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Should You Get A Thyroid Ultrasound?

An ultrasound uses sound waves to develop images, and it is the most sensitive imaging modality available for examining the thyroid gland.  A thyroid ultrasound also has the benefit of being non-invasive, it doesn’t use ionizing radiation, and it is less expensive than other imaging techniques such as an MRI and CT scan.  But does this mean that everyone with a suspected or confirmed thyroid or autoimmune thyroid condition should consider getting a thyroid ultrasound?  I’ll of course answer this and other questions you may have in this blog post.

When I was diagnosed with Graves’ Disease, the endocrinologist I saw didn’t want to do a thyroid ultrasound.  After palpating my thyroid gland she didn’t detect any thyroid nodules, and while I appreciated her trying not to recommend any unnecessary tests, I talked her into doing a thyroid ultrasound.  Other than some thyroid swelling it came back clean, as I had no thyroid nodules.

Since I requested a thyroid ultrasound even though my endocrinologist didn’t think it was necessary, does this mean that I recommend for everyone with a thyroid or autoimmune thyroid condition to get an ultrasound?  I can’t say that I recommend for all of my patients to order a thyroid ultrasound.

The reason I chose to get a thyroid ultrasound is because I don’t think that palpating the thyroid gland is always sufficient to detect thyroid nodules.  But even if I had one or more thyroid nodules show up on an ultrasound, would I have done anything differently while taking a natural treatment approach?  The honest answer is probably not.  And even if I had one or more thyroid nodules, I probably would not have had them biopsied, although this would depend on the characteristics, which I’ll talk about shortly.

When Is A Thyroid Ultrasound Indicated?                         

According to the American Association of Clinical Endocrinologists (AACE), a thyroid ultrasound is indicated in the following situations (1):

1. To confirm the presence of a thyroid nodule when the physical examination is equivocal.  So if the physical exam is inconclusive for thyroid nodules then a thyroid ultrasound would be indicated.

2. To characterize a thyroid nodule.  In other words, to measure the dimensions accurately and to identify internal structure and vascularization.

3. To determine whether a thyroid nodule is benign or malignant.  Although an ultrasound can’t always differentiate between a malignant and thyroid nodule, sometimes this can be determined based on the appearance of the nodule.

4. To differentiate between thyroid nodules and other cervical masses.  While thyroid nodules are the main focus of a thyroid ultrasound, other masses that can show up include enlarged lymph nodes, a thyroglossal cyst, or a cystic hygroma.

5. To evaluate diffuse changes in the thyroid parenchyma.  What is the thyroid parenchyma?  The thyroid parenchyma is simply the tissues that comprise the thyroid gland.

6. To detect post-operative residual or recurrent thyroid tumor or metastases to the neck lymph nodes.  For example, if someone has thyroid surgery to remove a malignant nodule, then a follow-up thyroid ultrasound would understandably be indicated.

7. To screen high risk patients for a thyroid malignancy.  This includes people with a family history of thyroid cancer, or perhaps if someone had radiation exposure to their neck in childhood.

8. To guide diagnostic and therapeutic interventional procedures.  For example, if someone needs to get a biopsy of a thyroid nodule then an ultrasound may be used to help guide the placement of the needle within a nodule.

Getting Back To My Situation…

If you read the eight indications above then you’ll notice that the first one mentions that a thyroid ultrasound is indicated “to confirm the presence of a thyroid nodule when the physical examination is equivocal”.  When I received my thyroid examination the endocrinologist seemed pretty confident that I didn’t have any thyroid nodules, yet I overruled her and asked for a thyroid ultrasound anyway.  And even though I paid out of pocket for the ultrasound, I didn’t have any regrets, as I didn’t want to rely on the palpation skills of the endocrinologist, and I had peace of mind knowing that I didn’t have thyroid nodules.

But what approach would I have taken if the ultrasound revealed thyroid nodules?  Earlier I mentioned that if the thyroid ultrasound I received revealed one or more thyroid nodules I probably wouldn’t have done anything different with regards to the natural treatment protocol I followed.  I also mentioned how I probably wouldn’t have had a biopsy done.  However, one benefit is that I could have done a follow-up ultrasound in the future to monitor the thyroid nodules and make sure that they weren’t getting larger.

Ultimately the decision to request a thyroid ultrasound is up to you.  If the endocrinologist you are working with recommends an ultrasound due to one of the indications I listed above, then it probably is a good idea to get one.  On the other hand, if after palpating your thyroid gland they are confident that you don’t need a thyroid ultrasound, then it’s fine not to get one.  If you’re skeptical like I was and want to get one anyway then of course there is nothing wrong with politely asking the doctor.

You might think that the endocrinologist I was working with was willing to order the thyroid ultrasound because I’m a chiropractor, but I actually didn’t tell her my profession, and I didn’t put it down on the health history form.  The reason I didn’t let her know my profession is because I wanted to see how she treated someone who wasn’t a healthcare professional.  And I must admit that she was very pleasant to work with, although I only saw her for that single visit.  Probably the main reason she was willing to order a thyroid ultrasound is because not only did I ask her politely for it, as I told her that it would give me peace of mind, but she also knew that I was paying out of pocket for it.  As a result, from a health insurance perspective there was no concern as to whether the ultrasound was medically necessary.

Hashimoto’s, Graves’ Disease, and Thyroid Ultrasounds

What I’d like to do next is specifically talk about both Hashimoto’s Thyroiditis and Graves’ Disease, and when a thyroid ultrasound should be considered.  But wait, shouldn’t the indications I listed above apply to these two autoimmune thyroid conditions?  Well yes, these indications do apply, but there are other circumstances when getting a thyroid ultrasound might be a good idea, especially with Hashimoto’s Thyroiditis.

Hashimoto’s Thyroiditis.  Although the diagnosis of Hashimoto’s is usually confirmed by an elevated TSH combined with the presence of thyroid peroxidase and/or thyroglobulin antibodies, these antibodies are not always positive in those with Hashimoto’s.  When this is the case, getting a thyroid ultrasound can be beneficial, as many times this can confirm the presence of Hashimoto’s Thyroiditis.

Graves’ Disease.  Just as is the case with Hashimoto’s, most cases of Graves’ Disease are characterized by elevated thyroid antibodies…specifically TSH receptor antibodies, with the most common type being thyroid stimulating immunoglobulins.  While I can’t say that everyone with Graves’ Disease needs to get a thyroid ultrasound, I did want to mention that many doctors recommend for people with hyperthyroidism to get a radioactive iodine uptake test.  This involves taking a small dose of radioactive iodine, and the justification for this test is that a high uptake reading can confirm Graves’ Disease, and this test can also reveal if someone has thyroid nodules, and give an idea as to whether they are benign or malignant.

The reason why I’m not a big fan of this test is because 1) Graves’ Disease can usually be diagnosed by the presence of elevated thyroid stimulating immunoglobulins, and 2) a thyroid ultrasound can detect the presence of thyroid nodules, and can also give a good idea as to whether the nodules are benign or malignant.  And of course the thyroid ultrasound is less invasive than the radioactive iodine uptake test, which is why I’m more in favor of getting an ultrasound.

Understanding Ultrasound Terminology

Remember that ultrasound involves waves, which are formed in the head of the instrument the doctor or radiologist applies to the body, which is also known as a transducer.  Echogenicity of the tissue refers to the ability to reflect or transmit ultrasound waves in the context of surrounding tissues (2).  Based on echogenicity, a structure can be characterized as hyperechoic (white on the screen), hypoechoic (gray on the screen) and anechoic (black on the screen) (2).  Cartilage appears hypoechoic, including thyroid cartilage, and on an ultrasound Hashimoto’s Thyroiditis usually presents as diffuse enlargement of the thyroid gland, along with heterogeneous and hypoechoic parenchymal echo pattern.  Graves’ Disease actually presents with a similar pattern.  Thyroid blood vessels appear black or anechoic.

The thyroid gland is highly vascular, and certain types of ultrasound devices (i.e. Doppler ultrasound) can measure the vascularization of the thyroid gland, and so you might also see this on an ultrasound report.  Hypervascularization means that there is an increased blood flow to the area, while hypovascularization refers to a decreased blood flow.  Graves’ Disease is usually characterized by very high vascularity on an ultrasound.  While you might expect Hashimoto’s and hypothyroidism to be of low vascularity, most cases of hypothyroidism are also characterized by high vascularity.  If the ultrasound shows a small atrophied gland then this usually indicates that the person has had extensive damage to the thyroid gland, and this is sometimes referred to as “end stage” Hashimoto’s Thyroiditis.

What’s The Thyroid Ultrasound Pattern for Multinodular Goiter?

Although most of my patients have either Graves’ Disease or Hashimoto’s Thyroiditis, multinodular goiter is the most common cause of diffuse asymmetric enlargement of the thyroid gland (1).  Not surprisingly, in people with multinodular goiter a thyroid ultrasound will reveal a diffusely enlarged thyroid gland, along with multiple nodules.  I spoke about the vascularity of Graves’ Disease and Hashimoto’s, and the vascularity can help to differentiate multinodular goiter from a carcinoma, as someone who has thyroid nodules with an increased blood flow has a higher risk of malignancy (3).

More About Thyroid Nodules…

Although I have written separate articles on thyroid nodules and I don’t want to focus too much on this here, I do want to add that it is very common to have thyroid nodules.  So while I requested a thyroid ultrasound from my endocrinologist because I was concerned about having thyroid nodules, what I didn’t realize at the time was that more than 50% of people will have thyroid nodules on an ultrasound (4).  The good news is that most of these thyroid nodules are benign.  And so please don’t get stressed out if you have one or more thyroid nodules show up on an ultrasound.

While a thyroid biopsy is used to confirm whether a suspicious thyroid nodule is benign or malignant, one of the indications I listed earlier mentioned how a thyroid ultrasound can give an idea as to whether a thyroid nodule is benign or malignant.  And the way it does this is by looking at the following characteristics:

  • The size of the nodule
  • The presence of microcalcifications
  • Irregular margins
  • Solid composition
  • Marked hypoechogenicity

So while a biopsy might be indicated to confirm whether a “suspicious” thyroid nodule is benign or malignant, most people who have one or more thyroid nodules don’t need to get a biopsy.  Plus, keep in mind that biopsies aren’t perfect, as they don’t always confirm or rule out a malignancy.  One more thing I want to add is that the presence of multiple nodules doesn’t increase the likelihood of a malignancy.  In other words, if someone has five thyroid nodules, each nodule will have an equal risk of being benign or malignant when compared to someone who has one or two nodules.

In summary, an ultrasound is the most sensitive imaging modality used to examine the thyroid gland.  Some of the indications for a thyroid ultrasound include to confirm the presence of a thyroid nodule when the physical exam is inconclusive, to characterize a thyroid nodule, and to differentiate between thyroid nodules and other cervical masses.  Many people with Graves’ Disease are told to get a radioactive iodine uptake scan when many times a thyroid ultrasound (along with testing the thyroid stimulating immunoglobulins) would be sufficient.  And sometimes an ultrasound can be used to diagnose Hashimoto’s Thyroiditis when the person has negative thyroid antibodies.


Graves’ Disease, Hashimoto’s, and The Triad Of Autoimmunity

In past articles and blog posts I have briefly mentioned the triad of autoimmunity.  This is also known as the “three-legged stool” of autoimmunity, and it consists of a genetic component, an environmental trigger, and an increase in intestinal permeability (a leaky gut).  The theory is that all three of these are factors in the development of an autoimmune condition such as Graves’ Disease or Hashimoto’s Thyroiditis.  And if this is the case, then these factors need to be addressed when trying to restore someone’s health.

What I plan on doing in this blog post is to discuss the individual components of this triad, and hopefully give you a better understanding of what you can do to address the individual components.

Component #1: Genetics.  With regards to the three components of the triad of autoimmunity, genetics of course is the one component that can’t be modified.  This is the reason why I try not to use the word “cure” when I talk about treating these conditions naturally.  So when I talk about restoring one’s health back to normal, or reversing the autoimmune component, the goal is to get the person into a state of remission, and after this has been accomplished the next goal is to help them maintain a state of wellness.

But since the genetic component can’t be modified, you might wonder how it’s possible to get someone into a state of remission AND to help them maintain their health.  Perhaps this can best be explained by looking at a different autoimmune condition, Celiac disease.  With Celiac disease, the autoimmune trigger is gluten.  Of course I’ll talk in greater detail about environmental triggers shortly, but I’m bringing this up here because if someone with Celiac disease completely avoids gluten, then they will remain in remission from this autoimmune condition on a permanent basis.  This is true even though nothing can be done to change the genetics associated with Celiac disease.

Sticking with the example of Celiac disease, another thing to keep in mind is that just because someone has a genetic predisposition for Celiac disease doesn’t mean they will develop this condition.  In fact, even if someone with the genetic markers for Celiac disease eats gluten, this doesn’t guarantee that they will develop Celiac disease.  It’s a similar situation with those people who have Graves’ Disease and Hashimoto’s Thyroiditis.  Those with a genetic marker for these conditions, as well as other autoimmune conditions, won’t necessarily develop the specific condition unless they are exposed to an environmental trigger and they also have a leaky gut.

Component #2: Environmental trigger.  As I just discussed, while having a genetic predisposition seems to be necessary for the development of thyroid autoimmunity, other factors are also necessary, which of course is the basis behind the “triad of autoimmunity”.  So in addition to having a genetic predisposition, an environmental trigger is also necessary to cause the development of Graves’ Disease or Hashimoto’s Thyroiditis.  Earlier I spoke about Celiac disease, and unlike most other autoimmune conditions, with Celiac disease we know that the environmental trigger is gluten.  And while it’s not easy for many people to completely avoid gluten, it still is a huge advantage knowing what the specific autoimmune trigger is.

This is what makes it challenging to help people with other types of autoimmune conditions, including Graves’ Disease and Hashimoto’s Thyroiditis.  With these conditions the environmental trigger can differ from person to person.  The following are just a few examples of environmental triggers of thyroid autoimmunity:

  • Stress
  • Foods (i.e. gluten)
  • Bacterial Infections (i.e. H. Pylori)
  • Viral infections (i.e. Epstein Barr)
  • Parasites (i.e. Blastocystic Hominis)
  • Environmental toxins (i.e. mercury)
  • Overtraining

So how do you find the environmental trigger?  As I mentioned earlier, this can be challenging, but it’s usually accomplished through a combination of a good health history and the appropriate testing.  For example, when I was diagnosed with Graves’ Disease, stress was a big factor in the development of my condition.  And this was verified through an adrenal saliva test I ordered, which showed that I had depressed cortisol levels, a depressed DHEA, and a depressed secretory IgA.  And while stress is a big factor with many others with autoimmune thyroid conditions, some people have other triggers.

Sometimes the person will test positive for multiple triggers.  For example, someone might choose to get an adrenal saliva test along with a comprehensive stool panel, and the results of the two tests reveal compromised adrenals and multiple infections.  Of course it is possible that only one of these factors was the “true” environmental trigger, but it’s challenging to know which is the primary trigger, and of course either way the goal should be to address all of these imbalances.  In other words, if someone has both adrenal problems and an infection, while it’s possible that dealing with a lot of stress weakened the person’s immune system and led to an infection, which in turn was the autoimmune trigger, the goal should be not only to eradicate the infection, but to help the person improve the health of their adrenals.

Component #3: Leaky gut.  Dr. Alessio Fasano is the researcher who came up with the theory that having an increase in intestinal permeability is a necessary factor in autoimmunity.  A few years ago I admittedly questioned this theory in a blog post I wrote entitled “Is a Leaky Gut Present In All Autoimmune Thyroid Conditions?”  A number of years ago I did more frequent testing for a leaky gut on my patients, and in this post I discussed how some people with elevated autoantibodies tested negative for a leaky gut, which either meant that the testing wasn’t completely accurate, or that Dr. Fasano’s theory was incorrect.

This blog post was written almost three years ago, and while Dr. Fasano’s theory still hasn’t been proven, it is widely accepted by many well known healthcare professionals.  And I agree that the mechanisms behind it make sense, which is why these days I don’t frequently test my patients for a leaky gut, and instead assume that this is a factor in those with Graves’ Disease and Hashimoto’s Thyroiditis.  After all, everything comes down to risks vs. benefits, and in my opinion it’s a greater risk to not give gut support to someone who has a leaky gut than to put someone who might not have a leaky gut on a gut repair protocol.  In other words, it isn’t harmful to treat someone for a leaky gut, even if they don’t have a leaky gut.

Removing The Leaky Gut Trigger

It’s important to understand that in order to heal the gut, it’s also necessary to find out the factor which caused the leaky gut in the first place.  This is where it can get confusing at times, as the “leaky gut trigger” can be the same as the environmental trigger I mentioned above, although this isn’t always the case.  For example, earlier I spoke about Celiac disease, and in this case gluten not only is the environmental trigger, but gluten also has been proven to cause an increase in intestinal permeability in everyone, regardless of whether or not they have a sensitivity to gluten.  In any case, with Celiac disease, gluten is both the “environmental” trigger and the “leaky gut” trigger.

However, there are situations where the leaky gut trigger might differ from the environmental trigger.  For example, someone with a genetic predisposition to Graves’ Disease or Hashimoto’s Thyroiditis might have a history of taking antibiotics, which can cause a leaky gut.  So this person has a genetic predisposition and a leaky gut, but the autoimmune process hasn’t started yet since they haven’t been exposed to an environmental trigger.  Then one day this person gets infected with Yersinia enterocolitica, which in this case is the environmental trigger, and they develop thyroid autoantibodies.  So in this example the antibiotics were the “leaky gut trigger”, but not the environmental trigger.

Differentiating Between The Environmental and Leaky Gut Trigger

The truth is that it can be challenging to differentiate between the environmental and leaky gut trigger.  In the example given above, while the excessive use of antibiotics might have caused the leaky gut, it’s also possible that the infection (Yersinia enterocolitica) caused the leaky gut.  So while gluten is both the environmental trigger and the leaky gut trigger in Celiac disease, it’s probably safe to say that in many cases of Graves’ Disease and Hashimoto’s Thyroiditis, the environmental trigger and the leaky gut trigger are also the same, although this isn’t always the case.  Hopefully you don’t find this to be too confusing, but the overall point is that the ultimate goal should be to remove anything that can be either an environmental trigger or a leaky gut trigger.

What Is Still Unclear About Environmental Triggers

While over the last decade we have learned a lot more about the different environmental triggers associated with autoimmunity, there is still a lot we don’t know.  For example, the research shows that Yersina Enterocolitica is a potential trigger of both Graves’ Disease and Hashimoto’s Thyroiditis (1) (2).  However, does this mean that everyone who has a genetic predisposition for thyroid autoimmunity and also has a leaky gut will develop Graves’ Disease or Hashimoto’s when exposed to this specific bacteria?

It would seem that this isn’t the case.  For example, not everyone who has a genetic predisposition to Hashimoto’s or Graves’ Disease has a negative reaction to iodine.  So this is one example of an environmental trigger which doesn’t trigger thyroid autoimmunity in everyone with a genetic predisposition (and a leaky gut).

Another example involves gluten, as this seems to be an environmental trigger in some people with autoimmune thyroid conditions, but not others.  In fact, you might have read posts in Facebook groups or in forums from people with Graves’ Disease or Hashimoto’s Thyroiditis who got into remission upon eliminating gluten alone.  On the other hand, there are people who have gone 100% gluten free for many months without getting into remission, which suggests that gluten isn’t an environmental trigger in everyone.  However, I did mention earlier that the research shows that gluten can cause a leaky gut in everyone.  So it can be argued that gluten is a leaky gut trigger in everyone, but not necessarily an environmental trigger in everyone.

Addressing The Triad To Achieve A State of Remission

In order for anyone with Graves’ Disease and Hashimoto’s Thyroiditis to achieve a state of remission it is necessary to identify and remove the environmental trigger, and to do things to heal the leaky gut.  The good news is that achieving this is very possible, but the bad news is that a relapse is also possible in those that don’t continue to live a healthy lifestyle.  For example, if stress was a big factor in the development of your autoimmune thyroid condition, while you can’t completely eliminate the stress from your life, you can do things to improve your stress handling skills.

Similarly, if the environmental trigger was an infection such as H. Pylori or Blastocystis Hominis, while getting rid of this infection is important, doing things to improve the health of the immune system is also necessary to prevent these and other infections from reoccurring in the future.  Improving the health of the immune system is perhaps even more important if the trigger was a viral infection such as Epstein Barr, which can’t be eradicated, but can be kept in a dormant state.  Of course since most people have been infected with Epstein Barr it can be argued that it is critical for everyone to do everything they can to have an optimally-functioning immune system.

And of course in order to have a healthy immune system you need to have a healthy gut, and so healing the leaky gut is not only essential to get into remission, but it’s also a necessary component of a healthy immune system.  As for how to heal a leaky gut, in addition to removing the “leaky gut trigger” you also want to heal the gut, which can be accomplished through both food and supplementation.  I’m not going to get into detail about this here, as I have discussed this in other articles and blog posts.

In summary, the triad of autoimmunity theorizes that three factors are necessary to develop any autoimmune condition.  These include a genetic predisposition, an environmental trigger, and a leaky gut.  Although not being able to modify the genetic component is the reason why we can’t cure conditions such as Graves’ Disease and Hashimoto’s Thyroiditis, the expression of our genes can change, and we of course can address the other two components, which can put the person into a state of remission.  And it is also is very possible to maintain a state of wellness by having a healthy gut and minimizing your exposure to environmental triggers.


5 Things To Know About Goitrogenic Foods

It’s been awhile since I’ve written an article on goitrogens, and so I figured I’d put together a blog post discussing 5 different things you should know with regards to goitrogenic foods.  For those reading this who are unfamiliar with goitrogenic foods, there are certain foods that can potentially suppress the function of the thyroid gland, and it accomplishes this by interfering with the uptake of iodine.  This in turn can result in the formation of a goiter, which is an enlargement of the thyroid gland.  There are also “environmental goitrogens”, which are certain substances or chemicals that can inhibit the production of thyroid hormone, although the focus of this blog post will be on foods.  According to the literature, the following foods have been identified as being goitrogenic (1):

  • Broccoli
  • Brussels sprouts
  • Cabbage
  • Cauliflower
  • Mustard greens
  • Radishes
  • Millet
  • Spinach
  • Cassava
  • Peanuts
  • Soybeans
  • Strawberries
  • Sweet potatoes
  • Peaches
  • Pears
  • Green tea

So now that you are aware of some of the more common goitrogenic foods, let’s go ahead and discuss five things you need to know about them.

1. There are no human studies showing that cruciferous vegetables can cause a goiter.  It’s very common for people with hypothyroidism or Hashimoto’s to express concern about eating cruciferous vegetables such as broccoli, kale, and cauliflower.  However, these are very healthy foods, and while some people with hypothyroidism might have problems eating cruciferous vegetables, this isn’t common.  Although there aren’t any human studies which demonstrate that eating cruciferous vegetables can inhibit thyroid hormone production, there are rat studies which show the goitrogenic effects of cruciferous vegetables.

One study showed that cabbage can significantly reduce plasma thyroxine (T4) levels within days, even when consuming a moderate amount of iodine (2).  One thing I need to say is that cooking foods can decrease the goitrogenic properties, although you of course don’t want to cook cruciferous vegetables for too long in order to avoid the loss of nutrients.

2. Drinking high amounts of green tea might have a goitrogenic effect.  A few studies have looked at the goitrogenic effect of green tea extract in rats, and found that catechin present in green tea extract might have antithyroid activity, and that drinking green tea at high doses can alter thyroid function adversely (3) (4).  Keep in mind that the study specifically said that drinking “high doses” of green tea can have adverse effects on thyroid function, which perhaps explains why I haven’t seen a problem with my patients drinking green tea.  And so I’m not suggesting for those with thyroid and autoimmune thyroid conditions to completely avoid drinking green tea.  Plus, remember that just as is the case with cruciferous vegetables, these studies were conducted on rats, and not humans.

3. Not all goitrogenic foods are created equally.  Some foods are considered to be more goitrogenic than others.  For example, cruciferous vegetables are supposedly more goitrogenic than other foods such as spinach, strawberries, and peaches.  Soy is perhaps the most goitrogenic food, but this isn’t the only reason why I recommend for my patients to avoid soy.  As I discussed in a blog post entitled “4 Reasons Why Soy Should Be Avoided In Those With Thyroid Conditions“, soy is a common allergen, soy has phytates, which can lead to a decrease in iron and calcium absorption, and most soy is genetically modified.  Although there are health benefits of eating organic fermented soy, the fermentation process apparently doesn’t reduce the goitrogenic properties.

4. A moderate to severe iodine deficiency can make goitrogenic foods more problematic.  As I mentioned in the opening paragraph, the way that goitrogenic foods can potentially inhibit thyroid hormone production is by interfering with iodine uptake.  So not surprisingly, those people who have a moderate or severe iodine deficiency are more likely to have problems when eating raw goitrogenic foods.  While it might be a good idea to test for an iodine deficiency, keep in mind that not everyone with thyroid and autoimmune thyroid conditions do well when supplementing with iodine, and there is some evidence of this in the comments section of a blog post I released in 2016.  This doesn’t mean that an iodine deficiency shouldn’t eventually be addressed, but in many cases it makes sense to improve the health of the immune system before addressing an iodine deficiency, which I discussed in an article I wrote entitled “An Update On Iodine and Thyroid Health”.

5. Turmeric can benefit those who eat a lot of goitrogenic foods.  I absolutely love turmeric, as it has many health benefits.  And one study involving 2335 residents of Pakistan showed that turmeric can help to reduce goiters (5).  669 of these subjects had a palpable goiter, and most were either hyperthyroid or euthyroid (had normal thyroid hormone levels).  The authors recommended that those who eat high goitrogenic diets should be educated to consume turmeric to reduce the risk of goiter development.  Keep in mind that turmeric isn’t well absorbed, which is why many turmeric supplements add piperine, liposomes, or other substances to help increase turmeric absorption.

So hopefully you learned a few things about goitrogenic foods.  What I want you to take away from this blog post is that most people with thyroid and autoimmune thyroid conditions can eat a few servings of cruciferous vegetables per day, and most of the other foods listed above can also be safely eaten, with the possible exception of soy, peanuts, and millet.   It’s also important to understand that since goitrogens interfere with iodine uptake, having a moderate to severe iodine deficiency can make someone more susceptible to the goitrogenic effects of certain foods.  It’s also useful to know that turmeric can help to reduce goiter formation, and while fermentation doesn’t seem to reduce the goitrogenic properties of soy, cooking cruciferous vegetables can decrease the goitrogenic activity.


What’s Your Experience With Food Sensitivity Testing?

Last week I wrote a blog post entitled “The Elimination Diet vs. Food Sensitivity Testing“.  In this post I spoke about both the pros and cons of an elimination diet and food sensitivity testing.  I’m personally more in favor of an elimination diet, although there are times when I will recommend food sensitivity testing to my patients.  For those reading this who have done food sensitivity testing, I’d like to get your feedback.

If you have had any type of food sensitivity testing done, whether it was an IgG food sensitivity test, an ALCAT, MRT, or another method, did you agree with the findings?  Of course this is assuming you had some foods that you tested positive for.  Although I realize that you can’t always go by symptoms, many times you can, and so I’m curious to know if you had a negative reaction to any foods you tested positive for.  In other words, did the results of your food sensitivity testing make sense, or were they not what you expected?

And for those who have done food sensitivity testing AND have also followed an elimination diet, I’d love to hear what your thoughts are as well.  Did you find an elimination diet or food sensitivity testing to be more helpful in identifying potential food triggers?  Or did you find neither of these methods to be helpful?  Please share your experience in the comments section below.  Thank you!


The Elimination Diet vs. Food Sensitivity Testing

Foods can be a trigger with autoimmune thyroid conditions such as Graves’ Disease and Hashimoto’s Thyroiditis.  As a result, I have most of my patients follow an elimination diet initially.  On the other hand, some healthcare professionals have all of their patients do food sensitivity testing to see what specific foods they are reacting to.  While there are benefits to both of these methods, there are also limitations to both an elimination diet and food sensitivity testing, and in this post I’ll discuss the pros and cons of each of these so that you can better make an informed decision.

Before comparing the elimination diet with food sensitivity testing I’d like to discuss how food can cause autoimmunity in the first place.  First of all, certain foods such as gluten can lead to autoimmunity by causing an increase in proinflammatory cytokines and a decrease in regulatory T cells (1) (2) (3).  Molecular mimicry can also play a role, as what happens is that frequent exposure to certain food allergens can result in a decrease of oral tolerance.  This in turn triggers an immune system response against various components of food proteins, and cross-reaction with B-cell molecules may trigger autoimmunity (3).  In other words, eating certain foods will result in the immune system attacking the food proteins, and in the case of mistaken identity the immune system can also attack bodily tissues with a similar amino acid sequence.

In addition to causing an increase in proinflammatory cytokines or resulting in a molecular mimicry mechanism, certain food allergens can also cause an increase in intestinal permeability, which is also known as a leaky gut.  According to the triad of autoimmunity, a leaky gut is one of three factors required for the development of an autoimmune condition.  The other two components are a genetic predisposition and exposure to an environmental trigger.  Keep in mind that not all foods will cause a leaky gut, and what can make it challenging is that a leaky gut can actually cause the development of food sensitivities through a loss of oral tolerance.

What Are The Most Common Allergens?

While it is possible to have a sensitivity to any food, the following are considered to be the most common allergens:

In addition, these foods are also commonly problematic in some people:

The Elimination Diet vs. The Autoimmune Paleo Diet

Most people reading this are familiar with the autoimmune Paleo diet.  This is similar to a standard Paleo diet, but also has people avoid eggs, the nightshades, as well as nuts and seeds.  The reason why these and other foods such as grains and legumes are excluded is because they can interfere with healing of the gut.  However, the autoimmune Paleo diet also serves as an elimination diet, as you would essentially be eliminating the most common allergens, although some healthcare professionals do allow their patients to eat shellfish.  The reason for this is because while shellfish is considered to be a common allergen, shellfish is AIP-friendly.

What Are The Benefits of An Elimination Diet?

There are a few reasons why I like to have my patients follow an elimination diet initially.  First of all, I find that many patients can identify their food triggers if they do this type of diet carefully.  Essentially you want to follow a strict AIP diet for a minimum of 30 days, and then after 30 days you would reintroduce certain foods one at a time, every three days, and pay close attention to symptoms.  I have written a blog post on reintroducing foods that I would recommend checking out.

Another benefit of the elimination/reintroduction diet is that it is more cost effective than doing food sensitivity testing.  Testing for food allergens can be expensive, which would be fine if the information provided was completely accurate, or close to it.  But food sensitivity testing is far from perfect.

What Are The Flaws of An Elimination Diet?

Although I start most of my patients on an elimination diet, this admittedly does have certain limitations.  First of all, while many people are able to identify foods they are sensitive to, this isn’t always the case.  For example, someone who follows an elimination diet and reintroduces a certain food might experience some obvious symptoms, such as bloating and gas, headaches, an increase in fatigue, brain fog, or other symptoms.  On the other hand, some people don’t experience any overt symptoms upon reintroducing foods, and the lack of symptoms doesn’t always rule out a food sensitivity.

I will add that most people will notice symptoms upon reintroducing foods they are sensitive to if they pay close attention.  Many times people are only focusing on digestive symptoms, but as I discussed above, other symptoms can develop as well.  But how do you know if a specific symptom is related to the food you introduced?

For example, if someone reintroduces eggs, and they experience headaches, how do they know if the headaches were caused by the eggs?  Perhaps it was a coincidence and the person might have experienced the headache regardless.  This admittedly can be challenging, but in a situation where you are unsure if the symptom experienced was a result of the food that was reintroduced, what you would want to do is take a break from that food for a few additional weeks, and then you can try reintroducing the food again.  If you experience the same symptom then you can almost be certain that the food is responsible for that specific symptom.

Another limitation of an elimination/reintroduction diet is that it is possible for someone to be sensitive to one or more of the “allowed” foods.  For example, someone can be sensitive to AIP-friendly foods such as broccoli, avocados, chicken, raspberries, and other foods that are not part of an elimination diet.  This admittedly is a major limitation of this diet, although I find that most of my patients don’t react to AIP-friendly foods.

What Does Food Sensitivity Testing Involve?

In the past I wrote an article entitled “Food Allergies, Food Sensitivities, and Thyroid Health”.  In this article I discussed the difference between a food allergy, a food sensitivity, and a food intolerance.  As I mentioned in the article, a food allergy usually involves an immediate reaction to a food, and is considered to be IgE-mediated.  This is the type of testing that most conventional allergists will conduct.

Food sensitivity testing usually involves a delayed reaction.  As a result, it frequently will take a few hours, and sometimes a few days before someone will have a negative reaction to a food.  While most food sensitivity panels involve Immunoglobulin G (IgG), there are other types of panels, including leukocyte activation testing (i.e. the ALCAT) and mediator release testing (MRT).

A food intolerance is usually the result of an enzymatic defect, and a good example of this is a lactose intolerance.  Having a histamine intolerance can be due to a defect in the enzyme DAO, although there can be other causes of this type of intolerance as well.

What Are The Benefits of Food Sensitivity Testing?

One of the main benefits of food sensitivity testing is that it has the potential to identify specific foods that you are reacting to.  And while I can’t say that I’m a big fan of such testing due to some of the limitations I’ll discuss shortly, I have had some patients successfully identify foods that were causing problems.  And in some of these cases the foods were allowed on an elimination/AIP diet.

Another potential benefit is that it might prevent the person from having to eliminate certain foods, although this is controversial.  For example, if someone is eating gluten or dairy on a regular basis and tests negative for both of these, does this mean it’s safe to eat these foods, even though they are excluded from an autoimmune Paleo diet, as well as many other diets?  Well, we need to keep in mind that false negatives are possible with this type of testing.  I personally recommend for my patients to avoid gluten and dairy while restoring their health, regardless of what a food sensitivity panel shows.  And with regards to some of the other “excluded” foods, we need to keep in mind that some foods aren’t excluded because they are common allergens, but instead are excluded because they have compounds which can affect the healing of the gut.

So for example, nightshades are excluded from an autoimmune Paleo diet due to the compounds which can potentially cause inflammation and/or an increase in intestinal permeability.  Solanine is one example, as it’s a glycoalkaloid found in the nightshade foods, especially eggplant and potatoes, although it’s also found in tomatoes and peppers.  But if someone tests negative for eggplant, white potatoes, tomatoes, and peppers on a food sensitivity panel, this doesn’t mean that these foods won’t cause problems.

Getting back to the potential benefits of food sensitivity testing, one additional benefit that comes to mind is that if someone tests positive, and if it is a “true” positive, then this serves as a baseline.  In other words, if someone tests positive for one or more foods, and if they decide to reintroduce the food in the future when their gut is healed, they can do another food sensitivity test after reintroducing the food to see if they are still reacting to that specific food.

What Are The Disadvantages of Food Sensitivity Testing?

While it might sound great to do food sensitivity testing to determine the specific foods you are reacting to, there are a few disadvantages to this type of testing.  Here are some of the main ones:

  • False results are possible
  • You need to either be currently eating the foods, or have recently eaten the foods you’re testing for to get an accurate result
  • Doing this type of testing can be expensive
  • Most food sensitivity panels are incomplete, meaning that they don’t test for all of the foods a person eats
  • There can be differences between cooked and raw foods, yet most food sensitivity panels don’t test for both of these

What Approach Do I Take In My Practice?

As I mentioned earlier, I have most of my patients with Graves’ Disease and Hashimoto’s Thyroiditis follow an elimination diet initially in the form of the autoimmune Paleo diet.  I have them do this for the first month, and if they are doing well I’ll encourage them to follow this diet for a longer period of time.  But eventually I’ll have them reintroduce some of the excluded foods, as the goal isn’t to keep them on this diet on a permanent basis.  However, there are times when I will order an IgG food sensitivity panel.  First of all, if someone insists on ordering this type of testing then I’m fine ordering it.

Another situation when I might order such testing is if the patient started out with an elimination diet, and followed my other recommendations, but a few months later they still aren’t progressing.  Another scenario where I might order a food sensitivity panel is if the patient is progressing but then they hit a roadblock and don’t show further improvement.  So there are times when I will order food sensitivity testing, but it’s not a test that I recommend to all of my patients.

How Should YOU Detect Food Allergens?

After reading this you still might not be sure what approach you should take.  Of course ultimately the decision is up to you, and if you are working with a natural healthcare professional then you might leave the decision making up to them.  Some healthcare professionals recommend food sensitivity testing to all of their patients.  On the other hand, others never recommend food sensitivity testing to their patients.  I also should mention that some healthcare professionals use something called applied kinesiology to detect food sensitivities, which is a type of manual muscle testing.

What I recommend is to do some of your own research, and then find a doctor who is compatible with what you’re looking for.  For example, if you decide that you don’t want to do food sensitivity testing, then it’s probably not a good idea to work with a healthcare professional who recommends food sensitivity testing for every patient.  And if you want to get a food sensitivity panel done, then it doesn’t make sense to work with someone who is unwilling to order one for you.

In summary, foods can be a trigger of Graves’ Disease and Hashimoto’s Thyroiditis.  And while I commonly have my patients follow an elimination diet initially, many natural healthcare professionals will have all of their patients do food sensitivity testing.  There are pros and cons with both an elimination diet and food sensitivity testing.  With regards to the different tests for food allergens, IgE testing is specific for food allergies, while IgG testing is for delayed food sensitivities.  Leukocyte activation and mediator release testing are two other options, although there isn’t a lot of research on these two methods.


Should YOU Test For A Gluten Sensitivity?

Recently I attended a conference where one of the presenters mentioned that she thinks it’s malpractice for healthcare practitioners to have all of their patients go gluten free without first testing for Celiac disease.  While I recommend for my patients to avoid gluten while restoring their health, I don’t require all of my patients to obtain a Celiac panel, and I’ll discuss some of these reasons in this blog post.  However, the presenter did make some valid points, which I’ll also talk about.  And so the goal of this blog post isn’t to convince you to order a Celiac panel (assuming you haven’t done so already), but only to provide you with information to help you make an informed decision.

What I’m going to do is first list some of the reasons why everyone with an autoimmune thyroid condition should consider doing a Celiac Panel.  I will then list some reasons why it might not be a good idea for everyone with Graves’ Disease and Hashimoto’s to do a Celiac panel.  This way you will see both perspectives.  I’ll then talk about the different testing options for determining if you have Celiac disease or a non-Celiac gluten sensitivity.  Finally, for those who choose to go through the testing, I’ll discuss the approaches you should take if you test positive or negative for a gluten sensitivity.

Reasons Why Everyone With Thyroid Autoimmunity Should Consider Doing a Celiac Panel

1. Celiac Disease is more common in those with thyroid autoimmunity.  I discussed this in a separate article entitled “Celiac Disease and Thyroid Health”.  In the article I discussed how studies show that both those people with Graves’ Disease and Hashimoto’s Thyroiditis have a greater chance of developing Celiac disease.  In fact, some people develop Celiac disease first, and then years later they will develop an autoimmune thyroid condition.  But assuming someone with either Graves’ Disease or Hashimoto’s hasn’t been diagnosed with Celiac disease and hasn’t had any testing done to confirm this, due to the higher prevalence it makes sense to get a Celiac panel.  Those with other types of autoimmune conditions also have a greater chance of developing Celiac disease, and therefore they also might want to consider obtaining a Celiac panel.

2. If someone tests positive for Celiac disease they will need to avoid gluten on a permanent basis.  Regardless of whether someone has overt symptoms when consuming gluten, if a person tests positive for Celiac disease then they will want to avoid gluten on a permanent basis.  Not doing so can not only prevent their autoimmune thyroid condition from going into remission, but there are other risks of untreated Celiac disease, including the following (1):

  • Iron deficiency anemia
  • Early onset osteoporosis or osteopenia
  • Infertility and miscarriage
  • Vitamin and mineral deficiencies
  • Central and peripheral nervous system disorders
  • Pancreatic insufficiency
  • Gallbladder issues

3. It’s best to find out if someone has Celiac disease sooner than later.  Why is it best to find out if a person has Celiac disease sooner than later?  Because if someone has Celiac disease then they need to completely avoid gluten, and so it does make sense to find out sooner than later to make sure you do everything you can to avoid gluten.

4. You can’t rely on symptoms alone.  Although most people with Celiac disease will experience overt symptoms upon consuming gluten, this isn’t the case with everyone.  In fact, some people have silent Celiac disease, which is when they don’t experience overt symptoms, yet test positive for the markers of Celiac disease.  When this is the case the person should avoid gluten on a permanent basis, even if they feel fine when consuming gluten.

Reasons For NOT Testing Everyone For a Celiac Panel

1. If someone has been gluten free for awhile this test won’t be accurate.  One of the downsides of testing for Celiac disease, or any other testing for gluten antibodies, is that you need to be eating gluten for the test to be positive.  The reason for this is because for those who have Celiac disease, eating gluten will cause the immune system to produce certain antibodies, and these antibodies are measured during the testing.  If the person hasn’t eaten gluten for a few weeks, or perhaps even a few months, then there still can be detectable antibodies on such a test.  However, if the person has been completely gluten free for a prolonged period of time then such testing will come out negative, even if the person has Celiac disease.

2. Some people are fine giving up gluten forever even without a diagnosis.  Another reason not to test everyone for Celiac disease is because some people have no problem avoiding gluten on a permanent basis, even if they haven’t confirmed that they have Celiac disease.  This is especially true for those who feel better when avoiding gluten.  However, I mentioned earlier how not everyone with Celiac disease experiences symptoms when consuming gluten.  In my experience, patients are less likely to give up gluten on a permanent basis if they don’t experience any noticeable symptoms when eating gluten.  However, if someone tests positive for Celiac disease or a non-Celiac gluten sensitivity, they are more likely to give up gluten on a permanent basis, even if they don’t experience any negative symptoms when consuming gluten.

3. A negative Celiac panel doesn’t always rule out Celiac disease.  Although it would be great if such testing was 100% accurate, this isn’t always the case.  Here are some of the factors which can lead to a false-negative test result (2):

  • Age of less than 2 years
  • Laboratory error
  • Reduction or elimination of gluten from the diet
  • Selective IgA deficiency
  • Use of corticosteroids or immunomodulating drugs

So if an adult is eating gluten regularly, an IgA deficiency has been ruled out, and if they aren’t taking corticosteroids or immunomodulating drugs, then how can they tell if this is a false negative?  Well, if Celiac disease is suspected in this situation even if someone has negative test results, one option is to have them get a biopsy of the small intestine.  In addition, they can test for the genetic markers of Celiac disease, which are HLA-DQ2 and HLA-DQ8.  If the Celiac panel is negative and both of these genetic markers are also negative then chances are the person doesn’t have Celiac disease.

4. A negative Celiac panel doesn’t rule out a non-Celiac gluten sensitivity.  It’s possible to not have Celiac disease, yet have a sensitivity to gluten.  I’m not going to get into detail about this here, as you can read my article on Celiac disease and Thyroid heath for more information.  The good news is that there is more comprehensive testing available for gluten, which I’m about to discuss next.

What Are The Different Testing Options For Gluten?

There are numerous testing options to determine if someone has Celiac disease, or a non-Celiac gluten sensitivity.  Here are some of the main options:

Gliadin antibodies.  Gliadin is a protein of gluten, and while this is part of a Celiac panel, the reason why I listed this marker alone is because many healthcare professionals will only test this single marker.  While elevated gliadin antibodies will confirm that you have a gluten sensitivity (not necessarily Celiac disease), a negative finding doesn’t rule out either Celiac disease or a non-Celiac gluten sensitivity.  With that being said, patients with Celiac disease are more likely to have positive gliadin IgA antibodies, while those with non-Celiac gluten sensitivity are more likely to have positive gliadin IgG antibodies (3).

Celiac panel.  Unfortunately there isn’t a single Celiac panel available.  For example, if you visit the Labcorp website and do a search for “Celiac tests”, you’ll notice a few different options.  All of the panels will test for the IgA and IgG deamidated gliadin antibodies, along with tissue-transglutaminase IgA and IgG.  In addition, most panels will test for immunoglobulin A as well, which will help to rule out a false negative result.  Some panels will also test for the endomysial antibodies, although many medical doctors will test for only the gliadin and transglutaminase antibodies.  In my opinion, the more comprehensive the panel, the better.

Intestinal biopsy.  An intestinal biopsy is still recommended by some gastroenterologists to diagnosis Celiac disease.  However, it’s debated whether a biopsy is required to confirm the diagnosis of this condition.  If the person is presenting with the signs and symptoms of Celiac disease and has a positive Celiac panel, then there’s a very good argument that a biopsy isn’t necessary.  On the other hand, if the person presents with signs and symptoms indicative of Celiac disease, yet the Celiac panel comes back negative, then this might be a good time to conduct an intestinal biopsy.

Cyrex Labs Wheat/Gluten Proteome Reactivity And Autoimmunity (Array #3).  This is the most comprehensive test available for determining if someone has a gluten sensitivity.  This test measures the antibody production against multiple wheat proteins and peptides, transglutaminase-2, 3, and 6, and the gliadin-transglutaminase complex.  Although Cyrex Labs claims that this test isn’t diagnostic of Celiac disease, many times it can give a pretty good indication if someone has this condition, or a non-Celiac gluten sensitivity.

Enterolabs gluten sensitivity stool test.  This is also a pretty good test, although it’s not as comprehensive as the one from Cyrex Labs.  The reason I listed this here is because it’s a popular test, and over the years I have had numerous patients order this test prior to working with me.

Genetic testing.  When combined with a negative Celiac panel, genetic testing can help to exclude Celiac disease.  The genetic markers associated with Celiac disease include HLA-DQ1 and HLA-DQ8.  Approximately 0.4% of patients with Celiac are both HLA-DQ2 and HLA-DQ8 negative (4).  But as mentioned earlier, if someone has been eating gluten and has a negative Celiac panel, and also has both genetic markers negative, then there is a very high probability that they don’t have Celiac disease.  Genetic testing can also be considered if someone has been following a gluten free diet for a prolonged period of time, as one doesn’t have to be eating gluten for the results to be accurate.

What Approach Should You Take If You Test Positive For A Gluten Sensitivity?

If you choose to get one or more of the tests I listed above and it comes out positive, should you avoid gluten on a permanent basis?  Or is eating a small amount of gluten every now and then okay?  Well, some will argue that anyone with Graves’ Disease or Hashimoto’s Thyroiditis (or any other autoimmune condition) should avoid gluten on a permanent basis regardless of what the test results show.  And one of the main reasons for this is because regardless of whether someone has a gluten sensitivity or not, the research shows that gluten causes a leaky gut in everyone.  And for this reason alone, a good argument can be made that anyone with an autoimmune condition who tests positive for Celiac disease, or a non-Celiac gluten sensitivity, should ideally avoid gluten on a permanent basis.

In fact, someone with a confirmed case of Celiac disease should even be cautious about eating certain packaged gluten free foods.  And there are a few reasons for this.  First of all, gluten free foods aren’t always 100% gluten free, as they can include less than 20 ppm of gluten, yet some people react to as little as 5 ppm.  In addition, some “so-called” gluten free foods have greater than 20 ppm of gluten, and so if you do choose to eat packaged gluten free foods, please make sure they are certified gluten free.  For more information on this I would visit the websites for the Gluten-Free Certification Organization and Beyond Celiac.

In addition, if you test positive for a gluten sensitivity you also need to be cautious when eating out.  And the reason for this is because if you suspect that a food is gluten free, or even if it’s labeled as being gluten free on the restaurant menu, cross contamination is common.

What Approach Should You Take If You Test Negative For A Gluten Sensitivity?

As I mentioned earlier, there is always the chance of a false negative result.  I also mentioned that if you suspect Celiac disease but if the Celiac panel comes back negative then you can consider obtaining an intestinal biopsy.  But perhaps a better, less non-invasive option is to order the genetic markers of gluten, HLA-DQ2 and HLA-DQ8.

Just keep in mind that a negative intestinal biopsy doesn’t rule out a non-Celiac gluten sensitivity, and the same is true if someone tests negative for the genetic markers associated with Celiac disease.  But even if you’re 100% confident that you don’t have Celiac disease or a non-Celiac gluten sensitivity, it is a good idea to minimize your consumption of gluten.   Not only is gluten unnecessary to consume, but as I mentioned earlier, even if you’re not sensitive to gluten, it can cause a leaky gut, which is theorized to be a factor in everyone with Graves’ Disease or Hashimoto’s Thyroiditis.

In summary, many people with autoimmune thyroid conditions such as Graves’ Disease and Hashimoto’s Thyroiditis should consider doing a Celiac panel.  The reason for this is because Celiac disease is more common in thyroid autoimmunity, and if someone has Celiac disease they need to avoid gluten on a permanent basis.  Also remember that you can’t rely on symptoms, as while most people with Celiac Disease will experience overt symptoms when consuming gluten, this isn’t always the case.  Just keep in mind that you need to be eating gluten for a Celiac panel to be accurate.  Also, a negative Celiac panel doesn’t always rule out Celiac disease, and it’s also possible to have a non-Celiac gluten sensitivity.  An intestinal biopsy is also recommended by some gastroenterologists to diagnose Celiac disease, and Cyrex Labs has a comprehensive test that can help determine if someone has a gluten sensitivity.


5 SIBO Resources For Those With Graves’ Disease and Hashimoto’s Thyroiditis

Although my practice focuses on thyroid and autoimmune thyroid conditions, over the years I have seen more and more patients with Graves’ Disease and Hashimoto’s Thyroiditis with small intestinal bacterial overgrowth (SIBO).  As a result, I have done a good amount of research on SIBO, and I have attended numerous SIBO conferences (including the recent 2017 SIBO Symposium via livestream).  In this email I’d like to give those with SIBO five valuable resources.

Note: The fifth resource I listed is time sensitive, and so depending on when you read this blog post it might no longer be available.

1.  My recent blog post on SIBO.  Recently I wrote a detailed blog post on SIBO entitled “Can SIBO Trigger Thyroid Autoimmunity?“.  If you have SIBO and haven’t read this I would do so when you get the chance.  In this post I discuss four of the most common causes of SIBO, along with the relationship between IBS and SIBO.  I also discuss how SIBO is diagnosed, including the different testing options.  I go into detail about the different types of diets, and I finish up by discussing both conventional and natural treatment options for SIBO, including the role of prokinetics in preventing a relapse.

2. Dr. Allison Siebecker’s website.  Dr. Siebecker has a practice that focuses on SIBO, and her website has a lot of valuable information.  While there is plenty of information on her website, I find her video series on the elemental diet to be especially helpful.  Although Dr. Siebecker wasn’t a speaker at the 2017 SIBO Symposium, she presented at the previous ones, and is one of the main speakers in the upcoming SIBO Summit mentioned below.

3. Dr. Nirala Jacobi’s SIBO podcasts.  A patient made me aware of these a few months ago, and I must admit that the information is excellent.  One of my favorite podcast interviews is Dr. Donna Beck’s discussion on SIBO and salicylates.  But there are many other excellent interviews as well.

4. SIBO Discussion/Support Facebook Group.  This group has both healthcare practitioners as members, along with patients who have SIBO.  It’s an awesome group for those with SIBO looking for support and/or those who are willing to give advice and provide emotional support to others with SIBO.

5. The SIBO SOS Summit.  This is a free online summit that focuses on SIBO, and it starts on June 24th. There are some amazing speakers participating, including Dr. Allison Siebecker and Dr. Nirala Jacobi, along with other SIBO experts such as Dr. Lisa Shaver, Dr. Gary Weiner, Dr. Michael Ruscio, and Dr. Leonard Weinstock.  And there are other well known speakers including Dr. Datis Kharrazian, Dr. Daniel Kalish, and Donna Gates.  You can register for the free summit by clicking here.

I hope you find these resources to be valuable. If there are other SIBO resources you know of which you have found to be valuable, including but not limited to other websites, podcasts, and support groups, please feel free to share these in the comments section below.


What’s Your Experience With Low Dose Naltrexone?

Recently I wrote an article entitled “Low Dose Naltrexone and Thyroid Autoimmunity”.  In the article I discussed how more and more medical doctors are prescribing low dose naltrexone (LDN) for autoimmune conditions such as Graves’ Disease and Hashimoto’s Thyroiditis.  I also discussed some of the risks associated with this medication.

While in most cases the benefits of LDN outweigh the risks, it’s still not something I usually recommend initially to my patients.  And the main reason for this is because it’s not addressing the cause of the problem, and quite frankly, most people don’t need to take it.  However, there are some cases when I will recommend LDN to my patients.  One of these situations is when someone has severe symptoms that aren’t being managed through conventional or natural treatment methods.  Let’s look at a few situations when LDN might be a good option:

Scenario #1: Someone with hyperthyroidism or Graves’ Disease who isn’t able to effectively manage their symptoms with herbs such as bugleweed and motherwort, and isn’t able to take antithyroid medication due to side effects they experience.

Scenario #2: Someone with hypothyroidism or Hashimoto’s Thyroiditis who is still very symptomatic despite taking thyroid hormone medication and following a natural treatment approach.

Of course there are other situations when LDN might be worth giving a try, but these are two common scenarios.  In any case, besides not doing anything to address the cause of the problem, another downside of LDN is that it doesn’t work in everyone who takes it.  I personally have seen mixed results for those patients with Graves’ Disease and Hashimoto’s Thyroiditis who have taken LDN.  I’ve seen some autoimmune thyroid patients significantly lower their thyroid antibodies when taking LDN, but there are also people who took LDN and didn’t show any improvement.

When LDN doesn’t work there can be a few different reasons why this is the case.  One reason is due to low or depressed vitamin D levels.  Another reason can be due to having a Candida overgrowth.  Both of these are common problems, and ideally should be addressed before someone takes LDN.  However, there are some people who have taken LDN and didn’t receive good results, even with healthy vitamin D levels, and without an overgrowth of Candida.

The main purpose of this blog post is get the feedback of others with Graves’ Disease and Hashimoto’s Thyroiditis who took LDN.  If you took LDN and if it benefited you please let me know!  If you took LDN and didn’t notice any positive changes please let me know!  And if you took LDN and had any negative side effects please let me know!  Thank you so much for sharing your experience with others.


5 Things To Know About Thyroid Eye Disease

Many people with  Graves’ Disease have thyroid eye disease, which is also known as Graves’ ophthalmopathy or Graves’ orbitopathy.   While dealing with Graves’ Disease alone can be scary, it can be even more stressful to experience eye symptoms associated with this condition, including eye swelling, pain, bulging, and double vision. I have written a few other blog posts and articles in the past on thyroid eye disease, but I figured I’d put some of the more important information in this “5 Things To Know” blog post.

1. Like Graves’ Disease, thyroid eye disease is an immune system condition.  Thyroid eye disease involves the immune system attacking the tissues of the eyes.  Most people with moderate to severe eye symptoms will have very high thyroid stimulating immunoglobulins.  Since the immune system is the main factor with thyroid eye disease, the primary goal should be to detect and remove the autoimmune trigger.  Below I’ll talk about some conventional and natural anti-inflammatory agents that can help reduce the inflammation associated with thyroid eye disease, but in order to reverse thyroid eye disease you need to detect and remove the autoimmune trigger.

So how do you find and remove the autoimmune trigger?  Well, I’ve discussed this in greater detail in other articles.  But two of the main methods healthcare professionals use are a comprehensive health history, along with the proper testing.

2. Radioactive iodine can worsen thyroid eye disease. Numerous studies show that radioactive iodine is associated with an increased risk of thyroid eye disease (1) (2) (3).  It’s important to understand that not only can radioactive iodine treatment exacerbate an existing case of thyroid eye disease, but since many cases of thyroid eye disease are subclinical, receiving radioactive iodine can lead to the development of overt eye symptoms in someone who was previously asymptomatic.  One of these studies showed that taking oral glucocorticoids did not prevent the activation of thyroid eye disease after radioactive iodine (3).  However, intravenous glucocorticoids were effective, although keep in mind that the study was small, involving only nine patients (3).

This doesn’t mean that everyone with thyroid eye disease will experience a worsening of their eye symptoms upon receiving radioactive iodine treatment.  Some people with this condition have received radioactive iodine and didn’t experience any problems.  But since it’s impossible to predict who will do fine, and who will have an exacerbation of their eye symptoms, this isn’t a decision you want to take lightly.

3. Moderate to severe thyroid eye disease isn’t always reversible.  The good news is that most cases of thyroid eye disease are mild or subclinical.  However, some people do experience problems such as exophthalmos, conjunctival edema, or ophthalmoplegia, and a very small percentage experience optic nerve compression.  Can these problems be reversed through natural treatment methods?  It really does depend on the person.  For example, if some has moderate to severe exophthalmos then this might not be completely reversible.  Similarly, surgical decompression is necessary in some people who experience optic nerve compression.

4. High dose natural anti-inflammatory agents can help with the symptoms.  Since inflammation is a big factor in thyroid eye disease, it makes sense to do things that will help to reduce the inflammation associated with this condition.  From a conventional medical standpoint, prednisone is commonly recommended for those with thyroid eye disease.  Although taking a corticosteroid such as prednisone might be required in severe cases of thyroid eye disease that involve optic nerve compression, most people don’t need to take this drug.

Can natural anti-inflammatory agents help to reduce the symptoms associated with thyroid eye disease?  When a patient of mine is dealing with thyroid eye disease I do commonly recommend natural anti-inflammatory agents.  In fact, I commonly recommend natural anti-inflammatory agents to just about all of my patients with Graves’ Disease.  But if someone has moderate to severe eye symptoms then I will get more aggressive.  In other words, I will usually give higher doses of certain supplements and herbs to patients with moderate to severe thyroid eye disease.  I spoke about this in greater detail in a different blog post entitled “What Supplements Can Help With Thyroid Eye Disease?”, but below I’ll also list some of the supplements that can be beneficial in higher doses:

  • Fish oils
  • Gamma linolenic acid
  • Turmeric
  • Resveratrol
  • Vitamin D

This doesn’t mean you need to take all of these that I listed here.  I recommend for most of my patients to take a fish oil supplement, and I commonly recommend gamma linolenic acid as well, which you can find in borage oil, black currant seed oil, and evening primrose oil.  Getting back to the fish oils, some people question why I don’t recommend another type of omega-3 fatty acid such as cod liver oil or krill oil.  And the reason is because these typically won’t have high enough levels of EPA and DHA to combat the inflammation.  I usually recommend a minimum of 2,000 mg of EPA and 1,000 mg of DHA per day.

There is a lot of research with both turmeric and resveratrol as anti-inflammatory agents.  But once again, larger doses are usually required to help with the symptoms of thyroid eye disease.  For example, someone might need to take 2,000 mg or more of turmeric in the form of a curcumin supplement.  You also want to make sure you have healthy levels of vitamin D.  I recommend for lab values to be at least 50 ng/mL (125 nmol/L), and between 60 and 80 ng/mL might be even more beneficial.

Keep in mind that taking high doses of these anti-inflammatory agents alone frequently isn’t sufficient to completely eliminate the symptoms of thyroid eye disease.  As I mentioned earlier, you also must detect and then remove the autoimmune trigger.  This is also the case with corticosteroids such as prednisone, as these drugs don’t do anything to address the cause of the problem.

5. There is a good amount of research involving selenium and thyroid eye disease.  I’m not going to discuss this in detail, as I have written a separate article on this entitled “Can Taking Selenium Help To Reverse Thyroid Eye Disease?”  But the way selenium seems to help is by reducing oxidative stress that is associated with thyroid eye disease.  And the way it accomplishes this is by forming selenoproteins, which are powerful antioxidants.  Many reading this are familiar with glutathione, which is an antioxidant that is dependent on these selenoproteins.  So if you have a selenium deficiency, this will result in low levels of selenoproteins, along with low glutathione levels, which can be very problematic in someone who has a lot of oxidative stress.

You might wonder if you can help to reduce oxidative stress by taking a glutathione supplement.  The answer is “yes”, as taking an acetylated or liposomal form of glutathione can help to reduce the oxidative stress associated with thyroid eye disease.  However, since healthy selenium levels are required for healthy glutathione levels, it’s important to make sure you have sufficient selenium levels as well.  But since selenium toxicity is a concern you don’t want to take too high of a dosage of selenium, which I discuss in greater detail in the separate article I wrote on selenium and thyroid eye disease.

Should You Choose A Natural Treatment Approach?

After reading this blog post you might not be sure if taking a natural treatment approach is the best option for your thyroid eye disease condition.  After all, I mentioned how taking natural anti-inflammatory agents and selenium can help, but I also explained the importance of detecting and removing the autoimmune trigger.  And so it can be challenging to overcome thyroid eye disease naturally.

However, I do think that most people with thyroid eye disease should consider taking a natural treatment approach.  And the reason for this is because the conventional medical treatment methods don’t do anything to address the underlying cause of the condition.  So for example, if you choose to receive radioactive iodine or a thyroidectomy, not only is there a chance that your thyroid eye disease symptoms can worsen (especially with RAI), but neither of these procedures will do anything to improve the health of your immune system.  And as I have mentioned in previous blog posts and articles, the research clearly shows that someone with one autoimmune condition is more likely to develop other autoimmune conditions in the future.

So hopefully you have a better understanding of thyroid eye disease.  Just remember that this is an immune system condition, and so while it’s understandable to do things to help manage the eye symptoms, it’s also necessary to address the autoimmune component.  And while conventional medical treatment methods sometimes are necessary, hopefully you’ll consider trying some of the natural treatment options I discussed in this blog post.  But in addition to using natural anti-inflammatory agents and selenium to help manage the symptoms, you also want to do everything you can to detect and remove the autoimmune trigger.


How Do You Know When You’re In Remission?

When someone with Graves’ Disease or Hashimoto’s Thyroiditis takes a natural treatment approach, the ultimate goal is to achieve a state of remission.  But one of the questions I commonly get asked is “how can someone tell if they are in remission?”  In this blog post I am going to discuss what someone should expect when they reach this state.  I’ll also discuss what you can do to maintain a state of wellness once remission has been achieved.

Before I talk about this, I’ll admit that I don’t like the word remission.  I like the word “cure” much better, as it of course sounds better to say “my autoimmune thyroid condition has been cured”, rather than say that “my autoimmune thyroid condition is in remission”.  While I have been guilty of using the word “cure” in the past, since genetics plays a role in the development of autoimmune thyroid conditions, the word remission is more appropriate.  However, I like to aim for a “permanent” remission, which is the next best thing to a cure.

The Difference Between Cancer And Thyroid Autoimmunity

If you visit www.cancer.gov they explain the difference between cure and remission with regards to cancer.  They mention that a “cure” means that there are no traces of cancer after treatment and the cancer will never come back.  On the other hand, they label “partial” remission as meaning the signs and symptoms of cancer have been reduced, whereas in complete remission the signs and symptoms of cancer have completely disappeared.  And when it has been completely gone for at least five years this is frequently labeled as being a cure.

But then they go on to say that even after five years there is a chance that the cancer can come back.  And when cancer returns after five years then a so-called cure was essentially a prolonged remission.  And I’d say that there are similarities between cancer and thyroid autoimmunity, as someone like myself who has been in remission for over five years is less likely to relapse than someone who has been in remission for less than five years.  But I’ve also worked with people who have been in remission for over five years and relapsed, which is why I can’t honestly say there is a permanent “cure” for thyroid autoimmunity.  On the other hand, there is a chance to achieve remission and stay there without relapsing, which is why I prefer to use the term permanent remission.

3 Signs That You Have Achieved A State Of Remission

So how do you know when you have achieved a state of remission?

1. Your symptoms have completely resolved.  One of the main goals is to get complete resolution of your symptoms.  For example, when I was dealing with Graves’ Disease I had an elevated resting heart rate, palpitations, tremors, weight loss, an increased appetite, and a few other symptoms.  All of these symptoms eventually resolved upon taking a natural treatment approach, and the same thing occurs with most of my Graves’ Disease patients.  And of course the same goal applies to my patients with hypothyroidism and Hashimoto’s Thyroiditis.

While most people who take responsibility for their health receive great results, unfortunately not everyone who follows a natural treatment protocol will get complete resolution of their symptoms.  Why is this the case?  When someone doesn’t get into remission, in most cases it’s because the underlying cause of their condition hasn’t been addressed.  Thyroid autoimmunity can be challenging, and finding the autoimmune trigger isn’t always easy.

But symptom resolution doesn’t always come down to finding and removing triggers, as sometimes certain imbalances can’t be completely resolved.  For example, if someone with Graves’ Disease or Hashimoto’s Thyroiditis has small intestinal bacterial overgrowth (SIBO) due to damage to the migrating motor complex, which in turn is caused by an autoimmune process, not everyone will have complete resolution of their symptoms.  This doesn’t mean that tremendous improvement isn’t possible, but a person in this situation might still have some mild symptoms after treating SIBO, and in order to prevent SIBO from coming back they might need to take prokinetics on a continuous basis after treatment.

2. Your thyroid panel and other blood tests are normal.  Of course we want the thyroid panel to normalize, and this includes the thyroid antibodies.  But other markers that were out of range initially should normalize as well.  For example, if someone had low or depressed vitamin D levels upon starting the natural treatment protocol, then upon restoring their health this should be within a healthy reference range.  If someone has elevated liver enzymes, which is common with hyperthyroidism, then these should normalize upon remission.

It’s important to understand that certain markers on a blood test might be important to normalize, but at the same time don’t directly relate to your condition.  And if this is the case, then these markers might remain out of range, even if someone is in a state of remission.  For example, some people will have an elevated homocysteine, but this doesn’t always directly relate to one’s thyroid or autoimmune thyroid condition.  This doesn’t mean that we don’t want to do things to lower the person’s homocysteine, but my point is that it’s possible to be in remission even with elevated homocysteine levels.  However, one wouldn’t be in an optimal state of health in this situation.

By the way, I’m not suggesting that having a high homocysteine level isn’t significant, but only that it might not be directly related to one’s thyroid or autoimmune thyroid condition.  However, an elevated homocysteine level indicates problems with methylation, which can be a factor.  I spoke about homocysteine and methylation in an article entitled “Methylation, MTHFR, and Thyroid Health”.

3. Other tests have normalized.  When I was dealing with Graves’ Disease I obtained an adrenal saliva panel, and the initial test results revealed depressed cortisol levels, a depressed DHEA, and a depressed secretory IgA.  All of these markers eventually normalized, and I expect the same with my patients who have compromised adrenals.  If someone tests positive for a gut infection in the blood or stool, such as H. Pylori or Blastocystis Hominis, then of course you want them to test negative for this in the future.

Does this mean all tests need to be perfect before someone achieves a state of remission?  Just as is the case with the high homocysteine example I gave above, some markers are more significant than others.  Let’s look at a different example that relates to testing the sex hormones.  If someone has low levels of progesterone and testosterone, even though these low levels are causes of concern, it still is possible to get into a state of remission.  However, a person with low or depressed hormone levels isn’t in an optimal state of health, and if chronic stress is the cause of the low sex hormones then this can prevent the person from maintaining a state of wellness.

How Can You Maintain A State of Remission?

So once you have achieved a state of remission, how can you maintain your health?  I admit that maintaining a state of wellness can be a challenge, especially initially.  But even after being in remission for many years there still is always a chance of a relapse.  However, doing the following will greatly increase the chances of maintaining a state of wellness:

1. Continue to eat well most of the time.  What do I mean by “most of the time”?  In other words, does the 80/20 rule apply here where someone can eat healthy 80% of the time, and indulge 20% of the time?  The truth is that it depends on the person, as some people are able to get away with eating “bad foods” more than others, while others need to eat more strictly in order to maintain a state of wellness.  But since you won’t know what you can get away with when you’re in remission I wouldn’t indulge too much…at least not initially.  I definitely don’t eat a perfect diet, but I do try to eat healthy most of the time.

In addition, over the last couple of years I’ve been following a 21-day liver detoxification program three or four times per year.  And while eliminating toxins is important, during the 21 days I also follow a very strict diet.  And so essentially I’m following a gut repair diet for 21 days.  As a result, even if I get into a bad eating spell, which I admit does happen every now and then, I can count on giving my body a 21-day break every three or four months.  Once again, this doesn’t mean I eat poorly for 3 or 4 months and then go on a 21-day liver detoxification, as I do try to eat well most of the time in between.

2. Always work on stress handling.  Stress was a big factor in the development of my Graves’ Disease condition, and it’s a factor with many of the people I work with.  In fact, when someone relapses it frequently is due to chronic stress.  This might be a concern to some people reading this, mainly because stress is a factor with just about everyone.  This is true, and this is why managing your stress is important.

However, just as is the case with diet, this doesn’t mean that you need to be perfect in the stress department.  And while completely getting rid of your stressors isn’t feasible, improving your stress handling skills is something you can do.  I’m not suggesting that it’s easy to do, but just like anything else you need to block out the time to do it and get into a routine.  If necessary I’d start by blocking out five minutes per day, and make sure you choose some type of mind body medicine that you enjoy doing.  Then once you’re in the routine of blocking out five minutes per day for stress management you can work on increasing the duration.

3. Minimize your exposure to other autoimmune triggers.  Sometimes this is easier said than done.  For example, in addition to food allergens and stress, two other potential autoimmune triggers include environmental toxins and infections.  While avoiding certain foods and improving your stress handling skills can be challenging, it’s impossible to avoid all of the environmental toxins you’re regularly exposed to.  And it’s not always possible to prevent an infection such as H. Pylori, Blastocystis hominis, Lyme disease, etc.  In the case of environmental toxins you obviously won’t be able to avoid exposure to every chemical out there, but you can do a lot of things to change your home environment, which can help a great deal.  And you can also do regular detoxifications like I do.

Just keep in mind that your body is always detoxifying, and so while every three or four months I personally follow a 21-day program to further support my detoxification pathways, you don’t necessarily have to take this approach.  Eating healthy foods on a daily basis, especially plenty of vegetables, will help to support your detoxification pathways.  If you have access to an infrared sauna then this can also help with the elimination of toxins.  And so in no way am I suggesting that most people need to follow three or four 21-day liver detoxifications per year.

With regards to preventing infections, the best way to do this is to improve the health of your immune system.  And of course this is the main goal for anyone who has Graves’ Disease or Hashimoto’s Thyroiditis, although even if you have a thyroid condition that doesn’t have an autoimmune component you still want to have a healthy immune system.  As for how to achieve a healthy immune system, I talk about this in other articles and blog posts, but I will say that following some of the advice given in this post will greatly help.

4. Get sufficient sleep.  Once you achieve a state of remission, in order to maintain a state of wellness you also want to get sufficient sleep on a consistent basis.  This doesn’t mean that staying up late once in awhile will cause you to relapse, but most people need to get at least a minimum of six or seven hours sleep each night, and many people do better getting seven or eight hours of sleep each night.  And “catching up” on sleep doesn’t work.  For example, if you only get four hours sleep Monday through Friday, and then sleep 10 to 12 hours on Saturday and Sunday, the extra sleep on the weekend isn’t going to compensate for the sleep deprivation during the week.

In summary, the primary goal of following a natural treatment protocol should be to achieve a state of permanent remission.  Three signs that you have achieved remission include 1) complete resolution of your symptoms, 2) normalization of your thyroid panel and other blood tests, and 3) normalization of other tests.  As for how to maintain a state of remission, you of course want to eat well most of the time, you should always work on improving your stress handling skills, minimize your exposure to other autoimmune triggers, and you also need to get sufficient sleep on a regular basis.


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Testimonials

Here are some of my patients with thyroid and autoimmune thyroid conditions who have benefited from following a natural treatment protocol.

I was concerned about an ongoing "mental fog" and forgetfulness I had - which is one of the symptoms of Hashimoto's. I was having trouble losing weight and also felt very low in energy. Since following Dr. Osansky's recommendations I have found that I have a greater sense of calm - something I didn't expect from the treatment and changes in diet and lifestyle. In addition to getting my Hashimoto's under control, I have enjoyed other health benefits as well. I no longer suffer from anemia, my Vitamin D levels are normal and my immune system is strong. My thyroid blood tests also improved. Although it's a commitment and initial expense, it is completely worth it in the long run. Given the alternative (taking thyroid medication for the rest of your life), in my opinion it's a no brainer. If you give a natural treatment protocol a fair chance you'd be surprised at how much more empowered you'll feel about your illness and treating it. A natural treatment protocol is an effective solution that puts you in the driver's seat when it comes to your health. Traditional methods do the exact opposite.

Maria DeSimmone
Howard Beach, NY

Since following the natural treatment protocol I have all of the energy that I had before Graves' Disease, and not being on the meds feel wonderful. Being able to do all of the things that I used to do is fantastic, as we all take so many things for granted in life, and our health/body is very sensitive so what we feed it is so important, good in good out. Little by little my blood work came back to the normal range (within 4 to 6 months) but you have to follow the protocol.

Michael Addario
Albany, NY


When I first began the natural treatment plan for my autoimmune hypothyroid condition my top five symptoms were chest pain (diagnosed with costochondritis), fatigue, memory loss, stomach upset, and muscle weakness. No matter how much rest I got, I was still tired. Additionally I did not sleep well either. Originally, I didn't feel much different. I believe the reason for that to be because I was only taking a portion of the recommended natural supplements, as well as the fact that I had only changed some of my diet. When I really got serious about making changes is when I began to really see improvements. Although this does require a change in lifestyle, I feel much better today. The natural treatment protocol allowed me to delve deeper into the root of the problem and address it so that I will hopefully not need to be on these supplements for the rest of my life. I have already cut back on some of my supplements since my last blood work results.

Adah Thompson
Rossville, GA

Through my own research, I discovered that there are many side effects to radioactive iodine treatment. However, every visit to the endocrinologist ended with them stating that this was the only treatment for Graves Disease. In fact, one endocrinologist yelled at me and stated that I had to have the procedure done by November because of the dangerous side effects of the medication. I found Dr. Osansky’s website and read all his articles. I was immediately convinced that he could help me because one of his articles described his symptoms and it seemed as though he was describing my symptoms. I wanted a doctor who had this experience and could tell me what to expect.

Since starting the natural protocol, I feel full of energy. I look forward to seeing my students instead of dreading each day. My eating habits have totally changed. I can actually function when I get home. I used to sleep during the two week Christmas holidays, but this year I actually painted, cleaned and exercised. It has truly been a lifestyle change. My blood tests show tremendous improvement. In fact the same endocrinologist who yelled at me sent me a letter indicating that I should immediately start lowering the Methimazole.

Norma Lopez
Houston, TX
 
 
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