Hypothyroid, Hashimoto's, and Labs

I frequently see patients  who have been diagnosed with hypothyroidism who do not know the answer to one of my first questions: is the cause Hashimoto’s Disease?  More often than not, the answer is, “I’m not sure, my doctor said that didn’t really matter because the treatment is all the same.” Respectfully, I could not disagree more.

Hashimoto’s is the number one cause of hypothyroidism in the United States, and it is an autoimmune disease.  With Hashimoto’s, the immune system inflames and attacks the thyroid gland.  White blood cells accumulate in the thyroid and cause it to enlarge, but thyroid hormone production is reduced because the thyroid is systematically damaged. Symptoms often gradually and insidiously develop to include:

  • Fatigue

  • Weight gain

  • Feeling cold

  • Constipation or sluggish digestion

  • Hair thinning or dry hair

  • Difficulty becoming pregnant, or miscarriage

  • Irregular or heavy periods

  • Depression

  • Foggy feeling or forgetfulness

  • Muscle aches or pain

  • Headaches

Traditional teaching is that all hypothyroidism is created equally, and all is treated with levothyroxine (Synthroid).  Levothyroxine is the nation's most prescribed medicine, it is the very definition of a one size fits all approach. In my experience, levothyroxine is a wonderful and often life saving medication for many people, but not everyone responds equally.  

Levothyroxine works by supplying T4 thyroid hormone, which is converted throughout the body into the more usable T3.  That process works well for people whose hypothyroidism is not caused by an autoimmune inflammatory process.  In Hashimoto’s however, one of the antibodies made by the white blood cells (TPO Antibodies) attacks the enzyme that helps convert T4 to T3, rendering artificial supplementation with T4 inadequate. Unless, that is, you manage to dramatically reduce your TPO antibody level, allowing T4 to effectively resume conversion to T3.  

You are probably wondering at this point where you start and what you do to investigate and treat your thyroid condition properly.  I want to make this as clear and applicable as possible so here is a step-wise breakdown of what I recommend.

1) If you have symptoms of hypothyroidism, begin by asking your family if anyone has been diagnosed at any point with a thyroid condition.  Go as in depth as you can and ask about aunts, uncles, and grandparents, as well as your nuclear family.  Hashimoto’s hypothyroidism runs in families.  In my experience, if one person has it, someone else does (or will) as well.    

2) Get as full of a thyroid panel as your budget reasonably allows.  Lab tests can be pricey, and insurance often does not cover the full testing functional medicine practitioners recommend.  My definition of essential preliminary testing for investigating a thyroid issue is:  TSH, free T3, free T4, TPO antibodies, and Thyroglobulin antibodies.  If money's no object, add in a reverse T3.  If you’ve already had an abnormal thyroid test, I would also recommend assessing vitamin and micronutrient levels, which are critical to optimal thyroid health.  Specifically, vitamin D, ferritin (iron), selenium, zinc, and magnesium (RBC levels).  Some labs such as Genova Diagnostics and Spectracell have test bundles, allowing for more extensive testing at a deeply discounted price.  

3) Understand that what is considered “normal” on most lab reports truly just means adequate for survival, not necessarily what makes you feel well. The ranges that I consider optimal for my patients are much tighter than those used in the traditional approach to managing hypothyroidism.  This is one area where Allopathic (M.D.) medicine and Functional Medicine differ greatly. This is also why many of my patients have come to me, they are tired of being told that they are “fine” when they feel less than.  I can’t begin to count the number of Hashimoto’s patients who have come to me after being told that their symptoms are not due to their thyroid and that they should instead consider seeing a Psychiatrist.  

4) If you have been found to have Hashimoto’s hypothyroidism, or elevated thyroid antibodies in the setting of normal thyroid function, don’t try to go it alone.  Find a physician who is able spend adequate time getting to know you and your health.  Functional and Integrative Medicine doctors enjoy the investigation and thrive on putting all of the pieces together.  Willingness to use alternatives to levothyroxine, such as whole thyroid replacement, compounded T3 and T4, nutritional therapy, micronutrient repletion, herbs, and adaptogens, may be challenging to find, but it will be worth your time and energy to do so.  Don’t be afraid to ask potential practitioners how they most often treat Hashimoto’s so you have a sense of whether or not they are open minded and a good fit.  I love my physician colleagues, but when referring my patients, friends, and family to them, I am sure to seek out the ones who are willing to at least consider life beyond what we all learned in medical school.  

If you are diagnosed with an autoimmune condition, you are at risk for development of additional autoimmune diseases such as MS, Rheumatoid Arthritis, Lupus, or Psoriasis.  Getting a handle on gut health, toxin exposure, vitamin and micronutrient levels, and inflammation is the path to healing.  I liken the thyroid to the canary in the coal mine, you have warning and you can change your destiny.  Unless you want to steadily increase your levothyroxine dose for the rest of your life while continuing to feel unwell, break free of the one size fits all approach to hypothyroidism.  It’s not in your head, this doctor believes you.

Allison Fox, M.D.

Your Annual Physical Just Isn't Enough

“What?? How could she be sick? She just had her annual physical and everything was fine!”

It may seem perfectly logical when somebody says this, but here’s the surprising truth: Neither the standard annual physical exam, nor the routine blood tests associated with it, have ever been shown to make a measurable difference in helping people detect life-threatening diseases at an early stage.  

If you’re shocked by this, you’re hardly alone. Although in many cases disease can be halted or reversed if detected in the early stages, the most intentional thing that most of us do to protect ourselves is to go for our annual checkup. And sadly, that annual physical won't keep you from getting sick, or help you live longer -- at least according to every study ever done on the subject. Luckily, the answer isn’t simply to despair, or sit idly by and wait for illness to develop.    

The human body is capable of healing itself. When we are exposed to stress (think radiation, toxins in our air and water, tobacco smoke, certain drugs, ozone, charred foods, etc.) that stress damages our cells. That cellular stress is called oxidative stress, and it is the very thing that triggers aging and illness.  Yes, you heard that correctly - oxidative stress is exactly what makes you age, and get sick.  

The only way to prevent oxidative stress is with something called an antioxidant.  Some antioxidants are found in our diet, and some our made in our cells.  If, in addition to maintaining healthy levels of your own antioxidants, you also eat a diet high in the food-based antioxidants below, it is the cellular equivalent of doubling your defense budget.  

The ones that are made in our cells are:

  • glutathione

  • CoQ10

  • alpha lipoic acid

  • catalase

  • superoxide dismutase (SOD)

The ones that are found in our diet are:

  • vitamin C

  • vitamin E

  • carotenoids (carrots, sweet potatoes, cantaloupe, dark leafy greens, broccoli, peas)

  • polyphenols (ginger, dark chocolate, cloves, elderberry, raspberries, blackberries)

But that leaves us with a million-dollar question: If our body's are so capable of fighting disease, why do we still get sick? Simply put, when the sheer volume of stress surpasses the bodies ability to heal itself and recover, the scale tip over (and not in your favor). You can picture it like a game of Jenga – when all of the pieces are together and the tower is complete (your body at full capacity) it takes a whack to knock it over. But once a whole bunch of blocks have been pulled out (your body under extreme stress), just breathing the wrong way can send the tower toppling.

It probably won’t surprise you to hear the usual suspects that stress the body and rob it of its self-healing ability: inadequate sleep, emotional stress, untreated depression, immobilization, and exposure to toxic substances like pesticides, some medications, food dye, artificial sweeteners, or even plastic..

Scary? Well, sure, it can be. But my hope is that this information will empower you and encourage you to take your control back. Knowing that there are highly sophisticated systems in place in your body to fight disease is the first step to regaining your health. The second step is to shore up your defenses by testing your antioxidant levels and correcting any deficiencies through diet and supplements.  This type of specialty testing is available through Functional Medicine, an approach to care that is rapidly disrupting the entire healthcare industry in its approach. Functional Medicine physicians test for cellular levels of antioxidants and create customized plans to improve them.  Not something you were offered during your last physical, right?  

While it might be tempting to just take a boatload of antioxidants in supplement form as opposed to precisely measuring and carefully replenishing them, there is good evidence that too much of a good thing… well, it might not be a good thing at all (actually, it might be plain dangerous).

Once you've tested your antioxidant levels and brought them up to a healthy range, it is critical to remove any toxic substances from your body that might currently be making you sick. There are now tests available that can check your levels of heavy metals, pesticides, BPA, phthalates, parabens, VOC's,  and PCBs.  If your levels are abnormally elevated, which is pretty common given the sheer number of chemicals we are exposed to every day, a Functional Medicine physician can then create a plan to remove them from your body once and for all.  Flushing cancer-causing chemicals from the body will help prevent depletion of your antioxidants, which ultimately means preventing disease.  

After increasing your antioxidant levels and flushing out disease-inducing chemicals, taking a thoughtful look at your lifestyle from the perspective of inflammatory triggers is next.  This means really focusing on sleep, exercise, diet, and your overall happiness as a means of maintaining or restoring health.  

It is easy to see why these lifestyle factors are the focus of most health advice. However, science has come much further than this.  If it is as simple as eating well and exercising, why do people who do both still get cancer?  While looking at the triggers for disease, and the mechanisms that worsen or progress it, there is no smoking gun.  

All sickness begins with health.  It is a spectrum, and it is multi-factorial.  There is a widespread belief that one day a switch gets flipped and you go from being well to being sick.  Everything we know about science and medicine actually refutes this and instead validates that illness begins at the cellular level.  

The Functional Medicine approach also begins at the cellular level, and then it expands from there to ultimately address our day-to-day lifestyle choices that either keep us well or make us sick.  This new paradigm ensures that the patient is no longer in the passenger seat.  This new paradigm helps you to reclaim your health, your vitality, and your control.  

Allison Fox, M.D.

The Straight Buzz on Coffee

I've noticed an intriguing phenomenon over the last several years that I've fondly nicknamed coffee shame.  What is coffee shame?  Thewell-intentioned, but typically misguided, guilt or remorse over one’s coffee consumption.

As I obtain my patients’ full medical and social history, their alcohol, exercise, and green vegetable "habits" rarely seem to provoke the kinds of explanations their coffee consumption so frequently does. "I know I should be drinking less", "I tried so hard to give it up, but I just couldn't do it", and "I've been doing half-caff, that's better, right?"-just a handful of the disclaimers that patients tend to lead in with.  

All of this coffee shame, combined perhaps with my personal love for the age-old brew, has prompted me to attempt to set the record straight.  In the wise words of Clark Gable, “I never laugh until I’ve had my coffee.”  So here are some facts about coffee to smile about. The proven benefits of low to moderate coffee consumption are plentiful.  I have listed them below for you.  Of note, low to moderate is defined as less than three eight-ounce cups per day.


  • Increase in alertness and ability to concentrate

  • Decreased risk of Parkinson's disease

  • Slightly lower or delayed risk of Alzheimer's disease

  • Decreased risk of Type 2 Diabetes

  • Improvement in acute headache symptoms

  • Modest decrease in constipation symptoms

  • Decreased risk of alcoholic cirrhosis

  • Slowed progression of liver disease in those with advanced Hepatitis C

  • Reduced risk of gout

  • Decreased risk of liver cancer

With all of these incredible potential benefits that low to moderate coffee consumption can have, are there downsides?  Well, just like anything that is enjoyable, there are.  The downsides can include:

  • Difficulty sleeping

  • Increased anxiety and agitation

  • Increased risk of cardiac arrhythmias and cardiac events in those that are susceptible

  • Physical and/or psychological tolerance or dependence on caffeine

  • Caffeine withdrawal symptoms in those that are tolerant or dependent

  • Mild elevation in cholesterol when consuming unfiltered coffee (e.g. French press, espresso)

  • Slowed growth and even potential risk of miscarriage or preterm birth when consumed in pregnancy (the studies are mixed on this so always ask your OB)

When I explain all of this to my coffee-loving patients, I usually tell them that there are two magic numbers to keep in mind. Those numbers are two and twelve. Try to keep your coffee consumption to two eight-ounce cups per day, and drink those two cups before twelve o'clock noon.  Pushing the limits of what is considered safe intake of anything is never a good idea, and drinking caffeine of any kind in the afternoon often leads to problems sleeping.  I do have several patients that I recommend stop drinking coffee altogether for various health reasons, so it is extremely important to always check in with your doctor before assuming that your cup of joe is a safe habit.  

Allison Fox, M.D.

Top 5 Misconceptions About HPV

1. “Once you have HPV, you have it for life.”

Not at all! If your immune system is healthy, you can get rid of the infection for good. It may take a little time, but by taking appropriate steps, you will again test negative for HPV.

2. “I had the HPV vaccine, I can’t catch the virus.”

Despite the HPV vaccine being highly effective at preventing certain strains of HPV, it absolutely does not protect you from every strain out there. You can get the HPV vaccine and still get HPV, I’ve seen it happen many times.

3. “Condoms protect you against all STDs, including HPV.”

This is a dangerous misconception. HPV is a virus that is spread through skin to skin contact. While condoms are clearly extremely important in the prevention of most STD's, they only reduce the risk of HPV spread.  In other words, you can use them 100% consistently and correctly and still get HPV.

4. “After a colposcopy removed the damaged cells, the virus is gone.”

The colposcopy procedure removes the cells of your cervix that have been damaged by HPV. However, the virus itself lives throughout your body, which is where my diet and lifestyle recommendations come in. A healthy immune system will help clear the virus up from your body for good.

5. “Older women don’t need Paps, they are for women of childbearing age.”

One in 4 cases of cervical cancer occurs in women over the age of 65. Forty one percent of cervical cancer deaths also occur in this age range. While every woman does not need a Pap every year, every woman does need a visit to see their physician to discuss their personal risk and decide on the best plan.

Allison Fox, M.D.

If You've Ever had an Abnormal Pap, This Article is for You

HPV (The Human Papillomavirus) is the single most common STD in the U.S., affecting upwards of 79 million Americans. It is so common that approximately 14 million people become infected every single year.  Based on my own experiences when counseling my patients about their HPV diagnosis, most people do not realize how much they can do themselves to help their body eliminate it.

HPV is screened for on routine Pap smears, which is of course only a fraction of the reason why seeing your healthcare provider routinely is so critically important.  The HPV virus causes genital warts, abnormal Pap smears, and ultimately, if left untreated, cervical cancer.  HPV is also responsible for several other less common, but unfortunately on the rise, cancers.

When HPV is found on a Pap smear, the conversation usually goes something like this: "You have an STD called HPV. Sometimes your body gets rid of it on its own, and sometimes it doesn't. We would like to get a better look at your cervix to see if the virus has caused damage. Be sure to schedule that test, which is called a colposcopy, before you leave. The procedure is quick, but it is not painless. You’ll want to take ibuprofen ahead of time to help with the discomfort. If left ignored and untreated, it could cause cervical cancer." Yikes! Is it any wonder that most people leave these appointments confused and mortified!?

Here is the part of the story that rarely makes it to prime time.  With so many other important topics to go over on you routine doctors visit, there is often not enough time for this. There are in fact things you can do to help clear the infection up.  I’ve outlined them below for you.

1) Eat your folate! Folate is a B vitamin found in dark green leafy vegetables, and it has been proven to  help rid the body of HPV.  It is always preferable to obtain your vitamins through food, but there are supplement options as well. Dosage and formulations vary, and make a huge difference, so I don't recommend navigating this one on your own.  It’s important to know that some people have a gene that actually makes synthetic folate (folic acid) dangerous. There is, however, no risk to experimenting with that new kale, swiss chard, broccoli, or spinach recipe you've been wondering about - your body will thank you!

2) Quitting cigarette smoking is also proven to help clear up the HPV virus.  If you smoke, your body is constantly fighting an uphill battle to stay healthy. The HPV virus loves smokers! My patients that smoke seem to be perpetually HPV positive despite their best efforts to heal the infection.  

3) Stress and poor sleep make recovery from HPV more difficult.  High emotional stress levels are associated with increased oxidative stress.  Oxidative stress is linked to an increase rate of progression of HPV to cancer.  If you needed one more reason to learn to meditate and get a good night's rest, perhaps your abnormal Pap smear is it.  Learn more about fighting oxidative stress here

4) There is convincing evidence that other essential vitamins and nutrients also play a role in healing from HPV. Some of those other supplements include Vitamin B12, Vitamin C, Vitamin E, Retinol, Beta and Alpha-Carotene, Lycopene, Lutein/Zeaxanthin, and Cryptoxanthin.

5) Long term use of hormonal contraceptives (the pill, the ring, the patch, etc.) is linked to persistent and aggressive HPV infection.  There are safe effective contraceptive options that do not involve the use of systemic hormones.  Talking to your provider about them is never a bad idea, especially if you have HPV.

The most important piece of advice I can give you is to rethink your body's relationship with the HPV virus.  You are not a helpless victim of this virus, you are at war with it - and if you work with a knowledgeable physician to make a few adjustments in your diet and lifestyle, you can win.   

Allison Fox, M.D.