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.

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.