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by by Mary Shomon

July 2003 --Glenn Rothfeld, M.D. is founder and medical director of WholeHealth New England, an integrative medicine practice. He has practiced both conventional family medicine, and complementary therapies since 1977. He is Clinical Assistant Professor of Family Medicine at Tufts University School of Medicine, where he teaches. He holds one of the nation’s first Masters’ Degrees in acupuncture, and has practiced acupuncture since 1985. Dr. Rothfeld is the author of 8 books on natural medicine topics, the most recent being Thyroid Balance, which was published in 2003. In July of 2003, I had an opportunity to ask Dr. Rothfeld about his approaches to thyroid treatment, and some of the theories he discusses in his book.

1. You talk in the book about the "find it, fix it" mentality we see among many medical practitioners. Can you describe a bit more what this is, and why it's such a problem for thyroid patients?

"Find it, fix it" is the prevailing attitude in much of conventional medicine, and leads toward a very restricted view of health and disease. The psychologist Larry LeShan has written about "the Mechanic" and "the Gardener." Conventional, modern doctors are like mechanics; they look for specific problems (usually abnormal laboratory tests) and take measures to correct them, without much attention to the overall picture or how that problem developed. A gardener doesn't only attack problems themselves (imagine going out to the garden with a knife and cutting out all the black spots on your tomatoes!) but considers the weather, condition of the soil, watches the growth pattern, and comes to understand why the plant grows like it does. In medicine, this means taking a "holistic" look at the patient, including the diet and nutritional status, the genetics, the effects of environment, and thereby understanding why certain symptoms occur.

In conventional medicine, we spend a lot of time chasing down lab numbers and treating them. The current rage of treating serum cholesterols of barely over 200 with drugs is one example. Certainly a very common example is the reliance on TSH measurements as the sole determinant of thyroid function.

This mindset has prevented thousands of people from getting the proper hormonal support that they need, and has ignored the fact that the thyroid is intimately connected to the other hormonal and organ systems. And, it controls metabolism in all the cells. If the metabolism is sluggish, the thyroid function has to be considered, whether the test is "normal" or not.

Do you feel that the "find it, fix it" mentality toward thyroid disease is changing for the better?

I think this "find it, fix it" mentality is still pretty ingrained in the medical system. While I think that liberalizing the rigid definition of a TSH of 5.5 or below as "normal" is helpful, we remain with a system that looks at a single number for the choice of treatment or not, instead of taking a broad look at metabolism and the factors that can affect it.

2. What are your thoughts about the new National Academy of Clinical Biochemistry guidelines on TSH value that are looking to revise normal range to .3 to 3.0?

In the past, BMR (basal metabolism rate) was replaced by T3 and T4, then by TSH as the true measurement of thyroid function. Each time, a group of people not previously defined as low thyroid were included in the new definitions. Revising the TSH normals to define anything over 3.0 as hypothyroid will help some of the patients who have previously gone untreated, and I support it. But, clinically, a TSH over 2.0, symptoms of low thyroid (particularly fatigue, sluggish bowels, dry skin and cold intolerance) with a normal TSH, and a low underarm basal body temperature all raise the possibility of sluggish thyroid function, and these groups of patients will still be "normal thyroid" according to the Academy guidelines. So, guidelines are just that, suggestions that help to inform a physician's decision, but should not be adhered to at the expense of evaluating the patient.

3. Do you feel that soy products are safe for thyroid patients? Do you differentiate between fermented soy products, and soy pills/powders?

I am not aware of any proof that a diet rich in soy products is detrimental to thyroid patients. For instance, this is not the common finding in Japanese research. The problems with soy seem to be when the isoflavone components are given in a concentrated form. Certainly this is the case in soy-based infant formulas and some of the menopause-related products on the market. Even with soy pills and powders, I think it takes a significant amount to have a suppressing effect on the thyroid, but I try to limit These products in patients with sluggish thyroid function. In fact, I generally emphasize an increase in soy foods rather than soy supplements, and I prefer other phytoestrogenic supplements like flax, alfalfa and black cohosh. The same is true for cruciferous vegetables. I consider their positive health benefits to far outweigh possible effects on the thyroid, but I do have thyroid patients avoid supplements made of these foods.

On occasion, when I've had problems managing a patient's thyroid function, I have them eliminate soy and cruciferous vegetables, but this situation is rare. And, I don't restrict fermented soy products in any circumstance.

4. You mention in the book that using T3 in a cycled treatment for addressing high Reverse T3 levels (sometimes called Wilson's Syndrome) is gaining interest. Do you follow the protocol Wilson has outlined?

In my book Thyroid Balance, I did mention that Wilson's protocol is gaining interest. Unfortunately, this does not necessarily imply efficacy or success. I find Dr. Wilson's explanation of the formation of reverse T3 and its subsequent blocking effect on the proper utilization of T3 in the cells, to be quite interesting and supported by research, although I've measured rT3 in people to be normal when I know they are not converting T3 adequately. The place that Wilson's Syndrome really breaks down for me is the idea that cycling the patient in the way that the Wilson's Syndrome protocol does will "capture" the temperature and thus re-set the proper thyroid hormone balance. In honesty, I don't buy it as a therapeutic strategy, I don't see why it would work and I don't think Dr. Wilson gives a convincing explanation.

Do you prescribe this sort of therapy yourself in your own practice?

Perhaps because of this (there is research that suggests that a treatment is more effective if the prescribing doctor believes it's effective!) I haven't gotten good results with the dozen or so patients that I have tried on this therapy.

Do you have a sense of the level of patients who may need this sort of T3-only therapy, and among those who try it, how many find it effective?

I do frequently make the judgment that people are having problems converting to active T3, although I don't often call this "Wilson's Syndrome." I look for several things: [1] symptoms of low thyroid [2] symptoms of sluggish adrenal / stress function (since this will promote rT3 formation) [3] low basal body temperatures, usually underarm. I also do a metabolic laboratory urine test called an Organic Acid test, it looks at all of the products of metabolism, and you can frequently see the imprint of a sluggish thyroid by finding multiple low metabolic products. When I see this, I give T3 therapy in the following manner: I have a compounding pharmacist make up time-release T3, usually 7.5 mcgm capsules, and I give them twice daily (sometimes three times daily). After three weeks, I gradually increase the dose.

At the same time, I look for other factors compounding metabolism. This Is the idea of the "Metabolic Matrix" that I described in my book, the idea that thyroid and metabolic function can't be separated from looking at the digestion, the detoxification organs, the adrenal / stress system, the neuroregulatory system, the sex hormone system, the immune system and the environment. Thus, I give (where appropriate) digestive support, adrenal support, immune support, detoxification, heavy metal assessment, etc. This gets back to the question of the "find it, fix it" mentality. We cannot significantly improve patient health by changing from T4 to T3 therapy. What we really have to do is to look through a wider lens at the question Of metabolism and thyroid function.

5. How do you suggest patients get beyond their physician's resistance to prescribing natural desiccated thyroid, or T3 supplementation?

A tough question, but one that I believe is becoming a bit easier to Answer as time goes on. Just yesterday, I received an e-mail from a very conventional physician in my community asking what I would advise about natural hormone replacement therapy (HRT) for menopausal women. He had a patient that was having symptoms related to menopause, she did not want to take synthetic hormones due to recently-publicized negative research, and this physician was open-minded enough to consider a natural alternative. A good relationship with an open-minded physician would be my most critical bit of advice.

Beyond that, I suggest that patients become well-informed. Your physician is overwhelmed with the amount of new research, new recommendations and new therapies, and is barely able to keep up with the most important ideas, in the environment of increasing insurance regulations, HIPAA compliance, etc.

Many physicians welcome information delivered by patients, such as information from this website, that comes from clinical experience. In the case of T3, which is produced commercially as Cytomel, I suggest that patient ask their doctors to add a bit of Cytomel to their T4 treatment, then try to taper the T4 and build up the T3. Or, use one of the combination products on the market. In a couple of cases, I had my compound pharmacist prepare some information to send to the physician, and I found that to be helpful. In the case of natural desiccated thyroid, it becomes more difficult since there is a bias against natural medications that is entrenched in physicians' minds. Having the physician prescribe Armour as "no substitution" helps sometimes, asking the physician for a three month trial sometimes is helpful. But there is no substitute for a physician who sees himself or herself as a partner in healing.

6. What about iodine supplementation, and use of herbs like kelp that contain high levels of iodine? Do you think they can help -- or hurt -- thyroid patients?

I sometimes use an iodine-tyrosine combination supplement, and I frequently have patients use kelp as part of a metabolism-boosting program. However, there is a "more-is-better" mentality in our culture generally, and it certainly affects people who use natural products. I often find patients who are taking too much iodine in the thought that it will boost their thyroid, and I don't recommend this. There are many unqualified nutritional advisers from the person who might be behind the counter at the Vitamin Shoppe to the massage therapist who advises her patients.

Unfortunately, the idea that "iodine is good for the thyroid" can be transmitted to the patient. Iodine is certainly necessary for good thyroid function. But, in today's world when table salt is iodized and fish is plentiful everywhere, it is unlikely that iodine deficiency is a major cause of thyroid dysfunction. And, too much iodine can unnecessarily stimulate a thyroid gland, leading to a worsening of tumors and overactive glands.

7. Why do you feel, as you state in the book, that synthetics are more stable that natural desiccated thyroid hormone replacement drugs?

First, let me say that I use a fair amount of natural desiccated thyroid, though my preferred therapy these days is time-released T3. Any natural product is subject to certain risks that synthetics are not. The clearest risk is the possibility that livestock is infected with a virus or other substance that will not be broken down in the processing of pills. Although there are no reports of mad cow disease being transmitted through the processing of drugs from livestock, the tiny possibility of some sort of infection exists, and thus I look for other possibilities. Also, an argument has long been made that there is less control of the exact amounts of hormone in the natural products, while a single-hormone product like thyroxine (T4) can have identical doses every time. This is less of an issue for me in prescribing medications. For one thing, our own thyroid glands are constantly changing their activity to respond to the internal and external environment, and we are not going to match that with a single-hormone synthetic product. Also, natural desiccated products contain a number of substances barely understood but probably having some significance to us (for instance, T2, T1, and T0 in tiny amounts).

8. What do you feel are some of the most promising avenues for thyroid patients in terms of alternative and complementary medicine?

I'm very interested in what is being termed "functional medicine". Most Of our current medical system is more "structural," that is, we look for specific problems such as abnormal TSH, cysts and tumors, etc. Functional medicine looks at how our body systems function or malfunction, and there are a number of novel laboratory tests that are helpful. For instance, we measure adrenal function by serial saliva samples that can be collected at home, and show how the stress organ works throughout the 24 hour cycle. Thyroid function can likewise be monitored by saliva testing. Innovative urinary testing for metabolism can show a variety of nutrient and metabolic problems that can cause symptoms without causing a discrete disease. This type of testing assists me in evaluating the entire Metabolic Matrix function.

Another important factor in thyroid treatment is the increased use of compounding pharmacists. This allows us to create our own type of treatments without being locked into the choices developed by pharmaceutical companies. For instance, one of my current treatments of choice is time-released T3, which is more physiologic than taking a once-a-day synthetic T4. Compounding pharmacists are versed in preparing all sorts of unique natural hormone therapies, including topical, sublingual and injectible forms.

Complementary therapies such as acupuncture are being more accepted by conventional medicine. Being an acupuncturist by training, I incorporate acupuncture into many thyroid treatments. Research has shown that acupuncture can stimulate TSH release. I find acupuncture particularly helpful to control the symptoms of hyperthyroidism, although it does not by itself cure the problem.

Finally, I am very excited by the increasing understanding of our human genome. We now know that genes are not a blueprint that is used to create us and then discarded. Rather, our genes are constantly active and controlling all aspects of our metabolism and hormonal function. Minor variations in our individual gene function (called "single nucleotide polymorphisms" or "SNiPS") can cause significant problems in proper body function. By understanding the nutritional and environmental factors influencing those genes, we can begin to truly individualize treatments in a natural and lasting way, rather than picking a symptom or lab test and putting everyone on the same synthetic medication.

FOR MORE INFORMATION

For more information on Dr. Rothfeld’s approach, read his book, Thyroid Balance.

CONTACT

Glenn S. Rothfeld, M.D., M.Ac.
Medical Director, WholeHealth New England
180 Massachusetts Ave., Suite 303
Arlington, MA 02474
Phone 781 641-1901
Fax 781 641-3963
Web: http://www.WholeHealthNE.com

Copyright © 2003, Mary Shomon. Originally published at http://www.thyroid-info.com/articles/rothfeld.htm.

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