THE THYROID AND AUTOIMMUNITY

Autoimmune thyroid disease (AITD) is on the rise and a presentation I see in clinic often. The development of AITD is the combination of genetic and environmental factors that lend one toward loss of immune tolerance. Herein, let’s understand the AITD presentations Hashimoto’s and Graves’ and how they can be managed. First we must understand that AITD is not an issue of the thyroid, it is an immune system issue where immune cells start to mistakenly attack its own tissues. Knowing that the immune system has gone rogue is necessary for considering remedies and support. As a naturopath, understanding why we have lost immune tolerance, whilst supporting immune system modulation, is mainstay in our treatment plans.

Suspicions for Loss of Immune Tolerance

  • Nutrient deficiencies (i.e. low selenium and vitamin D can hype up an immune system)

  • Gut integrity issues/dysbiosis (the gut-immune axis can be important in autoimmunity)

  • Gluten, wheat and/or dairy intolerance or undetected coeliac disease

  • Exposure to heavy metals and environmental chemicals

  • Hormonal dysregulation (i.e. high oestrogen is linked to an aberrant immune system)

  • Viral infection (can throw out immune system function entirely)

  • Maternal immune changes in pregnancy and postpartum

HASHIMOTO’S

Hakaru Hashimoto, a Japanese physician, was the first to name the condition of intense infiltration of lymphocytes in the thyroid that destroys thyrocytes (cells inside the thyroid that produce its hormones). The presence of thyroid peroxidase antibodies (TPO) and/or thyroglobulin (Tg) antibodies denotes the diagnosis of Hashimoto’s. It is suggested that within 5 years of the presence of these antibodies, one will develop overt hypothyroidism. So, antibodies can be present in euthyroid (normal thyroid) and subclinical hypothyroidism. If antibodies are found, it’s good to monitor the thyroid every 3-6 months. Hashimoto’s is the leading cause of hypothyroidism because these antibodies interfere with the production of thyroid hormones (T4 and T3) and damage thyroid tissue. Over time, with less functional tissue, the thyroid can no longer compensate and will require support (i.e. a bio-identical thyroxine like Levothyroxine). 


Thyroid Peroxidase Antibodies

These are the main antibodies in Hashimoto’s. Thyroid peroxidase is the enzyme responsible for adding iodine to tyrosine to create our thyroid hormones (T4 and T3). 

Thyroglobulin Antibodies

Thyroglobulin is a gooey glycoprotein that stores iodine, ready for thyroid hormone production. It lives inside the thyroid gland, though when attacked by the immune system, iodine spills out and can be a disaster zone for attracting more autoimmune activity. 

Hashimoto’s Hypothyroidism

As thyroid hormones decreases and/or the thyroid gland is compromised, negative feedback to the brain increases TSH to try to keep up with thyroid hormone production. Basically, we can imagine our brain beginning to yell at our thyroid ‘make more hormones!’. And it gets louder and louder (increasing TSH) the lower thyroid hormones go in its attempt to maintain euthyroid levels when the gland is compromised. TSH is a stimulating hormone and so this can lead to goitre (enlarged thyroid gland). It is a very oxidative process, creating lots of stress in the thyroid and systemically. This can lend one to feel quite lowsy, even before going into complete overt hypothyroidism (under functioning thyroid). Watching a TSH creep up over time is worth investigation!

Subclinical hypothyroidism = Mild elevation of TSH, with T4 and T3 in range
Overt hypothyroidism = Elevated TSH, with low T4 (and likely low T3)


Management

From a medical perspective, there isn’t much to be done for antibodies—usually a ‘watch and wait’ situation, meaning continued monitoring until the thyroid goes into hypofunction. Holistic naturopathic management has immense benefit in calming the immune system, decreasing antibodies, mitigating oxidative stress in the thyroid gland, and increasing time to hypofunction. If overt hypothyroidism is already present, a bio-identical thyroxine will likely be prescribed. This provides the thyroid with T4 so it doesn’t have to work so hard. Sometimes a prescription will also be advised in subclinical hypothyroidism to take the pressure off the thyroid. There are also ways in which botanicals and nutrients can improve thyroid function in general (whether medicated or not). For example, improving the conversion of T4 to T3.

GRAVES’

Robert Graves, an Irish physician, first described the condition of generalised hyperthyroidism caused by an aberrant immune system. The presence of TSH receptor antibodies (TRAB) and/or thyroid stimulating immunoglobulin (TSI) denotes the diagnosis of Graves’ disease. Both of these work the same*, stimulating the thyroid to produce excessive thyroid hormones, going into hyperfunction. Essentially, the immune system has hijacked the thyroid and taken over thyroid hormone production. The pituitary no longer controls the thyroid with TSH, and so we see a dramatic decrease in TSH (usually <0.09). There is no TSH in the house because the immune system has the controller for the thyroid now. T4 and T3 are usually sky high, well above the reference intervals. This can be very dangerous, leading to a thyroid storm (felt as increased heart rate, blood pressure and body temperature) requiring urgent attention. Graves’ antibodies also create excessive oxidative stress in the thyroid, as production of thyroid hormones is a very busy process and there is a lot of that going on! Left untreated, or poorly managed, Graves’ disease can cause many complications in the long term.

Hyperthyroidism = low/undetectable TSH, with high T4 and T3


Management

From a medical perspective, this is usually managed with Carbimazole, which suppresses the synthesis of thyroid hormones. This medication is unsafe in pregnancy though, so if pregnant, or wanting to become pregnant, Propylthiouracil (PTU) might be used instead. An endocrinologist will be within the team of those managing Graves’ thyroid function and usually they will recommend a patient be in remission, or close to, before trying to conceive. The other option for Graves’ is having a complete thyroidectomy. This is usually a last resort when regaining immune control and seeing the thyroid function on its own is not considered to be within reach.

From a botanical and nutritional perspective, there are many ways to help reduce thyroid function, block conversion of T4 to T3, and manage unwanted symptoms (i.e. heart palpitations and sleep issues), as well as protect the thyroid from oxidative stress, decrease antibodies, and calm the immune system. Our big goal is to move someone into remission as quickly as possible.

*To throw a spanner in the works: Some TRAB can be ‘blocking’ and thus lend towards thyroid hypofunction. In any event, if TRAB is present, it is prudent to have a thyroid specialised GP and/or endocrinologist in your corner to better understand the presentation. TSI helps to differentiate between stimulating and blocking antibodies. However, TRAB can shapeshift between one or the other at any time (though blocking TRAB is very rare).


To summarise

AITD is becoming increasingly more common. This is a great video building on this blog. It is wise to test antibodies if the thyroid is in hypo or hyper function, whether overt or subclinical, to understand if autoimmunity is a reason for this. Once antibodies are detected, know that there is so much we can do from a nutritional and botanical perspective alongside medical management. If the thyroid is still happy, but Hashimoto’s has been diagnosed, it is not a ‘sit and wait’ scenario. Actively addressing the immune system, nutritional elements, and any other individual factors that could be contributing can be hugely impactful for the progression and management of the disease. Co-management during Graves’ is a potent way to efficiently move toward remission, whilst remedying symptoms that come with an overactive thyroid.

If you’re currently in the throws of thyroid disease, sending you lots of love. It can be a really uncertain and scary time, especially given that you can feel quite unwell. Know that you are not alone and there is so much support out there for you. It’s just about finding the most robust health care team to support you. If you are interested in holistic thyroid management, I would love to be a part of that team. You can book an appointment here.

 
Claire Hargreaves