Hashimoto's Thyroiditis (Hashimoto's Disease)

A condition with an exotic name affecting tens of millions of Americans!
More than 10 million Americans, or 3 percent of the population, suffer from Hashimoto's thyroiditis, and it is estimated that another 10 million are undiagnosed. Despite these large numbers, the need for information about this disease among those affected is enormous. Many affected individuals are struggling to find a treatment that will help them feel better.

For many years, the medical community has focused on treating the "hypothyroid" aspect of Hashimoto's autoimmune thyroiditis - by replacing missing thyroid hormones with their man-made counterparts. For most patients, this seems sufficient - however, as many as 30% of people with Hashimoto's experience that despite taking the pills regularly, their symptoms hardly improve.

What is Hashimoto Thyroiditis?
The disease is named after the Japanese physician Dr. Hakaru Hashimoto, who first described it in 1912.

Hashimoto's Thyroiditis (synonyms: Hashimoto's disease, chronic autoimmune thyroiditis, chronic lymphocytic thyroiditis) is an autoimmune disease, i.e. a misguided immune attack that leads to a mostly painless, chronic inflammation of the thyroid.
As a result, the thyroid gland becomes smaller (destruction of the glandular cells) or, rarely, enlarged (the glandular cells are replaced by connective tissue). In both cases, hormone-producing cells are destroyed, and the thyroid gland becomes underactive, with numerous negative consequences for the organism.
The disease progresses in phases (relapsing-remitting), like many autoimmune conditions, and is considered to be incurable.

Contrary to the exotic name, Hashimoto's thyroiditis is the most common cause of hypothyroidism (under the function of the thyroid).

How common is hypothyroidism?

From the largest population-based follow-up study, the Whickham study, we have learned that:

elevated levels of thyroid autoantibodies can be found in the blood of ~10% of the general population
In up to ~7.5% of the population, TSH levels were increased with normal values of thyroid hormones fT3 and fT4 (subclinical hypothyroidism)
~2 percent of the population had a manifest hypofunction of the thyroid gland, i.e. elevated TSH levels and low fT3 and fT4 levels

Who develops Hashimoto's disease?
Women between the ages of 30 and 60 or 8 percent of all women before and 16 percent of all women after menopause are particularly affected. Overall, women suffer from Hashimoto's about 10 times more often than men.

What is the function of the thyroid?

The thyroid is a small (18-22 grams in weight) butterfly-shaped organ located in the neck, right in front of the trachea (windpipe). When the thyroid is working properly, we feel light, active, and agile - like a butterfly.
The thyroid is involved with most functions of our body - in a very subtle way:

temperature regulation
oxygen utilization
iron metabolism
physical and mental "energy"
regulation of water balance
regulation of protein, fat, and carbohydrate metabolism
calcium metabolism and (bone) growth
mental health and wellbeing

Symptoms of low thyroid
If the hormone production of the thyroid is not sufficient, as is sometimes the case in untreated Hashimoto's thyroiditis, then those affected do not feel like butterflies, but rather like caterpillars:

fatigue
apathy, lack of energy
brain fog
difficulty focusing
feelings of depression an inability to make decisions
sensitivity to cold
muscle and joint pain
weight gain and inability to lose weight
doughy and dry skin
constipation
hair loss and brittle hair
lack of libido
infertility

While fatigue, hair loss, dry skin, constipation, and cold intolerance are usually improved after starting Levothyroxine (the synthetic form of thyroid hormone), many other symptoms will fail to improve (brain fog, joint issues, weight issues, decreased libido).

Sometimes, Hashimoto's thyroiditis can also cause symptoms of hyperthyroidism, particularly during the initial phase or subsequent phases of "flare-up". Sometimes it is impossible to differentiate Hashimoto's from its autoimmune sibling, Grave's Disease.

Hashimoto's symptoms are often not recognized

Many symptoms of Hashimoto's go unrecognized or are dismissed if TSH levels are deemed "in the normal range" - this can be pretty unnerving and stressful for Hashimoto patients. Particularly challenging for millions of women is the time around early menopause. Oftentimes, menopausal symptoms are masked by concomitant hypothyroidism; once the latter is treated with Levothyroxine, symptoms of menopause start to surface and are frequently misinterpreted as symptoms of hyperthyroidism – the start of a stressful rollercoaster for affected individuals.

Polyglandular autoimmune syndrome and Hashimoto

Hashimoto's thyroiditis and Graves' disease can occur together with other autoimmune diseases as "polyglandular autoimmune syndrome" (PAS type I to type III): celiac disease, alopecia areata, vitiligo, pernicious anemia, rheumatoid arthritis, mucocutaneous candidiasis, Addison's disease, chronic hypoparathyroidism, type 1 diabetes.

What causes Hashimoto’s thyroiditis?

Unfortunately, we don’t quite understand what triggers the immune system in Hashimoto's thyroiditis. Genetic predisposition seems to play a role, however, a specific inheritance pattern was not found. Another hypothesis is molecular mimicry, where the immune system mistakenly attacks body structures that resemble closely “foreign” structures. Stress seems to play a major role both in the initial trigger and the progression of this condition. Besides obvious stressors, like grief, family, or job issues, many biological and hormonal “phases” can be quite stressful on our body and trigger autoimmunity: hormonal transition phases: puberty, pregnancy/delivery, starting/stopping oral contraceptives, perimenopause, polycystic ovary syndrome, viral infections, etc.

For many years, endocrinologists have focused on hormone replacement when dictated by hormone levels. Accordingly, the only measure for treatment success was the “normalization” of TSH, T4, and T3 levels. If these lab markers are within the normal range, patients are considered healthy, and symptoms that oftentimes continue to persist are dismissed as “unrelated to thyroid function”.

This is understandably disappointing and quite unsatisfactory for the majority of patients who want to find out more about triggers and treatment options for Hashimoto's, and who feel left alone.

How is Hashimoto’s thyroiditis diagnosed?

Hashimoto's thyroiditis can be clearly diagnosed by sonography (ultrasound) and laboratory tests.
1) Palpation and sonography of the thyroid
A thyroid gland that feels rubbery on the exam and appears hypoechoic on ultrasound has a 95 percent probability of Hashimoto's thyroiditis.

2) Thyroid hormone levels

The most commonly determined levels are T4, T3, and T@H, which is a pituitary hormone. Sometimes we have to measure reverse T3 if a T4->T3 conversion disorder is suspected.

3) Antibodies
Thyroid Peroxidase antibodies (TPO) and Thyroglobulin antibodies help make the diagnosis. Sometimes, however, antibodies are negative and become apparent as the disease progresses. This is called seronegative autoimmune thyroid disease. The diagnosis is then made using sonography.
A check of the antibodies is not necessary at all visits, because they do not allow for any reliable conclusion about the course of the disease.

Can Hashimoto's Disease be Cured?

While a complete cure for Hashimoto's thyroiditis is rarely achievable, we do know interventions that can improve the well-being of Hashimoto patients tremendously and help them regain control over their own bodies:

treating nutrient deficiencies and making sure the thyroid is provided with everything needed to function properly (see below)
healthy nutrition and regular physical exercise, both of which help lower overall stress levels
behavioral therapy and self-awareness can be crucial success factors in the treatment of any autoimmune condition. Many patients are telling me: “I no longer recognize myself”, “I’m merely functioning, I no longer seem to control my life”.

Nutrients and supplements for Hashimoto’s Disease

Every day we are bombarded with ads for supplements, IV treatments, and miraculous cures. Unfortunately, it is very difficult to make an informed decision. That’s why I am sharing here my practical experience with micronutrients and supplements in the treatment of chronic inflammation of the thyroid, based on some valid scientific studies, patient testimonials, and my own observations in practice.

I believe that the most important aspects of Hashimoto’s are sleep hygiene, clean nutrition, physical exercise, and vitamin D +/- thyroid hormones whenever needed. To these, I would add L-Thyrosine, Magnesium, Zinc, Selenium, Vitamin A, Vitamin C, and, maybe, Iron (but not together with Magnesium). Many of these nutrients are abundantly present in healthy diets (like the Mediterranean Diet), and some of them may need to be added as supplements.

Vitamin D3: Many studies have shown the detrimental effects of vitamin D deficiency on autoimmune conditions, and I consider vitamin D to be a mainstay of Hashimoto’s treatment. I recommend a target vitamin D level between 40-60ng/ml.
L-Tyrosine is a semi-essential amino acid and is the main building block for levothyroxine, but also for the adrenal hormones adrenaline and noradrenaline, as well as for the "happiness hormone" dopamine.
Magnesium is needed to activate vitamin D and has a significant anti-inflammatory and calming effect.
Zinc is essential for thyroid function and has immunomodulatory properties, also.
Selenium deficiency can worsen Hashimoto's and there are some “soft” data that Selenium can help lower antibody levels in Hashimoto’s and Graves. Selenium is an important cofactor in the formation of active thyroid hormones and at the same time necessary for the conversion of the inactive form of thyroid hormones (T4) into the active form (T3). Eggs and some types of fish such as salmon, mackerel, or cod, as well as Brazil nuts and coconuts, but also legumes, porcini mushrooms, and shrimp, contain large amounts of Selenium.
Vitamins A, C, and E are strong antioxidants and have anti-inflammatory properties, and help the immune system work efficiently
Iron (if Ferritin < 35 µg/l; target value approx. 100 µg/l). Iron supplements are oftentimes associated with side effects such as diarrhea, constipation, heartburn, and nausea. Plant-based iron, combined with vitamin C, which improves iron absorption, seems better tolerated.

Should Hashimoto's patients avoid iodine?

Iodine is an essential trace element and is OK for Hashimoto's patients in the amounts ingested through regular foods. Issues may arise if iodine intake exceeds 200 micrograms/day, as this can further fuel the inflammatory process.

Is there a special “Hashimoto diet”?

No. While it is important to avoid foods that promote an inflammatory milieu (sugars, saturated fats, nitrites) there is no “Hashimoto” diet that works for all affected individuals.

In general, I recommend a “Mediterranean Diet” that is rich in antioxidants like vitamins A, C, and E, trace elements like selenium and zinc, and healthy fats.
All of these are found in fresh fruit, vegetables, and legumes, in salads, herbs, and sprouts, in nuts and vegetable oils that are rich in omega-3 fatty acids as well as some animal products like eggs and certain fish types and spices such as ginger, pepper, turmeric or coriander which contain many secondary plant substances with anti-inflammatory effects. Furthermore, Curcumin and Resveratrol are personal favorites that I consider helpful for a healthy metabolism.

Which foods to avoid with Hashimoto's?

Whether there are foods that can worsen or trigger symptoms of Hashimoto's is a matter of controversy. Some "health gurus" claim that vegetables like cauliflower, broccoli, kale, Brussels sprouts, radishes, mustard, horseradish, soy, onions, garlic, or leeks contain so-called "goitrogens", compounds that, once ingested, are converted to thiocyanates and may prevent iodine uptake in the thyroid tissue. The fact is, that we would need to consume huge (barely achievable) amounts of these foods in order to have a biologically measurable effect.
So far, we do not have sufficient data to recommend avoiding foods in individuals affected by Hashimoto's. If you don't feel affected by consuming these foods, you don’t need to eliminate them from your diet. Many of these foods have quite impressive nutritional value!

How about gluten? I have heard about many people with Hashimoto's who felt much better after eliminating gluten.

Gluten is a "sticky protein" that is found in many grains, such as wheat, rye, oats, and barley. We can only recommend consistently avoiding gluten in people with proven gluten intolerance or "celiac disease".
However, we have observed, that some Hashimoto patients, in whom an intolerance to the gluten protein was never formally proven, feel significantly better if they avoid foods containing gluten.
It is therefore worth trying to eat gluten-free for a while. If the symptoms improve, you should maintain a gluten-free diet at least until you feel completely healthy again. Gluten-free alternatives are amaranth, buckwheat, chickpeas, quinoa, and rice.
If there is no noticeable improvement in the symptoms of the disease, it is not necessary to avoid gluten.

Thyroid hormone replacement in Hashimoto’s

When to treat Hashimoto's Disease?

This is a matter of controversy in the medical community. Some practitioners prefer to wait until the lab values are consistent with hypothyroid and the TSH rises above levels of 4.5. I prefer an individualized approach and my threshold to treat has been, in general, lower because I believe, that giving the thyroid gland some rest calms down the immune attack, similar to type 1 diabetes. However, if patients do not feel better after taking hormones, I will revisit my decision and stop: oftentimes, increasing the dose in these situations will worsen the clinical symptoms.

For me, factors like duration of disease, ultrasound appearance, and consistency of the thyroid gland, comorbidities like lipid disorders, age, fertility concerns, and, of course, subjective well-being are much more important than lab values.

What treatment options do we have for Hashimoto's?

Synthetic Levothyroxine (aka T4, LT4, L-Thyroxine, Synthroid, Levoxyl, Tirosint, etc) is the most commonly used thyroid hormone replacement and oftentimes sufficient to treat thyroid hormone deficiency.

Synthetic Liothyronine (LT3, T3, Cytomel)

In some cases, particularly when the conversion from T4 to T3 is impaired or sluggish, the active form of thyroid hormone, Liothyronine (LT3, T3, Cytomel) can be added to the mix and titrated to alleviate symptoms. Treatment with T3 can be tricky because of its much shorter lifespan (hours versus days for Levothyroxine) and oftentimes we must use several doses throughout the day.

How about natural thyroid extracts – aren’t those much better for me?

For most patients, the answer is “no”.

While the use of thyroid extracts seems alluring because the thyroid synthesizes several other hormones besides Levothyroxine, which are not commonly replaced, natural thyroid extracts are problematic because of many reasons:

It is unknown, how much active thyroid hormone they contain, making dose finding very difficult
The ratio between T4 and T3 is much different compared to humans, and is typical for the animal from which the extract was obtained, commonly leading to an overreplacement with T3. When this occurs, the body loses some of its ability to convert T4 into T3 and patients oftentimes encounter the typical “afternoon dip” in energy levels
Because of the high T3 content, commonly used lab assays become very unreliable
In a scenario, where the immune system erroneously attacks its own structures, it seems counterproductive to introduce foreign compounds, that bear great similarity to the attacked body structures and continuously fuel the immune attack
There are rare instances, where patients can only tolerate thyroid extracts – those are exceptions and must be acknowledged as such

Hashimoto’s in pregnancy

Many women with Hashimoto's Disease worry that their condition could adversely affect their pregnancy. However, with close monitoring and care, the vast majority of women with Hashimoto's thyroiditis have normal pregnancies and deliver healthy babies.
It is important that the thyroid hormone and TSH levels are in the normal range when planning a pregnancy. I recommend a TSH target between 1.0 and 1.5. Furthermore, thyroid hormone levels should be checked regularly during pregnancy, preferably every six weeks.

I was diagnosed with Hashimoto’s – what should I do? Should I just take all these supplements?

This webpage cannot replace a personal evaluation, and while some of the supplements and treatments mentioned here can be helpful, not all of them are indicated for everyone.

If you have been diagnosed with hypothyroid and/or Hashimoto's and have been struggling to find answers or to improve your symptoms, call us and make an appointment with me – I have been treating patients with Hashimoto’s for almost 20 years and I will try to find ways to help you, too.