the complexity in testing that I’ll address below. In order to simplify language, it’s common to refer to the interplay of thyroid-related hormones simply as “thyroid.” I’ll follow that common convention here.

    OK. That’s what your thyroid is. But why is that little butterfly in your throat so critical to all of your body’s functions?

    Your thyroid hormones help your mitochondria to function properly. Your mitochondria are the energy powerhouse in your cells. Since the thyroid has this critical role in energy production, its dysregulation has major downstream ramifications that can affect everything else in your body.

    In addition to mitochondrial function, a few of the thyroid functions include:

    • Tissue repair and healing
    • Controlling blood flow
    • Managing protein, fat, and carbohydrate metabolism
    • Regulating nutrition and vitamin consumption
    • Managing digestion
    • Controlling other hormones

    As you can see, the thyroid plays a major role in blood flow, metabolism, digestion, and hormone balance. This role of hormone control is key. High levels of thyroid can feedback and affect insulin and cortisol secretion. Interestingly, low levels can do the exact same thing. And now, perhaps, it makes sense that the thyroid is the conductor of your hormone symphony.

    But what happens when the thyroid does become imbalanced?

    Low Thyroid (Hypothyroidism)

    Thyroid Deficiency: A Silent Epidemic

    Low thyroid function, also known as hypothyroidism, is already incredibly common and on the rise. About 4% of the population currently has hypothyroidism as defined by elevated TSH levels. But once you realize the nuances of subclinical hypothyroidism, the true picture is that about 20% of the population has thyroid autoantibodies. We’re currently missing a lot of low thyroid and other hormonal dysfunctions.

    We’re currently missing a lot of low thyroid and other hormonal dysfunctions

    Symptoms of Low Thyroid

    • Acne
    • Agitation
    • Allergies
    • Anxiety
    • Bruising easily
    • Carpal tunnel syndrome
    • Cold hands and feet, or general cold intolerance
    • Cognitive decline
    • Constipation
    • Dizziness
    • Drooping eyelids
    • Drooping facial expression
    • Dry skin
    • Elevated cholesterol
    • Elevated cortisol
    • Elevated homocysteine
    • Elevated insulin
    • Endometriosis
    • Excessive wax in the ear canal
    • Facial changes (e.g. loss of outer 1/3 of eyebrows)
    • Fat pads over the collarbone
    • Fibrocystic breast disease
    • Frequent urination at night
    • Gall stones
    • Hair loss throughout the body and sparse hair that is coarse and dry
    • Heart disease
    • Infertility
    • Infections
    • Inability to concentrate
    • Iron deficiency (anemia)
    • Irregular heartbeat
    • Irregular periods
    • Joint aches and pains
    • Low body temperature
    • Low sugar episodes (reactive hypoglycemia)
    • Miscarriage
    • Morning stiffness
    • Muscle and/or joint pain
    • Muscle cramps and muscle weakness
    • Muscle spasms
    • Nutritional imbalances
    • Panic attacks
    • Paraesthesia (tingling or burning sensation typically in the extremities)
    • Poor circulation
    • Poor night vision
    • Puffy face
    • Ringing in ears
    • Sleep apnea
    • Slurred speech
    • Swollen hands, legs, or feet
    • Thinning bones (osteoporosis or osteopenia)
    • Weight gain
    • Yellow skin (from an inability to convert beta carotene into vitamin A)

    Let’s acknowledge together: that’s a long list!

    You can see how low thyroid function can be confused with pretty much anything else. It also reinforces the importance of testing. Symptoms alone are not adequate to diagnose thyroid problems.

    What are some of the causes of hypothyroidism (and how can we address them)?

    Causes of Low Thyroid

    • Blood Pressure Medications
    • Excess Calcium
    • Excess Copper
    • Excess Cruciferous Vegetables
    • Estrogen Replacement Therapy
    • Hashimoto’s Thyroiditis
    • Insufficient Fat & Protein
    • Nutrient Deficiencies
    • Oral Contraceptives
    • Stress

    Compilation of images that shows inflammation to different parts of the body

    Don’t Forget the Role of Inflammation

    I’ve written quite a bit about inflammation as the underlying cause of chronic disease. Inflammation is a shorthand for “dysregulation of your immune system.” In this case, when your adaptive immune system begins producing autoantibodies — attacking healthy cells (a.k.a “inflammation”) — you end up on a trajectory towards one or more autoimmune diseases. One of those autoimmune diseases is Hashimoto’s Thyroiditis, or low thyroid. Currently, 1 of 12 people have some kind of autoimmune disease and 1 of 5 has a positive autoantibody. If you haven’t read my articles on inflammation and chronic health issues, I encourage you to read (or re-read) them. Join me in connecting the dots.

    Root Causes

    In addition to inflammation, I’d like to call attention to some of the specific root causes of low thyroid.

    Nutrient Deficiencies: First up, we should look for and address nutrient deficiencies. In the case of thyroid, we’re looking for:

    • Copper
    • Iodine
    • Iron
    • Selenium
    • Vitamin A
    • Vitamin B2 (riboflavin)
    • Vitamin B3 (niacin)
    • Vitamin B6 (pyridoxine)
    • Vitamin C
    • Zinc

    Excess Minerals: An excess of certain minerals can also reduce thyroid function. Too much copper, for example, can cause low thyroid function. Calcium, in excess, can also suppress thyroid function. Think about all the calcium we’ve been told to take for the past 20 years. That calcium may have been causing or contributing to low thyroid function in women.The National Health and Nutrition Examination Survey (NHANES) from the CDC and the US Preventative Medicine Task Force (USPFTF) no longer recommend high calcium intake.

    Medications: Thyroid function can be affected by medications. Many medications including estrogen replacement therapy, oral contraceptives, and blood pressure medications can impact thyroid function.

    Stress: Stress can affect your thyroid function in two ways. Unmanaged stress can directly elevate cortisol levels, which feed back and suppress TSH in your midbrain, thereby also suppressing thyroid function. Stress can also indirectly affect thyroid function through adverse effects on sleep.

    Diet: Several dietary factors can also affect your thyroid function:

    • Too little protein in the diet
    • A diet too low in fat
    • Low carbohydrate diets
    • Excessive alcohol consumption
    • Eating excessive soy and soy products
    • Consuming too many cruciferous vegetables

    The problem with too many cruciferous vegetables is not with the vegetables themselves, but an issue with sourcing. Some cruciferous vegetables can have thallium in them, a heavy metal that can affect your thyroid function.

    Addressing Low Thyroid

    What are some things you can do to support your thyroid?

    First and foremost, you need to know your levels. At the risk of being repetitive, it’s crucial that you get a full panel test (see below).

    Nutrients & Botanicals

    If you find that you have thyroid levels that are technically “normal” but suboptimal, consider doing some basic nutrient repletion with fat-soluble vitamins, B vitamins, zinc, copper, selenium, and iodine, if appropriate. I always recommend testing and not guessing for all nutrient supplementation due to the intricacies and interactions of these nutrients.

    There are also some botanicals you can use to help support your thyroid function. These include ashwagandha, which is also a great herbal for helping balance cortisol. Coleus forskohlii and bladderwrack are also thyroid-supporting herbs to consider.

    Overall, you want a comprehensive thyroid evaluation with adequate follow-through to find the root cause. If you have an autoimmune issue, it’s important to also consider gut health and toxins to see if they’ve triggered the autoimmune process.

    Elevated Thyroid (Hyperthyroidism)

    Of course, low thyroid isn’t the only problem you might encounter. Your thyroid levels are intended to be balanced. Too much thyroid is also a problem, and often the result (as we’ll see) of overcorrecting for other issues.

    Symptoms of Elevated Thyroid:

    • Anxiety
    • Breast enlargement in males
    • Brittle fingernails
    • Bulging eyelids
    • Chest pain
    • Constipation or diarrhea
    • Fast heart rate
    • Hot or cold intolerance
    • Irritability
    • Muscle pains and weakness
    • Nervousness
    • Night sweats
    • Sexual dysfunction
    • Shortness of breath
    • Skin changes
    • Sweating and hot flashes
    • Tremors or shakiness
    • Weight change

    Once again, this list looks a lot like the other symptoms presented throughout this series, which reinforces the principle: Test…Don’t Guess!

    Causes of Excessive Thyroid

    Graves Disease

    In Graves disease, your body creates a thyroid stimulating immunoglobulin (TSI) that causes excessive thyroid symptoms. However, In 20 years as a doctor, having seen over 100,000 patients in 5 different countries, I have only diagnosed Graves disease 5 times. It’s really uncommon.

    Most of the excessive thyroid hormone levels I see are from either overdosing medications, supplements, and herbals.

    The most common medications causing hyperthyroidism are amiodarone and lithium. Sometimes thyroid medications are used to treat other non-thyroid problems. This bears repeating. I see a lot of people trying to treat issues like elevated insulin, cortisol, toxins, etc. Practitioners assume based on symptoms that there is a thyroid problem, so they sometimes prescribe too much thyroid medication when indeed other things are going on. As I’ve said before, it’s important to assess all your hormones before treating them. I especially recommend working with a skilled practitioner if you suspect you are dealing with hyperthyroidism because there are important nuances in testing for this condition. Test…Don’t Guess! is the mantra of this series.

    In addition to medications, excessive iodine, selenium, calcium, or copper, can cause excessive thyroid function. Aging, genetics, and ethnicity can also play a role. Elevated thyroid is actually more common in Japanese people than in other ethnicities. Toxin exposures such as cadmium or other heavy metals can cause the thyroid to over-produce. Pregnancy can also affect thyroid function as well as viral infections.

    Addressing Elevated Thyroid Function

    A few of the many benefits to treating hyperthyroidism include the treatment of the following conditions:

    • Elevated cholesterol
    • Chronic fatigue syndrome
    • Fibromyalgia
    • Endometriosis
    • Gall stone prevention
    • Infertility
    • Anemia
    • Arthritis
    • Attention issues (e.g. ADHD)

    Thyroid Testing

    Since thyroid dysregulation can cause such a broad range of symptoms, it’s critical to adequately test to get a full picture of thyroid function.

    Common Pitfalls

    Often, thyroid testing is missed entirely. Since the list of potential symptoms is so broad, patients and their providers may simply fail to connect the dots from symptoms … to thyroid. I see this all the time. Even if a provider does think to test for thyroid issues, most providers rely on a single test.

    Why Do Most Doctors Typically Only Test TSH?

    A single TSH is the best screening tool for both hypothyroidism (underactive thyroid) or hyperthyroidism (overactive thyroid). And for that reason, most providers only use TSH to screen for thyroid dysfunction. However, a broad range of thyroid function can produce negative symptoms while still operating within “normal” but sub-optimal levels. This is sometimes called subclinical hyper or hypothyroidism.

    Relying solely on the TSH can miss subclinical thyroid dysregulation. A single lab result is not sufficient to assess your thyroid function.

    Best Practices

    A full thyroid panel includes the following tests:

    • TSH
    • Free T4
    • Free T3
    • Reverse T3
    • Thyroid Antibodies
      The thyroid antibodies can include an antithyroglobulin antibody, an anti-TPO (anti-thyroid peroxidase), and a TSI (thyroid-stimulating immunoglobulin)

    A Note on Natural Thyroid Hormone Supplementation: If a patient is on a natural thyroid hormone supplement, I sometimes include a few additional tests:

    • Total T4
    • Total T3
    • Thyroglobulin levels

    Since natural thyroid hormones can suppress a TSH while having a normal T4 and T3, I am careful to check these to ensure I’m not overdosing the patient. I see this routinely, but I’ve learned not to get overly concerned about a low TSH in people on natural thyroid hormones as long as their total and free T4, T3, and thyroglobulin levels are balanced.

    Normal vs. Optimal Ranges for Thyroid Labs

    So what are the normal ranges for thyroid?


    • Normal Range: 0.3 – 5.5
    • Optimal Range: 0.3 – 2

    Free T3

    • Normal Range: 2.3 – 4.3
    • Optimal Range: 3.4 – 4.0.

    Free T4

    • Normal Range: 0.6 – 1.4
    • Optimal Range: 1.0 – 1.25

    Reverse T3

    • Normal Range: 8 – 25
    • Optimal Range: 10 – 20

    A Sidenote on Reverse T3: Reverse T3 is often not checked by endocrinologists and other specialists because of some of the nuances related to it. I think of the reverse T3 as the brakes. If reverse T3 is high, it’s blocking the function of free T3 so you can have a “normal” thyroid level but if your reverse T3 is high, you will still be symptomatic. In this case, the issue is not your thyroid but something at the level of the mitochondria in the cells that are causing your body to want to put on the brakes. This requires a deeper dive with a functional medicine specialist.

    To see the big picture around the thyroid, I want to stress the importance of running a full thyroid panel and considering optimal ranges, not just “normal” ranges.


    In most of my articles, I provide a rich set of potential solutions for any given disease or condition. This article is admittedly light on solutions, because I’ve repeatedly emphasized how critical it is that you test your hormone levels. Neither you nor I will be able to figure out if your thyroid is unbalanced simply by noting symptoms. I might have some strong suspicions. So might you. But unless we run a full panel, we cannot know which of your hormones are dysregulated (and in which direction).

    Test…Don’t Guess!

    In case you are wondering what is involved in working with a functional medicine provider, this is one of defining differences. All of the providers at Richmond Integrative & Functional Medicine are trained to address the intricacies of your endocrine system — your hormones in harmony. Partnering with our providers involves a process of testing your hormones and testing your nutrient levels (among other things). We believe in getting to the root cause … in other words, knowing where you are, so we can help you develop a plan for where you want to be.

    Further Reading

    Hashimoto's Thyroiditis

    Lifestyle Interventions for Finding and Treating the Root Cause
    Isabella Wentz PharmD

    In her first book, Dr. Wentz does a great job outlining the scientific basis for autoimmune thyroid disease and then discussing its treatment. This book is geared towards those with a more scientific background. Reading this book first and then diving into Hashimoto’s Protocol would be the ideal sequence for anyone wanting to know more about Hashimoto’s and then in implementing a treatment for it.

    Hashimoto's Protocol

    A 90-Day Plan for Reversing Thyroid Symptoms and Getting Your Life Back
    Isabel Wentz PharmD

    This book is a follow up to Hashimoto's Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause. The first book was more technical and research-based. In this book, she focuses on the basics of treating autoimmune thyroid disease, the diet changes, and protocol needed for treatment. This more clinically-based work is a must-read for anyone wanting a basic approach to treating their thyroid.

    Why Do I Still Have Thyroid Symptoms?

    When My Lab Tests Are Normal
    Datis Kharrazian DC

    This is a large work that does a great job of addressing autoimmune thyroid disease. It is very detailed and complex but it covers almost every aspect of autoimmune thyroid disease and gives many of the treatment modalities. This book in combination with Dr. Wentz’s are probably the best two resources on the topic but both are complex and will require the reader to invest time in digesting the information. If you are new to integrative and functional medicine this may be a little hard to digest.

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