EP 55: What Your Doctor May Not Know About Thyroid Function With Jim Paoletti, BS Pharmacy, FAARFM, FIACP

According to the American Association of Clinical Endocrinologists, an estimated 27 million Americans have thyroid disease, and more than half of those individuals are undiagnosed and unaware that they have a thyroid condition.

However, it’s important to understand that if more comprehensive thyroid testing was used by doctors and functional reference ranges were used to interpret that testing instead of the overly lax lab reference ranges, a much larger number of people would be classified as having some type of thyroid dysfunction.

Most doctors rely almost exclusively on the thyroid stimulating hormone or TSH test to detect thyroid dysfunction, yet TSH is not even technically a marker of thyroid function, it’s actually a marker of pituitary function. Even worse, the medical community can’t even agree on what the normal reference range is for the TSH test.

My other issue with conventional medicine is its refusal to actually look at underlying causes of thyroid dysfunction including but not limited to gut inflammation, chronic stress, adrenal issues, nutrient deficiencies, toxins in our food, air, and water, and chronic infections such as periodontal disease and h. Pylori.

The thyroid’s primary function is to control the body’s metabolism – the rate at which cells perform duties essential to living. It manages how we turn our food into energy by facilitating the processes of energy production in the mitochondria. I want you to think of your thyroid as your body’s “engine,” which sets the pace at which the body operates. Too little thyroid hormone can cause the body’s systems to slow down, and too much thyroid hormone can cause the body’s systems to speed up.

In today’s episode, I brought back my friend and pharmacist, Jim Paoletti, to talk about this amazing gland that does so much for us. In fact, there’s not a single cell in the body that doesn’t depend on thyroid hormone in some way.

Jim Paoletti, B.S. Pharmacy, FAARFM, FIACP is an independent clinical consultant on hormones, nutrition, and wellness. Jim has 40 years of experience with bio-identical hormone therapies in clinical practice, both in retail pharmacy and as a consultant and educator. Jim served previously as Director of Provider Education for ZRT Laboratory, Beaverton, Oregon, and as consultant and Education Director for Professional Compounding Centers of America in Houston, TX.

He is a graduate and former faculty member of the Fellowship of Anti-Aging and Functional Medicine. Jim has lectured extensively and internationally on all aspects of compounding and BHRT to medical practitioners and consumers, and has several articles published on BHRT and compounding pharmacy issues. Jim has published the book A Practitioner’s Guide to Physiologic Bioidentical Hormone Balance.

In this episode, we discuss:

Why your doctor may be relying on testing that provides an incomplete picture of thyroid function
How laboratory reference ranges don’t reflect optimal functional ranges that end up leaving patients frustrated and without resolution
Why assessing adrenal function is key to evaluating and treating thyroid issues
Why synthetic vs natural thyroid hormone replacement is misleading

Listen to the podcast here:

Within the below transcript, the bolded text is Samantha Gilbert and the regular text is Jim Paoletti.

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What Your Doctor May Not Know About Thyroid Function With Jim Paoletti, BS Pharmacy, FAARFM, FIACP

According to the American Association of Clinical Endocrinologists, an estimated 27 million Americans have thyroid disease and more than half of those individuals are undiagnosed and unaware that they have a thyroid condition. However, it’s important to understand that if more comprehensive thyroid testing was used by doctors and functional reference ranges were used to interpret that testing instead of the overly lax lab reference ranges, a much larger number of people would be classified as having some type of thyroid dysfunction.

Most doctors rely almost exclusively on the Thyroid Stimulating Hormone or TSH test to detect thyroid dysfunction. Yet TSH is not even technically a marker of thyroid function. It’s a marker of pituitary function. Even worse, the medical community can’t even agree on what the normal reference ranges for the TSH test. The risk of thyroid dysfunction increases with age and women are seven times more likely than men to develop thyroid problems.

My other issue with conventional medicine is its refusal to look at underlying causes of thyroid dysfunction, including but not limited to gut inflammation, chronic stress, adrenal issues, nutrient deficiencies, toxins in our food, air, and water, and chronic infections such as periodontal disease and H. pylori. The thyroid’s primary function is to control the body’s metabolism to the rate at which cells perform duties essential to living. It manages how we turn our food into energy by facilitating the processes of energy production in the mitochondria.

I want you to think of your thyroid as your body’s engine, which sets the pace at which the body operates. Too little thyroid hormone can cause the body’s systems to slow down and too much thyroid hormone can cause the body’s systems to speed up. In this episode, I brought back my friend and pharmacist, Jim Paoletti, to talk about this amazing gland that does so much for us. In fact, there’s not a single cell in the body that doesn’t depend on thyroid hormone in some way.

Welcome, Jim. Thanks for joining me in this episode. I’m so excited to have you back on the show.

I’m so happy to be back on the show.

The last time you were on the show, we talked about sex hormones and touched a bit on thyroid function. I wanted to bring you back on so we could dive deeper into the thyroid gland as well as appropriate treatments and testing. There are quite a few reasons thyroid function may be off such as cortisol imbalances, autoimmunity, stress, gut infections, and nutrient deficiencies, as you well know.

Functional Thyroid Testing

Let’s start off with testing. Many doctors only look at Thyroid Stimulating Hormone or TSH, which is a pituitary hormone that stimulates the thyroid gland to make hormones. As you know, it’s difficult to help someone without digging deeper and treatment is often inappropriate because the deeper investigative work was not done upfront. Jim, why is a full thyroid panel that also includes antibodies so important to the healing process?

Let me point out first. I avoid the use of the word panel. A panel is a set of tests that a laboratory puts together. They are for implying to a physician, “This is what you need to check,” and they want to make it easier for the physician. “You check this thyroid panel and you’re going to get everything you need, doc.” I always say, “If we do full, appropriate thyroid testing, then we can answer the questions we need to answer.”

As you mentioned, there are multiple causes. You have to answer the question. “Is this patient having an autoimmune reaction in the thyroid gland?” That’s the number one cause of thyroid disorders in the United States. You got to ask that question. Is this person for producing an optimal amount? Is this person converting T4 to T3? If you do the right set of thyroid tests, you’re able to answer those questions for the most part.

The number one cause of thyroid disorders in the United States is an autoimmune reaction in the thyroid gland. Click To Tweet

When you mentioned antibodies, that’s a key to me. Most practitioners I see do not test for antibodies. Endocrinologists have said it doesn’t affect their protocol, which makes no sense. You have an autoimmune and inflammatory reaction in the thyroid gland. It has been shown to damage the thyroid gland. That’s the gland you’re trying to regulate the function of and you’re ignoring that fact. It makes no sense based on physiology. However, I understand why most physicians do not test thyroid antibodies.

When a physician orders a test, if it comes back abnormal, they are either liable for treatment or referral to another physician. If you’re a regular physician, you refer to an endocrinologist and they ignore it. Your patient is not happy and that’s the feedback they get from the patients. It’s something that needs to be tested, but I understand why it’s not tested more.

Why do you think there’s hesitancy? Is it a liability? We know that when we go deeper, we get better results.

If you’re the practitioner, why would you order a test if you don’t know what to do with it if it comes back abnormal? If you had no training in how to treat hypertension, would you measure blood pressure? No. What we need to do is educate more physicians on, “This is how you measure and treat autoimmune disorders.” That’s the key.

I’m glad you said that. My question is more about the information and training readily available to physicians. In 2022, why is there still hesitancy when we have so much more information available to us?

If you’re a physician, how many years have you gone to school? How much money and time have you spent on this education? You get out and somebody tells you, “You don’t know enough.” They should be trained in school on these things. I would be reluctant if I had gone to school for 8 or 10 years and spent all that money. If I got out of school and somebody told me, “That’s not what it’s about.” That’s the problem with functional medicine. It requires so much additional time, training, and money. Not everybody can do that.

I’m glad you shared that with us. Your insight into a panel versus calling it full thyroid testing is also important.

I’m trying to get more of us to use the term functional thyroid testing.

What Increases Thyroid Antibodies?

Jim, since we’re talking about antibodies and it is what we commonly see, underlying that we often find gut infections, viral infections, and nutrient deficiencies. What else do you often see that is jacking up thyroid antibodies?

It’s usually the food sensitivities and they’re not being tested or identified. If a person’s having an inflammatory reaction to a food, an autoimmune reaction that’s causing leaky gut, they develop more and more food sensitivities over time. The symptoms can also become so random. If you have an autoimmune reaction, this is like having a fire in your gut. Every time you consume a triggering food, you’re pouring gasoline on the fire.

Having an autoimmune reaction is like having a fire in your gut. You're pouring gasoline on the fire every time you consume a triggering food. Click To Tweet

It’s damaging your gut, but where it manifests is a disease state, whether you have celiac, Crohn’s, Hashimoto’s, Graves, diabetes, or rheumatoid arthritis. There is a list of 100. Where it manifests in an individual, we don’t know what causes that but I try to explain to patients that it’s where the smoke is going. The smoke is going to your thyroid causing Hashimoto’s.

You can have ten people sitting in front of you. They’re all sensitive to gluten. They all have a different disease state that’s manifested. That’s what we don’t understand but the science is pretty clear now. If you have one autoimmune disease state occurring and you do not address it and stop that triggering, chances are that within fifteen years, you will manifest a second autoimmune disease. It’s a process that we need to learn to stop.

I’m so glad you said that there’s more susceptibility to getting additional diagnoses that are going to impact other areas of the body. If we can calm that fire and put out that flame early on, we can have normalcy and healing which is so critical. We talked about this last time. One of the reasons why we always have people stop inflammatory foods like sugar, gluten, and dairy is because we want to start off right out of the gate by fanning the flame of inflammation.

What’s the first thing I do with a patient that has an immune issue? Anti-inflammatory diet. I’m with you all the way. It starts with the diet. We can control these symptoms while we figure out what’s going on. What’s the most important thing? What you’re putting into your mouth.

Thyroid T3 Receptors, Vitamin D, and Ferritin

In addition to functional thyroid testing, we also like to look at vitamin D and ferritin. Why is that?

Vitamin D is a hormone. You can call it a vitamin as much as you want, but if you look at the structure, how it’s formed in the body, or how it is a messenger, it’s a hormone. Vitamin D receptors form dimer receptors with thyroid T3 receptors. There are interactions there, but vitamin D affects the response of the thyroid receptor. Now, you can have “normal” vitamin D. The normal range is 30 to 100 or 150 in the lab. How was 30 determined as the low end of the normal range?

About a century ago, we determined that if you have less than 30 as a vitamin D level, you may very well get rickets. Somebody comes in and they got a 32. The doctor says, “You’re normal,” and go, “Congratulations. You’re not going to get rickets.” For optimal thyroid function, bone formation, and possibly cancer protection, you want to get that across 60 or 70 ng/dL. That’s something we see with vitamin D deficiency. I don’t care if you soak in the sun for an hour a day. That doesn’t work for most people.

I had a friend, a physician who owns a laboratory up in Calgary, Dr. Gilson. It’s sunny up there. He goes out in the summer. He takes his shirt off at lunch and eats outside. He sits out in the sun every day for a month. Practically, there was no change in vitamin D. I have a construction worker in Houston who wears cutoff shirts and he is tan as can be. He has low vitamin D. On the other side, there are some people that can lower their vitamin D dose slightly in the summer. They do make more, but you can’t count on it.

Ferritin is also important for optimal thyroid function.

I understand why doctors don’t know this. They think of ferritin as iron. It’s a storage form of iron. Ferritin itself is not iron. Ferritin is the peptide that binds iron and stores it. It’s a backup iron supply in case you need a backup if you’re getting low on iron. Ferritin can also bind with free T3 and it is responsible for intracellular transfer. Getting that free T3 from the cell membrane down the nucleus where it works.

Ferritin ranges are horrible. The normal ranges start at 14.8. I’ve never seen any patient with ferritin under 50 that feels good. The optimal for thyroid function is 90 to 110. Ferritin does go up with inflammation so it’s tricky sometimes measuring it. That’s one thing. If you have a patient that you think has autoimmune symptoms and their ferritin is high, that’s probably from the inflammation.

Once you get the inflammation under control, the ferritin may drop. Ferritin is also tricky in this. Less than optimal ferritin causes lower thyroid function. Low thyroid function lowers ferritin. You get in this vicious circle. You may have a patient who has been running low vitamin D for three years developing symptoms and slight hypothyroidism and now their ferritin’s going down. What do you need to do to fix that patient? You need to give them ferritin and vitamin D.

Once you get the ferritin up to optimal, if you fix the other problems that caused low thyroid function, you should be able to take that patient off the ferritin, but you’ve got to get it up there. It’s a tricky little thing, but if you can get doctors to measure it, I have not seen a patient who’s had symptoms of low thyroid function for at least eighteen months. I don’t think I’ve ever seen one with a good ferritin level.

I’m in agreement here. I often see that myself. Another common mistake that we often see is basing treatment on conventional lab ranges versus the functional ranges that we’re talking about. That can also lead to inappropriate treatment. You mentioned a few, but would you mind sharing some more examples?

First of all, it’s TSH. The thyroid stimulating hormone is a pituitary messenger hormone. When your thyroid hormone levels go down in your blood, that’s released to make some more. As a test, that was designed as a screening tool. A screening tool test says, “Run this first. If it’s out of normal, do further testing.” Nowhere in science does it support using TSH to determine if you need thyroid replacement or adjusting the dose. It is used incorrectly on a daily basis, especially by endocrinologists. That’s how they adjust your dose. It’s a screening tool.

First of all, I always ask, “Do I need a screening tool?” I’ve got a patient set in front of me with twelve symptoms of low thyroid. Is that not a screening tool enough to say, “Do the testing?” Yes. A better screening tool is basal body temperature, but that’s it. Labs give you a range that goes up to 4.5. In some labs, it’s 6.5. There are two large groups of endocrine experts that have been saying this for over 10 years. That’s way too high. They say it should go up to 2.5 or maybe 3.

In functional medicine, the optimal is 0.2 to 2.0. The ideal is 1.0. You test with your doctor and you come back at 3.79. Your doctor says you’re fine. I’m like, “You’re not. We got a problem.” If you look at the actual hormone, total T4, free T4, and free T3. If you measure any of those, what is optimal? In my opinion, there are numerous different ranges with the labs. I’ve got a list. Every time I get a lab with a new range, I write it down. I’ve got twenty different normal ranges for free T4. Patients give me, “My free T4 is this.” If that’s the normal range for that lab, it doesn’t help me. I say, “Whatever lab it is, cut 25% off the low and the high end. That’s your optimal.”

The other one is the antibodies and this is a key one. When I was taking my Fellowship and Functional Medicine classes, Dr. Shari Lieberman taught me about immunity. She says, “It is not normal to have any antibodies to something that belongs in your body,” which makes perfectly good sense. What’s the normal range of TPO antibodies? Zero.

Why does the lab have a range of 0 to 34? It’s because autoimmune reactions can happen on a mild basis for a long time with people. They don’t show the symptoms and they’re included in the study group. Those tests are also not super accurate. If you have a lab where your normal range for TPO antibody or Thyroid Peroxidase antibody is 0 to 34, here’s how I classify it. Dr. Arem who wrote The Thyroid Solution shared this.

We’re teaching a group of doctors and he said to these doctors, “If you do an ultrasound of the thyroid gland, you will find that inflammation caused by the autoimmune reaction is five times more than the numbers will identify it. We’re missing a lot. He treats five and above as a positive. What I do is I treat 6 to 10 as possible, 11 and higher, you have a reaction. In what I’ve seen clinically, those people who come back at 11, I say you have an autoimmune reaction. If I do food sensitivity testing, we’re going to find something. It’s never failed.

How you interpret that test result is important. Thyroglobulin antibodies, the other one that’s commonly done, I don’t bother to do it anymore, and here’s why. In the last 30 thyroid antibody tests, I saw the same range come back from different labs. The normal range is 0 to 0.9. The result is always less than 1.0. If you’re a 0.95, you’re positive on a test that didn’t show that. What kind of a test is that? You can’t even rule out a positive. It’s not accurate enough to measure down to their normal range. You have to have a high reaction going on for that test. There are a lot of false negatives.

It amazes me that doctors don’t even look at the numbers and think, if higher than 0.9 is normal and you can’t measure some of these people, what are you running a test for? What I have people do now is call the lab that’s going to run your test. Ask them two questions. What is your normal range for this antibody test and how low can you measure? If it’s not clear, get back to me with those numbers. I’m going to say, “Don’t use that lab. You’re wasting your time and money.”

The best TPO antibody tests, the wider the range, it is easier to spot the people within the “normal range” or having a reaction. ZRT Laboratory has a normal range of 0 to 150. They call 70 and above borderline. That’s their way of saying that’s a positive. In my book, 25 to 49 is probable and 50 and above, you have a reaction going on. You can see that the wider the range, the easier it is to spot those. I’ve had patients take their order for TPO antibodies and they do their at-home capillary blood finger-prick test and turn it in to the insurance companies if they’re frustrated with getting good results.

How Functional Hypometabolism Affects Thyroid Function

Jim, what is functional hypometabolism, and how does this affect thyroid function?

The best way to explain it is to differentiate between hypometabolism, primary and functional. Primary hypometabolism is when you’re not making enough hormones. If you talk about hypothyroidism, by definition, that is, “I am not making a thyroid hormone.” In functional hypometabolism, you’re making plenty of hormones. You’re binding it excessively and not converting it or you have other issues as we talked about at the thyroid receptor and interference by cortisol.

That’s functional hypometabolism. You don’t need thyroid hormone. You’re making enough. We need to fix how you’re metabolizing it, how you’re handling it in the body, and how your receptors respond to fix the problem. How does it affect thyroid function? Big time. In my opinion, from my years of looking at my research and in the fellowship back in the old days, we thought it was going to become a PhD program. It’s a science, but I was preparing for writing a PhD paper on the thyroid. That’s why I got so into it.

I spent two years learning everything I could from every textbook on the thyroid. I’m not disappointed I didn’t go into the PhD program. I learned to help patients and that’s what counts. In my opinion, the most common cause of subclinical hypothyroidism, which is raging now, is the poor conversion of T4 to T3. If the doctor measures TSH and T4, there’s no reflection of that. You have to look at the free T4 and free T3 and compare those two to see if you’re optimally converting it.

If you talk about thyroid receptors, again, if you have everything else completely optimal, you have an optimal amount of free T3, but if your thyroid receptor is not responding because you have high cortisol and/or low vitamin D, you’re still going to have the symptoms. You have to look at the process all the way from the production of hormones down to, “This is the receptor responding.” Where are the problems there? That’s a functional analysis of thyroid function.

I firmly believe most patients have more than one issue. It’s rare to find someone who says, “This is what’s causing your thyroid problem. This low vitamin D. That’s it.” No. It’s usually multiple scenarios where they have 2 or 3 things we have to address. What’s the most common thing that causes low thyroid function? High or low cortisol. I always teach doctors, “If you’re going to address thyroid function, the first thing to do is you need to run four-point cortisol to DHEA and find out what’s going on with the adrenals.”

EFL 55 | Thyroid Function — Thyroid: Most patients have more than one issue. It’s rare to find just one thing causing your thyroid problem. It’s usually multiple scenarios where they have two or three things we have to address.

In fact, it’s a contraindication. For any of your thyroid products, if you read drug interaction, it’s a contraindication. What’s a contraindication? It’s hypoadrenalism. It doesn’t matter how you define hypoadrenalism. Whether you have to be so low, you have Cushing’s or you just malfunctioned, the fact that it’s a contraindication means that you need to check the adrenal function before you try to fix the thyroid. You have to. It’s a contraindication.

For people who don’t understand what is a contraindication, it’s pretty strong. The only stronger warning with drugs is a black box warning. Doctors avoid drugs that have black box warnings. Contraindication is the next strongest thing. To me, it’s something that’s been highly overlooked. Look at endocrinologists. They don’t check adrenal function at all, but they’ll give a thyroid medication that says, “Hypoadrenalism is a contraindication.” We’re not following the science.

If your cortisol is high, it suppresses TSH. It inhibits the conversion of T4 to T3. It decreases thyroid receptor function. That’s three strikes against you. If cortisol is low, less thyroid receptor response, less number of thyroid receptors, and less absorption of T3 into the cell. What if you got high and low cortisol? You had six different mechanisms. If you don’t address the cortisol, you’re not going to get the thyroid symptoms taken care of.

This is so common. Stress is a big part of this. We’ve talked before about how stress impacts the adrenals and also the nutrient deficiencies. This is where diet is key to helping with this whole scenario. We talk about stress and we all experienced stress, but because it’s not this tangible food on my plate that I can see, we forget about it. We don’t realize how much it impacts us until we’re not able to function, which is unfortunate. I want to make sure that we throw in the stress piece as well, especially in this world.

Since insufficient thyroid hormone affects every function of the human body, it’s not surprising that we can develop widespread symptoms throughout the body. When the thyroid isn’t working optimally. Among other things, the thyroid hormone affects brain development and gastrointestinal motility. Meaning the time it takes for food to move through the intestines is slowed when there’s low thyroid function. It also impacts stomach acid production because low thyroid function causes low levels of the hormone gastrin, which is needed to produce hydrochloric acid, otherwise known as HCL.

It also impacts gallbladder and liver function because low thyroid function makes the liver and gallbladder sluggish and congested, as well as reproductive hormone production and metabolism, because progesterone receptor sites lose the ability to allow progesterone into the cells and estrogen cannot be properly metabolized through the liver when there’s insufficient thyroid hormone.

It also impacts fat-burning because low thyroid function shuts down the sites on the cells that respond to lipase, an enzyme that metabolizes fat, preventing stored fat from being released and fat from the diet from being burned for energy. It also impacts protein synthesis and insulin and glucose metabolism because low thyroid function causes glucose to be absorbed more slowly and the cells don’t use it for energy as readily.

Additionally, it impacts bone growth and lipid levels because thyroid hormone is needed for the proper functioning of the LDL receptor. LDL can build up in the bloodstream when there’s low thyroid function. It also impacts body temperature because the thyroid maintains body temperature. Lastly, pregnant women with undiagnosed or inadequately treated hypothyroidism have a higher risk of miscarriage, preterm delivery, and severe developmental problems in their children.

Jim, what are some commonly prescribed medications that inhibit thyroid function?

There are a lot of medications that are listed, but probably the strongest is glucocorticoids. It messes up thyroid function, even prednisone for a while, which by the way, suppresses your natural cortisol production. Now, you’ve screwed up your cortisol rhythm. When you back off the prednisone, now it shoots up high. Dopamine antagonists and some statins are commonly used and there are some others.

If you talk about all the possible causes and if you read Dr. Brownstein’s book, Overcoming Thyroid Disorders, you’ll see a list of medications that can inhibit conversion like beta blockers. I’ve had that once, but over the years, I’d say medication other than glucocorticoids is probably the least significant factor in fixing the thyroid. Those medications are listed.

Most of them are usually mild effects and not one of the major causes of the problem. I will check my medications. The one gentleman years ago that I could not get worked out, we finally got the doctor to switch from the beta blocker. It made a difference. That’s the only time in all these years I’ve had a change in medication. It significantly affects thyroid function.

I appreciate your honesty there. We hear about SSRIs which many people are taking. I think also of antibiotics and how they shift the gut microbiome. In turn, that can impact the thyroid. That’s more of a second-generation impact but would you agree with that or do you see that?

That’s not a direct effect. That gets back to, “What’s the first thing you do when you have these general symptoms in a patient?” I fix the gut. You and I do that. That’s what we do. We start with, “What are you putting in? Let’s fix the gut.” If you take neurotransmitter imbalances, you’re low in serotonin and you’re depressed. Don’t take an SSRI. Fix your gut and make your own serotonin again. That’s where you make 80% of it.

I don’t care what the patient comes in with. You have to fix the gut. 9 out of 10 of them come in and the gut’s not in great shape. It may be okay, but it’s not in great shape. If you work on gut-first dietary habits and maybe probiotics, they got a leaky gut, and you heal it up, you are going to make that patient feel better even if you don’t do anything else. I agree with you. In that case, any drug that disrupts the normal flora is going to affect thyroid function.

Thyroid Replacement Therapy

Let’s shift gears a bit and talk about thyroid replacement therapy options. There are so many. I wanted to have you on the show because of your amazing expertise in this area but I’m curious, why is synthetic versus natural misleading?

It’s for a couple of reasons. First of all, those terms are marketing terms. That’s the battle in the old days. “Our thyroid’s better. It’s natural. Theirs is made in the lab. It’s synthetic.” What counts to me is when you put a substance in the human body, is it natural to the human body? Because a pork thyroid product is natural to a pig, it does not make it natural to the human being. The amount of bioidentical T3 and T4 in porcine thyroid, which would be Armour Thyroid and any thyroid USP product.

The amount of active bioidentical hormones that match what we have consists of 0.0004%. You have 99.9996% other pork stuff. How much of it is natural to your body? Just because it’s made in nature, it doesn’t mean it’s natural to you. How many mushrooms are out there that aren’t so good for you? “They are natural.” No. We misuse the word natural. It is highly misused. It comes from Mother Nature. It’s good. No.

Is it a naturalist system it’s going into? That’s the key. All thyroid products, I don’t care if they’re made in the lab, from scratch or not, go through the laboratory for purification. All the T3 and T4 in any porcine thyroid, in any levothyroxine that’s “synthetic” and in compounded, are 100% bioidentical. It matches the thyroid hormone that we will always make. That’s the key.

What’s different? The ratio of what’s in there, the T3 to T4, whether it’s all T4, all T3, a combination, or what’s the ratio of the tube and the fillers, the other stuff. A thyroid USP, per USP, can contain “suitable daily ones.” The three of them are lactose, dextrose, and cornstarch. How many people have food sensitivities or intolerances to lactose or cornstarch?

They’re put in a thyroid medication that’s adversely affecting their thyroid in that sense. If you have a lot of food sensitivity, I’m going to get you the compounded thyroid. Why? Because it’s 100% pure. I don’t have to mess with any of that stuff. Is it synthetic? The synthetic definition is made in the lab. It’s not synthetic to my body. It matches what I made for years. Those terms are so misleading, but I teach doctors that’s a marketing term. Don’t go there. It’s like calling Premarin a natural estrogen.

A horse is in nature and this comes from the horse’s urine. It’s more natural than pork thyroid because 50% of Premarin has estrogen in it. That’s bioidentical. 19% is estradiol. That’s bio-identical. It’s the other stuff that’s in there that’s harmful and it’s the fact that it’s way too much estrogen, but Premarin is more natural to your body than porcine thyroid as far as percentages.

I was excited to have this conversation with you because I had never heard before that it’s more of a marketing term, but it makes perfect sense, as you explain it and as I hear you talk about the fillers and all the derivatives. There are also some gluten derivatives in there, too, that I see a lot of people react to. To your point, that’s why often compounding is better for a patient depending on what their sensitivity is. There is also a lot of cross-reactivity with other things.

There’s another issue with a lot of the levothyroxine tablets out there, Synthroid included. Most of them include lactose. There’s a study from 1960 and 1961. It was published in The Lancet. Lactose interferes with the absorption of the thyroid. We make such a big deal if you’re taking thyroid medication, don’t take it within two hours of a meal. It’s because iron and calcium, which are so common in foods, decrease absorption. If you ate pure protein with no iron or calcium in it, you can eat it right with your thyroid. It is not going to affect it at all.

How do we overreact there? If we’re so over-reactive to the possibility of iron and calcium in our food decreasing absorption, why are we still allowing lactose to be put in there? I talked to one of the drug manufacturers one time about this. They said, “Nobody’s ever repeated that test.” “What? Have you done a test to prove it’s not true?” “No.” That’s our science right now. Lactose should not be in thyroid products. When you get a generic, get a list of the other ingredients. If it’s got lactose in it, get away from that.

Estrogen, Progesterone, and Thyroid Hormones

This is so important for our readers to learn. Jim, during our last show, we talked about estrogen excess, progesterone deficiency, and how that can also inhibit the proper functioning of thyroid hormones. It’s important to look at those alongside cortisol and DHA, as you were sharing. Are there any other tests that you recommend that people look at?

If they’re having symptoms that show imbalances in hormones, I like to get the complete picture. I’ll do a saliva test with ZRT that includes estradiol, progesterone, testosterone, DHEA, and cortisol four times a day. If they’re on estrogen that includes estradiol in it, I’ll include estradiol. Anytime they’re on it, I want to include that. If I get that complete picture along with functional thyroid testing and one other thing, I want to get the measurement of insulin resistance.

Doctors don’t measure that. They’re really big now on fasting glucose and hemoglobin A1C. If you look closely at the literature, hemoglobin A1C is not what everybody’s making it out to be. It’s not that accurate. I’m old school. I want to know what your actual insulin resistance number is. Insulin resistance develops over years. Diana Schwarzbein, a great endocrinologist taught me this years ago. She said, “The last place that develops in the body is in your liver and that’s when your number is going to change.” Your doctor says you have a problem and you’ve had it for years. You can spot it a lot sooner.

If a patient does fasting insulin and fasting glucose at the same time, there is a calculator, the HOMA Calculator. The latest one is called the HOMA2. It was developed at the University of Oxford. You can download it. Take those numbers and plug them in. You will get a number come up and they give you a little scale. It says, “This is what this means, low, moderate, and high.” You can see insulin resistance before a doctor is going to spot you have a problem.

If you really want the whole picture, get insulin. If you’re developing insulin resistance, that’s going to affect your cortisol which is going to affect the function of every other endocrine hormone, sex steroids, cortisol, and saliva, functional thyroid testing in serum, and insulin fasting glucose in serum. If the patient has symptoms of inflammation, I want a marker of inflammation. The sedimentation rate works. I like the high-sensitivity CRP, not the regular C-reactive protein, but if you get the high sensitivity, the old CRP is not so accurate. I’ve had people do both and compare them. It shows up with high sensitivity that they have inflammation but not so with the other tests, but the hs-CRP.

One other test that I would like to see as part of the yearly panel for health checking is homocysteine. High homocysteine has been correlated to the development of Alzheimer’s. That’s where everybody measures it. If you were doing the testing and said, “Jim, what tests do I get done?” The saliva test, the serum thyroid test, potassium, fats, and glucose, and also, hs-CRP if you’ve got any symptoms of inflammation and homocysteine. If you give me that information, I’m going to take care of you.

Thyroid Imbalances, Iodine, and Autoimmunity

Jim, iodine has gotten a bad rap over the years. I know you know this. It’s common to see a deficiency in people with thyroid disorders. A lot of people don’t react well to iodine because they weren’t properly tested. Also, they didn’t have what we call the companion nutrients on board, such as zinc and selenium. What has your experience been with iodine, thyroid imbalances, and autoimmunity?

Dr. DK wrote the book, Why Do I Still Have Thyroid Symptoms? When My Lab Tests Are Normal. He and other people say you can’t give iodine to somebody who is having an autoimmune reaction. It can raise your TPO antibodies. You have to understand the mechanism. Dr. Brownstein explained this so well in a lecture one time. Iodine is needed for the absorption of TPO into the cell and into the gland. If you’re lacking iodine and then you take iodine, you’re going to get more TPO into the gland. It means you now have a greater amount of substrate that you can react to. Do the antibodies go up because you have more TPO? The antibodies go up because you have a reaction going on that you haven’t controlled.

Iodine can cause TPO to go up. It’s not the cause. It’s not a reaction either. Get more substrate into the gland so you can react more. If I have an autoimmune reaction going on and they’re deficient in iodine, I will address the autoimmune issue. I will do food sensitivity testing. I’ll remove their food. I’ll heal their gut. I put them on selenium and zinc. You want antioxidant activity with selenium. Selenium is important for thyroid function. It’s the main factor in the conversion of T4 to T3, but it has great antioxidant activity.

I want antioxidant activity and I’ll usually put them on something else too as far as NAC, vitamin C and a combination of a couple of antioxidants at first. I’ll do that for 2 or 3 months. I’ll start low-dose iodine, maybe 6.25 milligrams twice a week. I’ve never had a problem, but you need to be careful. You need to go slow with the iodine. If you can’t get this patient compliant with the food elimination and healing of the gut, don’t go with the iodine. You can worsen the autoimmune reaction in the sense that you’re providing more substrate. You’re going to have more reactions.

I’m so glad you walked us through that. That’s what I see as well. We always have to be looking at the gut and what we’re consuming. It’s a huge piece, but in our day and age, we want a quick fix. We don’t want to change our diet. We want to take something that’s going to magically fix things. I hate to tell everyone that unfortunately, that’s not the way the human body works. I wanted to talk about iodine because it’s so misunderstood. Is there anything else you’d like to share with us?

I’d like to say thank you to Dr. David Brownstein who has taught me so much. I don’t know which talent is better, his interaction with patients or writing. He has the unique ability to write a book that is scientific enough. I’ll give it to any doctor and at the same time, give it to any patient and they understand. If patients are having thyroid problems, one of the key books I’d refer them to is Overcoming Thyroid Disorders by Dr. David Brownstein. If you ever get a chance to listen to him on YouTube or anywhere you can find him, the man is so helpful. He has taught me so much. I want to say thank you to Dr. Brownstein for his guidance in learning how to fix the thyroid because a lot of this comes from him.

I’m so glad you mentioned him and his books. Is there anything else you’d like to share with us or anything else you want people to know about the thyroid?

Let’s go back to thyroid medications and testing. If you are on thyroid medication, the timing of when you get your blood drawn compared to the timing of the last dose of medication is critical. If you have a doctor who’s looking at your thyroid tests and does not ask you, “When did you take your last dose prior to the test?”, they may not be interpreting correctly. You want to avoid peaks and valleys.

T3 Immediate release, Cytomel or generics, peaks in the first hour and a half or so. Give or take a half hour. It troughs in 4 to 6 hours. You want to test between 2 and 4 hours after your last dose. Immediate release T4, Synthroid, and generic, levothyroxine peaks in the first 2 to 4 hours so you don’t want to test it in the first four hours after a dose, but it’ll stay at a nice low from 4 to maybe 16 or 18 hours. You get long-range, but not within the first four.

If you have a combination like Armour Thyroid or any combination of T3, T4 Immediate release, if you test in the first four hours, you may peak at T4. If you test after four, we may be trough from T3 when you test four hours after the dose. If you use a compounded slow release, technically you go anywhere from 2 to 10 hours. I like to tighten it up to 4 to 8. The bottom line is this if you can’t remember what I said, what works for any thyroid replacement 4 hours after the dose? Now you’re avoiding peaks and troughs. Now you’re seeing a level that represents what’s happening throughout most of your day.

The other thing I’d say, if you’re going to get thyroid levels done, you need to show up early at the phlebotomist and sit for 15 minutes perfectly still because if you’re not at complete rest, you can be busy converting T4 to T3 and throw off your free T3 levels. That’s something that most phlebotomists are trained in but forget. Sit still for 15 minutes and do the timing right. If you’re not on thyroid medication, I don’t care what time of day or night to do your thyroid when they test it.

It’s amazing how things have been shared and come to the forefront decades earlier. We forget about them and then something new and sexy comes along. We talked about that last time with hormones and estrogen preparations and so forth that we’re seeing now. Often that original messaging is sound and it’s appropriate. It makes sense but we forget about it.

It’s new and better. There’s a combination of bioidentical estradiol and progesterone in an oral capsule. Why are we still giving estrogen orally? The literature is clear. Oral estrogen increases the clotting factors that increases significantly the risk of VTEs and strokes. It has been shown if you apply that same estrogen, the same amount to the skin or mucosa like vaginal application, you do not increase those risk factors based on that alone. Why are we still giving oral estrogen? I don’t care if it’s new.

The literature is clear. Oral estrogen increases the clotting factors that increases significantly the risk of VTEs and strokes. Click To Tweet

I’m going to do a lecture to some residents at a hospital in Lafayette. My title is Evidence-Based Hormone Therapy and I’m going to say, “Here’s the evidence. Why are we still using oral estrogen? Why are we still using synthetic progesterone? Here is all the evidence against it.” I’m going to get these residents thinking about when they get out and practice. Maybe I should look harder at this. That’s my goal. I’m not going to supply them with a whole list of studies. No, you’re the doctor. You’re prescribing this. You need to learn about this. It’s not my responsibility. I’m not a drug manufacturer. I don’t have a whole school of people that I paid to provide you with information. It’s only me so we need to research this. I get excited about teaching the residents.

The younger we get them, the better off we’re going to be as we move forward in this world that has a lot of interesting unknowns in terms of regulation and so forth, especially what we’re seeing now with the FDA and bioidentical hormones. I’m not sure what’s going to happen with that, but it’ll be interesting to see. Jim, you are such a blessing to the world and I’m so grateful for you. So many of us are grateful for you. Thank you again for coming on the show.

I’m grateful to you. This is fantastic. I enjoyed it and you do a wonderful job with your patients.

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I hope my conversation with Jim brought clarity and understanding about how your thyroid functions and what you can do to correct any imbalances. You have more tools and power than you realize to heal your thyroid, such as the type and quality of the foods you eat, how you manage stress, and the health of your gut microbiome.

EP 55: What Your Doctor May Not Know About Thyroid Function With Jim Paoletti, BS Pharmacy, FAARFM, FIACP