by Stephen Gascoigne
Thyroid disease is very common. Thyroxine is one of the ten commonest prescribed medications in the UK and USA. In the clinic, we frequently see people with under-activity of the thyroid (hypothyroidism) and, to a lesser degree, over-activity (hyperthyroidism). Such imbalances in endocrine glands indicate a relatively severe disturbance at a deep level of the person and the frequent presence of prescribed medication may further complicate the situation.
When discussing the thyroid and its investigations, it is helpful to understand a little of the conventional view of the endocrine system. Simply stated, many organs of the endocrine system are controlled by means of a feedback mechanism involving the hypothalamus, pituitary and end organ, in this case, the thyroid. The hypothalamus produces releasing factors which stimulate the pituitary to produce thyroid stimulating hormone (TSH) which, in turn, stimulates the thyroid to produce thyroxine (T4) and tri-iodothyronine (T3). If thyroxine levels rise, as in hyperthyroidism, then TSH levels will fall. If thyroxine levels fall, as in hypothyroidism, TSH levels will rise. The normal levels of these hormones vary according to the country and measurements as well as the laboratory which performs the estimations. A guide would be:
TSH: 0.3 to 4.0 mmol/l
T4: 10 – 22 pmol/l
T3: 1.07 – 3.18 nmol/l
In clinical practice, it is unusual for T3 levels to be measured. This has a significance which I will discuss later.
Increasingly, it seems, hypothyroidism and, indeed on occasions, hyperthyroidism are diagnosed on the basis of a rise or fall in TSH levels. This seems to be jumping the gun as people are then diagnosed early and given powerful medications with long-term consequences. It is helpful to assess first, all of the information and to work with less powerful interventions as it may be that such drug treatment is rendered unnecessary.
The issue here is that someone is diagnosed as having an under-active thyroid gland, the use of thyroxine supplements causes TSH levels to fall and for the thyroid gland to function less effectively. This is true whether or not the thyroid gland was under-active or not.
This is over-activity of the thyroid gland associated with increased levels of T3 and/or T4. TSH levels are low or un-recordable. Since these hormones have a role in controlling metabolic rate, symptoms include:
- Feelings of heat
- Intolerance of heat
- Increased appetite with weight loss
- Rapid heart rate
In cases where T3 and T4 levels are very high, there may be severe symptoms, which in some cases, can progress to heart failure. As I mentioned above, T3 levels are rarely checked in clinical practice and therefore some people with symptoms of thyroid over-activity (or, indeed, under-activity) are not diagnosed.
Conventional treatment is frequently aimed at destroying part of the thyroid so that levels of circulating thyroid hormones fall. This is done either by means of radioactive iodine or surgery. Such treatments irrevocably damage the thyroid gland and, therefore, hypothyroidism is a very common consequence some months or years after such treatment. Some people are offered drugs (carbimazole is a common prescription) which interfere with thyroid hormone production. A feared adverse effect is agranulocytosis - loss of production of a group of white blood cells important in fighting bacterial infection. In addition, other blood disorders such as aplastic anaemia and thrombocytopenia can occur. Using more gentle methods to balance the thyroid gland are therefore much more preferable in the long-term. One important point to consider is that the natural history of thyroid disorders is for over-activity to gradually be replaced by under-activity. This is a common observation with organ dysfunction. The initial disturbance of over-activity or over-stimulation is replaced later by exhaustion or depletion of the organ involved. If the conventional treatment involves destroying function, then the end result is even more likely to be one of under-activity.
In my experience, Chinese medicine is very effective at treating, or at least alleviating, hyperthyroidism. The clearer we are about the traditional diagnosis, the more effective will be the treatment. Giovanni Maciocia wrote an excellent article that will be published in a future issue of CMT on hyperthyroidism. In addition, Bob Flaws writes a section in his book ‘The Treatment of Modern Western Medical Diseases with Chinese Medicine’ (Blue Poppy Press, 2001).
Giovanni outlines the common conditions which are associated with hyperthyroidism. These are Liver Qi Stagnation, Heat in the Liver, Heart and Stomach, Liver and Kidney Yin Deficiency with Empty Heat and Phlegm-Heat in the Liver. He discusses very clearly the concept of Phlegm and its relationship to thyroid disease. In his opinion, and I agree with him, unless there is a goitre, the presence of Phlegm is minimal or absent. We should not assume Phlegm is to be treated just because someone has a thyroid disturbance. Certainly, if Phlegm is present, we need to adjust our treatment principles to take account of this.
Cases of hyperthyroidism
Mary is aged 45 years. She has always been very active mentally and emotionally. She developed a goitre about 5 years ago and blood tests suggested a mild degree of hyperthyroidism. She was advised to have an operation to remove the goitre which she declined. Her main symptoms are restlessness, anxiety, dream-disturbed sleep, and goitre which is larger before her period. The goitre can feel hot just before her period and when her emotional symptoms are stronger. Her tongue is red with little coat. Pulse is thin and thready on the left. I diagnosed Heart and Kidney Yin Deficiency with Empty Heat together with Liver Qi Stagnation and gave her a modification of Tian Wang Bu Xin Tang (Emperor of Heaven’s Special Pill to Tonify the Heart) as well as using acupuncture. A typical prescription would be Yinxi (HE 6), Taixi (KI 3), Zhaohai (KI 6), Taichong (LIV 3), Yintang, Jiuwei (REN 15). She finds that she is well with this treatment, her thyroid hormone levels are normal, the goitre rarely enlarges now and her emotional state, although not completely calm, is much more stable.
Jackie is 42 years old and developed hyperthyroidism together with multiple nodules in the thyroid gland a couple of years ago. She experienced symptoms of agitation and restlessness but to a much greater degree. She also had insomnia, tremor, hunger, weak muscles and was very emotional. Her pulse was rapid, up to 130-40 per minute at times. Her T4 levels were generally normal but with raised T3 levels. She received homoeopathic treatment where she lived in mainland Europe with little improvement. She was always keen to seek conventional treatment which was the least hazardous and least harmful in the long term. She did a lot of research and searching for opinions and eventually settled on ethanol injections into the nodules. This was successful and certainly less of a long-term problem than either surgery – removing part of the thyroid gland – or radioactive iodine. The point of this story is that there are many options available for people to choose from.
Hypothyroidism is characterised by a slowing of the metabolism with symptoms, which include:
- Lethargy and tiredness
- Coldness and sensitivity to cold
- Dry skin
- Coarse dry hair
- Weight gain
- Poor memory and concentration which can progress to confusion
- Slow pulse
In terms of Chinese medicine, we frequently see syndromes such as Qi and Yang Deficiency particularly of the Kidneys and Spleen together with Blood Deficiency. Depending on the degree of thyroid under-activity, treatment with Chinese medicine can be very effective. Some people then do not require conventional treatment. If they are already taking thyroxine, the required dosage can be reduced as the thyroid gland starts to recover with treatment.
Conventionally, people are given thyroxine supplements. In some cases, it is more a deficiency of T3 than thyroxine (T4) and so there is a limited response to medication. In previous times, supplementation would be with thyroid extract from cow or pig thyroid glands. There is a commercially available preparation derived from pigs, Armour Thyroid, which can be obtained in the UK on a medical prescription (this is unlicensed for use and so an individual doctor has to agree to prescribe this to the individual patient) and this can lead to symptoms being alleviated which were still present with thyroxine supplements. The use of this thyroid extract is somewhat controversial in conventional medical circles as the official line is that the sole use of thyroxine supplementation is sufficient.
The usual dosage for thyroxine is 100 to 150 mcg (micrograms) daily.
Case of hypothyroidism
A woman of 38 years had been taking thyroxine supplements for 20 years since a diagnosis of hypothyroidism. She was taking 200 mcg of thyroxine daily. This is a relatively high dosage but regular checks of thyroxine levels were always normal. She was keen to see if she could reduce her dosage and generally feel better. She complained of tiredness and lethargy, tendency to retain fluid, particularly before her period, desire for sweet foods, frequent urination, and low back ache. Her tongue was pale and swollen with a thready pulse particularly on the Spleen and Kidney Yang positions. I diagnosed Spleen Qi Deficiency and Kidney Yang Deficiency. I gave her a variation of Jin Gui Shen Qi Tang (Jin Gui Shen Qi Wan) and treated her with acupuncture. Typical points would be Zhongwan (REN 12), Qihai (REN 6), Zusanli (ST 36) with moxa and Fuliu (KI 7) with moxa. She did well with treatment and felt much better with more energy. After 3 months of treatment she reduced her thyroxine dosage to 150 mcg daily and to 100 mcg after a further 2 months. A blood test revealed that her TSH and T4 levels were normal. She continues with treatment and it will be interesting to see what level of thyroxine supplementation she eventually needs.
What is realistic?
Thyroxine levels of less than 12 are difficult to treat solely with Chinese medicine. The lower the level, the more likely is the need for thyroxine supplementation.
Previous treatment of hyperthyroidism by radioactive iodine and surgery means that thyroxine supplementation is frequently unavoidable.
Levels of serum thyroxine at the lower end of normal yet raised levels of TSH without symptoms can be safely treated solely by means of Chinese medicine together with regular checks, for example, every 3 months.
Everyone taking thyroxine supplementation should have annual checks of thyroxine and TSH to monitor that the dosage is correct. In people receiving treatment with holistic medicine, it is helpful to have checks more frequently, for example, every 4 months, as your treatment may improve thyroid hormone and therefore, require a reduced dosage.
The main consideration is the symptoms. You must know the warning signs which indicate more severe disease. These include:
- Pulse rate greater than 120 per minute
- Any symptoms which severely limit activity and functioning. Look for extreme agitation, restlessness or fever
- Chest pain, oedema or breathlessness
If treatment with carbimazole is considered essential, the concurrent use of Chinese medicine usually reduces the dosage required to control the over-activity of the thyroid.
A traditional Chinese diagnosis and appropriate treatment principles open the door to improving thyroid function.
Do not assume that 'abnormal' hormone levels inevitably require conventional medication.
Know the symptoms indicating more serious disease.
Regularly monitoring of thyroid hormone levels with blood tests is helpful in guiding drug dosage.
Seek supervision or guidance from practitioners with experience of treating people with thyroid disorders.