In this episode, Dr. Eric Osansky welcomes Johanna Dahlmann, also known as the “Alopecia Angel,” to discuss natural approaches to overcoming hair loss. Johanna shares her personal journey of reversing alopecia areata after being told there was no cure, and explains how that experience led her to help thousands of people around the world with autoimmune, hormonal, and other forms of hair loss. Together, they explore why hair loss is often a symptom of deeper underlying imbalances rather than simply a cosmetic concern.

Johanna discusses many of the commonly overlooked contributors to hair loss, including autoimmune disease, thyroid dysfunction, gut health, environmental toxins, breast implant illness, Botox, nutrient deficiencies, hormonal imbalances, and genetics. She also explains why personalized testing and functional medicine can help identify root causes, while emphasizing that no single diet, supplement, or medication works for everyone. Throughout the conversation, she challenges common myths surrounding hair loss and explains why healing requires an individualized, whole-body approach rather than a one-size-fits-all solution.

The episode concludes with a discussion about thyroid-related hair loss, realistic expectations for hair regrowth, and why consistency is essential for long-term success. Dr. Eric also shares his perspective on addressing thyroid and autoimmune thyroid conditions as a foundational step for many people experiencing hair loss. If you want a clearer, more balanced understanding of the root causes of hair loss and natural strategies to support healthy hair growth, you’ll get a lot out of this episode.

Click Here to listen to it on the Save My Thyroid podcast

Dr. Eric Osansky:

I am super excited to chat with Johanna Dahlmann. We are going to be talking about different types of hair loss, autoimmune hair loss, thyroid-related hair loss. Really excited for this conversation. Let’s dive into Johanna’s impressive bio here.

Johanna is also known as the “Alopecia Angel.” She is a health and high performance hair growth coach who follows functional medicine principles. She is also a professional speaker, podcast host of The Alopecia Angel Podcast, awakened to hair growth, and a proud mama and wife. She is now recognized as a leading expert in healing hair loss naturally.

Healing her own alopecia was Johanna’s biggest challenge, requiring out of the box thinking and innovative strategies. Drawing on her experience at Apple, she approached a rapidly progressing alopecia areata with a unique problem-solving mindset, fully reversing and healing her condition. This personal journey inspired her mission to empower others to heal hair loss naturally. Johanna has helped thousands of clients in over 67 countries, men, women, and children. She addresses autoimmune-related hair loss, including alopecia areata, alopecia totalis, and alopecia universalis. For men, she also provides support for androgenetic alopecia. Welcome, Johanna.

Johanna Dahlman:

Thank you so much for having me. Such a pleasure and honor.

Dr. Eric:

I agree. This will be a great conversation. It’s something that a lot of people deal with. A lot of women and a lot of men as well. Going over the bio, I went a little bit into your background. Maybe you could talk more about your experience with alopecia areata. How long ago were you diagnosed? Approximately how long did it take to reverse it?

Johanna:

I was diagnosed over 10 years ago. It took me a good four years to have my full hair come back. What started as one dime-sized bald spot on the back started with a second and then a third. They started connecting at the same time of alopecia areata. I was diagnosed at the hair salon, which beauticians and salon staff are able to diagnose you. Cosmetologists are able to diagnose you right there in the salon. I was getting my routine highlights, and my hairdresser of over 30 years said, “Johanna, you have alopecia.” I looked at him and wondered what the word was.

I started searching online on my phone. I started crying. It was very traumatizing to see and read all of the things that are there, to have this label of “no cure” wash over me, and see all the forums and articles, essentially saying that you’re either going to go bald, or you’re going to have to accept it. There is no cure.

To me, this was a little unnerving. At the same time, I wanted to understand more. Being there in the chair didn’t give me enough time to grasp it.

Much like many of my clients, I gave it time on its own. Let me see what it’s going to do on its own. I had a good maybe five months of researching and doing nothing about it. As I was having more and more spots, I also was shedding all over. I had telogen effluvium at the same time. That’s two different types of hair loss at the same time. It was rather unnerving.

Once it started getting bigger, then I started picking up the pace. What I never noticed until later on was that I lost about an inch of forehead, which I’ve recouped. I lost eyebrows and eyelashes as well, which I also recouped later on. The whole journey from start to finish was probably a good four years.

To me, it felt out of nowhere, almost if you were to be surprised with any type of diagnosis out of nowhere. You think you are the healthiest, which I was the healthiest, the fittest person in my friend group, my family. I was working out every day. I couldn’t believe that this diagnosis was mine to have.

It’s one of those things where I knew there was a way. I didn’t know how. This is how my journey started. Once I came over the hump, and I actually started seeing hair growth, it was this immense relief that came and washed over me. At the same time, all the ancillary symptoms that were ping-ponging along with alopecia had just left. It was like a veil that had been taken off. Anything from dry eyes to insomnia to lethargy to memory loss to fatigue to anything else that I was feeling or going through, depression, anxiety. It all just stopped. The old Johanna was coming back.

It was this very surreal experience of having this almost out of body experience of being in your body but not understanding it. All of a sudden, in my early 30s, I was experiencing all these symptoms that I had never experienced before. In the beginning, I’m going to the drugstore, trying to get the drops for the dry eyes or the extra lotion for the dry skin. In hindsight, it was all connected. The tsunami of symptoms beyond the hair loss were all connected. Once I got to the root causes of my situation, all of it lifted.

That’s when I was inspired to let other people know. I know there’s millions of men, women, and children going through this. In my 10 years of helping people worldwide, I’ve seen a huge uptick in children. Every day, I’m hearing that a four-year-old, five-year-old, six-year-old are being diagnosed. The research also shows this. I had this on my podcast about four weeks ago. The latest research is also showing that women and children are 4x more likely to be diagnosed with an autoimmune disease versus men.

Dr. Eric:

Do you know why it’s becoming more common in children?

Johanna:

We could speculate, and there is data, too. There are a lot of things that have changed in the last ten years for the diagnosis. Also, our environment has changed. Our food has changed. As someone who has lived in five countries and five states, I know it’s not perfect anywhere, just like healthcare systems. At the same time, there are ways to navigate it regardless of where you live. It’s just about being really smart and understanding of what this looks like in your area, in your country, in your hometown. It’s knowledge.

There is a lot of misinformation, first and foremost. A lot of times, the information that’s out there is not focused on us. It’s focused in a general term. For example, you have the food pyramid, which the U.S. government has had since the 1950s. This food pyramid is upside down in many ways. In many other countries, it’s also upside down. What you would see in Japan at a supermarket is not what we would recognize as food or a vegetable, yet for them, it is culturally.

If you view the nuances, how do you put pieces together when you are already ingrained in another way of thinking or living? You’re trying to marry this with your current medical situation of having alopecia. You can go back to basics.

This is what’s necessary. As a population, we are the sickest, the most obese, with the most adverse propensity toward chronic disease at this point in time. There are reasons for this. We have to scale back, simplify, and cut out a lot of damaging foods, additives, and ways of living that are not helping us.

Dr. Eric:

You’re right. The increased toxic world we live in and toxins and additives in the food we eat. Of course, all the stress that we deal with in this day and age. Electronic pollution is everywhere as well. It’s a myriad of different reasons why we’re seeing more and more not just autoimmune-related cases of hair loss but other types of autoimmune conditions as well.

What do you say are some overlooked causes of hair loss? I was listening to one of your interviews, so I know that you mentioned breast plant illness. Maybe talk about that and one or two others.

Johanna:

Sure. Having breast implants do cause autoimmune diseases. It is a foreign object in our bodies. It’s something that was very popular. Being from California, all of my friends, right at the cusp of high school, going into college, everyone was getting them. Lo and behold, often, when we start something, no one is talking to us about any warnings, side effects. Similar to medications, especially for alopecia. It’s only decades or years later that we will see huge side effects or ramifications with this. Breast plants are definitely a situation that if you have them, they can and do cause hair loss. They also cause other health situations that you want to be concerned about.

The other thing is Botox. Women talk about Botox freely. They have injections, fillers. All these toxins are also hampering our health. I actually just met a lady. We were in the sauna together. She was talking to me about how she had lupus and some autoimmune disease that affects her bones and cranial structure and creates a lot of migraines. Then she told me that she works at a doctor’s office with plastic surgeons, so she gets all this discounted Botox. I was like, “Well, there you go.”

We don’t put two and two together. I call these “blind spots.” We all have them. We absolutely all have blind spots. You don’t know what you’re doing, knowingly or unknowingly, that is holding you back from breaking through to thriving, to beautiful health.

This is the situation. A lot of these toxins won’t come with a warning. They will just talk about the benefits. This is why the pharmaceutical and beauty industries both are multi-million and trillion-dollar industries. We’re so focused on the beauty and the benefits, but no one is really talking about the side effects that could cause other damage in other areas, to other organs, or hamper a current medical condition that you may have that no one else has.

Having a personalized approach for anything is so key to your success. Even when it comes to hair loss. This is where a lot of people get frustrated. They are getting Nutrafol. “I will just do the specialty shampoo or serum.” None of these gimmicks work. This is the problem.

We are trying to fix a bigger problem. It’s not just the hair. It’s also internal. With just a mediocre, superficial solution. The scalp health and massagers and all these things are not attacking the root cause. That is the biggest frustration for most of my clients, including me.

I went down the rabbit hole, trying to see exactly what’s going on. It wasn’t until I started pulling out these root causes that I realized it’s so much bigger. This is why it’s a never-ending cycle of trying new things and failing for the majority of women, men, and even parents for their children.

Dr. Eric:

Let’s say someone has breast implant illness. They can remove the breast implants, not that it’s an easy process. You want to find an experienced surgeon. If one has hair loss as a result of Botox injections, can you still help them with that since they can’t undo that?

Johanna:

Yes, there are ways to detox. Just like if you were exposed to high amounts of heavy metals or radon in your house, there are ways to detox and support the body at any level or stage. It just may take a little longer. Just like anything, for example, the birth control pill.

Over 90% of women have taken the birth control pill at some point in their life. Many times, for many years or decades. Before getting pregnant, your ob-gyn will tell you that you need to detox from it. If you get pregnant right away, your baby can have certain side effects from the pill. Even with just something as simple as the birth control pill, your body needs to detox.

There are ways to help support it as well. At the same time, to ensure it is all taken out. Just like gutting the house, we can definitely revamp and rebuild our bodies to what we are striving for.

Dr. Eric:

What are some myths and misconceptions that people have about overcoming hair loss? Not just autoimmune-related hair loss but other types of hair loss, too.

Johanna:

I love this question. There are so many myths that we think are true. For example, #1 is you’re too old. I say this as a 45-year-old who grows an inch of hair a month. I track this because I have highlights, but I also have beautiful gray hairs.

This is the situation. We can be above average or average or below average. When it comes to hair growth, it’s the same thing. I grow more than what the internet search says. We can also support the body to achieve that. In the same manner, we can put aside that age is a situation of our hair loss because it’s not. Age is something that we go through, but it’s also about how we support that stage of life.

It’s much more than just the biological age. It’s also how we age. This is why you’ve seen centenarians who are running marathons at 102, or you also see centenarians who are strapped to a wheelchair and can’t move.

You have two sides of the story. It’s really up to us to choose which side do we want to do and choose for our lives. Everything in life is a choice. Health is a choice. Hair is a choice. Even though you think it’s genetics, it’s not. There is a bigger picture here and a bigger perspective.

Even when it comes to genes, there are ways to mitigate and modify. There are ways to help and support this, moreso for women than men.

Even with men, let’s say you have male pattern baldness. You can get a hair transplant. I have seen them in men, and they look fantastic. Just like anything, the sooner, the better. You won’t wait until you’re 60 to do this. You want to do this when you’re younger. Maybe for men, the hair transplant is the only option if you have male pattern baldness. For women, if you have female pattern baldness, you can mitigate this and support it regardless of your genes and what kind of hand you were dealt with at birth.

There are a lot of factors that you have to look at. It’s not just the genetic factor. There are so many other factors looking at this. Once you have that personalized attention, you can create a strategic plan that will benefit you. Depending on your situation, you can see results sooner rather than later.

When you have hair loss, it’s a cry for help from your body. Your body is wanting help and support. We are just neglecting it in some way that we may or may not understand or know. This is why functional medicine testing is so unique and special. Same with DNA testing.

I started providing DNA testing, and it’s been such a gamechanger. Instead of saying, “Oh, it’s this,” now you have data. It’s your DNA, but we can now focus on the weaknesses to create strength out of them. We can also help mitigate them. It may take a little longer. At the same time, we can also support it in the long run, so you can overcome any situation.

When it comes to other myths, if you have had alopecia areata or totalis or universalis for so long, or female pattern baldness for 20-30 years, it’s too late. No, it’s never too late. I always say that if you have a heartbeat and a desire to change something, you can. It’s an option. The gym is open 24 hours a day.

We choose our health every single moment of the day. It’s really about having the awareness and consciousness of saying, “I’m doing this, not because I have to, but because I want to. As I invest in myself, this compounds over the years.” For example, my inch of hair growth didn’t happen overnight. It came about because I’ve been doing what I’m doing for over 10 years. That’s compounded, just like my savings account. The more you put in, the better outcomes you have.

Another myth is people think they are doomed because they have been labeled as “no cure.” This is false. I have my podcast, which has over 250 episodes with so many client success stories of all different types of hair loss, including scarring. Scarring is a type of hair loss where your dermatologist, from what I hear from my clients, where they’re done. They can’t do anything for you. They send you medications and send you home. It’s a take it or leave it stance.

Those aren’t the two options to me. It’s not about accepting or embracing if you don’t want that. It’s also not about taking medications if you don’t want that.

I started my natural healing process because I wanted to be a mom. I wanted to have kids. I wanted to protect my fertility. If there was anything I would have done, it was to protect fertility. Thank god I did. Going the natural holistic route actually upgraded not just my health but also my fertility. I got pregnant on the first try at 40 and had my beautiful baby.

Everything we do has a ripple effect. We often don’t take that into consideration with the side effects or what the minoxidil can do over years of usage. Personally, I would encourage anyone to question the “no cure” stance. I would question everything that you’ve been told or read or what people are saying like gospel. More than likely, it’s not.

Let me clarify. When they say there is no cure to autoimmune disease, i.e. alopecia areata, it means that not one pill will work for everyone the same. This is true. However, it doesn’t mean you can’t heal it. It doesn’t mean you can’t be in remission. It doesn’t mean you can’t have and regrow all your hair because you can.

I think this is where the jargon, the propaganda, and even the marketing of it is a little skewed. For the regular person, their understanding is, “There is nothing to do. I can’t do anything.” I will tell you there will never be a cure for alopecia because it can never be a one size fits all.

This is like saying everyone should be following the same diet and lifestyle to lose weight. As we know, there are so many books on weight loss and drugs for weight loss, yet we still have an obesity epidemic. It’s not necessarily about what’s out there on the market. It’s about the desire and want because you have to want this.

You have personal training, so you can be told what to do that is tailored to you, so you can also see the results. In many ways, this is how it works. If you don’t do the work, you don’t see the results. You’re not going to get the results from a pill, a medication, a serum, or a lotion. It needs to look at you holistically. You need to be given a plan. Diet and lifestyle, potentially some testing. From there, you can see the results.

The no cure stance, I fight because as you see here, I’m 10 years in remission. Often, when people say, “It’s just stress,” that is downplaying a bigger situation. If it was just stress, this would go away really easily. At the time, I wasn’t that stressed.

I would also say that life is always going to give you different types of stress. For example, I woke up at 5:30am to go do a CrossFit exercise. Did I want to go? No. I still went. I did the exercise, and that is stressful. Lifting weights is stressful. Working out is stressful. But it’s a good, healthy stress. Life is always going to give you stress, but it’s all about us and how we ride this wave.

I will tell you that for over 10 years now, I haven’t had one little round patch of alopecia areata come back. I haven’t had hair loss. When you understand and control your triggers, your blind spots, your personal situation, you have the keys to life for full hair growth.

Dr. Eric:

With any chronic health condition, there is not a one size fits all approach. There is not a single pill or supplement anyone can take that will reverse the autoimmune component or cancer or anything like that. You summarized it well.

As you know, the audience consists of mostly people with thyroid conditions and autoimmune thyroid conditions. How common do you see thyroid-related hair loss?

A follow-up question is for those who have thyroid-related hair loss, do you also see a lot of these other potential causes of hair loss, meaning that it’s not just related to the thyroid, but other factors as well?

Johanna:

Great question. When it comes to my clients with thyroid and alopecia, because I do have clients who have three or four autoimmune conditions. I have seen children with four conditions. It’s wide-ranging.

When it comes to thyroid and alopecia, I have had probably a good 10% of my clients with a history of thyroid issues, be it autoimmune or not. The other side of this is I have also had clients with thyroid cancer in the past. They have been completely ablated and are on medications for life. Years later, they get alopecia areata, and we heal it.

I had one client with thyroid cancer. She healed it and started seeing hair growth in less than eight weeks. She had a massive spot. I have pictures before and after on my website. On the podcast, she has an interview with me at the time she started seeing hair growth and then three years later. Even following up with my clients three years later, they are still seeing hair growth.

When they’re doing my program, they see that not only does their hair loss completely heal and reverse, but their Graves’ or Hashimoto’s reverses, and they can come off their meds. It does take a little longer. For example, one client in particular who I’m thinking of, she healed her hair loss, but her Graves’ went into remission six months later.

It’s this consistent work of having a routine and keeping up with it that provides that savings account analogy that I mentioned earlier. It just compounds. The more we do for our health, the more it compounds. All these ancillary diagnoses and symptoms go into remission as well. This is a beautiful thing.

Many times, they can also lower the medication. They’re at a minimal stage versus a full dose because their body is acclimating. It’s a process; it’s not overnight. It’s wonderful to see how much their bodies are wanting to improve. Of course, that all comes from their own effort.

Dr. Eric:

How important in your experience is the gut when it comes to healing hair loss?

Johanna:

The gut is definitely one of the factors we look at. We do testing for it. I will say that it’s not everything, but it is one of the factors. When I approach any type of hair loss, even post-partum for 10 years, even long COVID, I always say it’s like a thousand-piece puzzle, and I need to look at all the puzzle pieces in order to create the strategy for each person. It’s going to look a little different ever so slightly. It will never be the same.

When it comes to approaching this, if you’re only uncovering just one factor, let’s say just the gut or the scalp or the shampoo, it’s not enough. You want to look at all the parts. The gut is important, for sure. Just like diet is. Diet alone is not going to move the needle. There is more to it. Diet will do a lot in general because it’s what we do three times a day, maybe more, depending. Yes, it’s foundational, but it’s not everything. Nor will it give you the full picture.

There are so many people who have tried this diet and that diet, Atkins and paleo, etc. It’s not always with good results. A lot of that is how we approach things. This is why I love that DNA test we offer. It presents the exact diet for you according to your DNA. It’s different from blood type. It’s really about your DNA and what you were given at birth.

For example, I can think back to a lot of my clients. When I see their DNA results, it varies. Let’s say you’ve had an autoimmune condition. I can get away with eating a bunch of things that maybe are not so good for me, especially when I travel. I like to partake in foods when I travel abroad. At the same time, you may experience some symptoms that your body is telling you that it’s not good for you. Maybe also it’s not so detrimental.

For example, I have a client where she ate something while she was traveling in Italy with her husband. She was in pain for 2.5 hours. That type of signal is stark, very black or white, versus the signals that I get, if that makes sense. It will all look different. This is why we need that personal awareness of what is good for us and how we can either choose not to do A, B, or C, or eliminate it altogether.

Dr. Eric:

Agreed. I say all the time that diet is a piece of the puzzle, but changing one’s diet alone isn’t usually going to reverse one’s health condition. You’re right, there is not one single diet that fits everyone perfectly.

Interesting about the DNA-based testing you mentioned. What other testing do you recommend besides genetic testing? You also mentioned you do some gut testing. What are some common tests you do?

Johanna:

We offer over 100 different tests, all functional medicine, gold standard. What I would say is that for anyone over the age of 30, you are going to want a baseline. As a female personally with so many ups and downs we have, I would love a baseline. A situation can go up and down real quick.

I even have a client at 25 who had such low progesterone, where they had to put her on HRT, so she could get pregnant. A 25-year-old. This could also be part of the puzzle when it comes to fertility rates that are on a huge decline around the world, but also in the U.S. It could be because something happened there, where her hormone levels were off. You would think a 25-year-old was solid. In reality, she wasn’t.

I would say a baseline for everything is good, at least every five years or so. Before, I used to do all the normal bloodwork, and that was okay for 25 years ago. Now, with so much information we have, I feel like I want to be more proactive, and I encourage everyone to be more proactive. A) It’s an investment in yourself. B) You can actually avoid things later on in life if you see that you have a bunch of issues, even though you have zero symptoms or very few symptoms.

It’s great to have a baseline, so you can compare where you were at at 40 or 30 versus 50 and 60. When you start looking at health, any diagnosis doesn’t happen overnight. It happens over years and decades in the making.

When I look back at my own situation of how in my early 30s, the fittest I was ever in my life, yet I was diagnosed with alopecia, I start to think back. How did this happen? What I realized was it was like a resumé not of my jobs but of my health. It was a resumé of what had been going on. At some point, just like when water fills up, it starts to overflow. That is when we have the diagnosis.

I highly recommend a DNA test. This is not a 23andMe. This is telling you what your MTHFR gene looks like, what your propensity for the APOE4 gene, for Alzheimer’s. It gives you the nuts and bolts of your DNA since you were born.

No one can change that. No doctor can tell you that except for this test. The beauty of this test is you can actually avoid things later in life. If you’re like me and are halfway through the game, I know I could have avoided my autoimmune disease. I could have avoided my cystic acne. I could have avoided my highs and lows with weight loss and weight gain in my teens and 20s. I could have avoided other things, too.

Now, I’m taking control. It’s not about looking at the past of I could have saved myself. It’s about let’s hone in on this technology and this high-quality testing. Let’s take care of ourselves from now to the rest of our lives. That’s 80, 90, 100, or beyond.

This is one of those things where it’s all a choice. The testing is a choice. Eating healthy is a choice. All of it is a choice. When you invest in your health, then everything else is a piece of cake.

Dr. Eric:

Agreed. You definitely need to take responsibility for your health, invest in your health. All we can do as practitioners is give recommendations. It’s up to people to go ahead and follow them.

It sounds like with the testing, for everyone, you recommend DNA testing. Maybe the other tests depend on the person. Would that be accurate?

Johanna:

It would.

Dr. Eric:

You said there are 100 tests, which I know you don’t recommend all to everybody.

Johanna:

No, not at all. For women in general, I would say you would want a full hormone panel and a full thyroid panel at the least. When I say “full,” I really mean full. Your regular doctor covered by insurance is just a blood test for hormones. That’s not giving you an accurate picture of what your hormones look like.

The test I recommend is 30 days of urine samples. That is an accurate look of the highs and lows and the waning of your cycle or no cycle or hormones in general.

This is such a wonderful test to have. Even if you’re not looking to get pregnant, or even if you’re not into menopause just yet, or maybe you’re beyond that, it’s good to have as a marker. Where were you at this certain point? The blood test will only tell you a fraction of that picture. Looking at TSH for example for the thyroid is only going to give you a fraction of the picture.

I say this from experience. I don’t have thyroid issues in my family. I have never had autoimmune issues. No one in my family has autoimmune issues. I was the only one with alopecia. All of a sudden, at 45, last year, I did all the testing because I wanted to be proactive. Lo and behold, my thyroid was off. This is odd. I have never had thyroid issues.

I looked deeper and started to uncover things. Even with my own functional medicine doctor, I had to go above her head and do more research because she wasn’t getting to the root cause. I will say doctors may not have the full breadth or fully focus on thyroid like you, Dr. Eric. Others are not. This is where sometimes you have to be proactive.

Having gone through what I did with alopecia, seeing a gazillion doctors and not getting anywhere, I’m much more on top of my own health. I found the root cause, and it’s done. It’s cleared. I got my bloodwork back, and it’s excellent.

I am also seeing all the ranges. It’s not just TSH. This is it. The TSH can lie to you. In my own case, I had a TSH that was great. When we did the full thyroid panel, there was other things there lingering that were off or subclinical, as she would say. This is the thing. You don’t know until you have the full picture of it. You can’t see one marker and think you’re good to go because you’re not.

This is actually a disservice that I find around the world. We should probably talk on another episode about healthcare around the world. I can give you a lot of insights.

Dr. Eric:

That would be interesting since you have lived in five countries. Maybe on a future episode.

As we start wrapping this up, what are realistic expectations for hair growth? It obviously depends on the person and the condition. You started out by saying it took you four years. You didn’t have the knowledge back then that you do now. If someone is seeing you for alopecia areata or a non-autoimmune case of hair loss, what can they expect on average, knowing everybody’s healing journey is different?

Johanna:

On average, we see 90% of folks have hair growth in eight weeks. That includes scarring alopecia, autoimmune alopecia, regular telogen effluvium, which is all over hair loss. It could be post-partum, stress induced, or any other types of underlying issues.

90% to see hair growth in less than eight weeks is because I am extremely results-driven. I want to get that person to have results sooner. You have the strategy laid out in the first week you start the program.

When it comes to shedding, the shedding stops anywhere from 1-6 weeks. I have had a gut health coach in Australia who did the program and was traveling. We started working together. Because she was traveling, she could only implement so many things. Within 24-48 hours, her hair loss of 20 years stopped. She is a gut health coach. Her hair loss stopped.

It’s often because we ourselves think, “Oh, this food is healthy, so I’m going to eat everything that’s healthy.” That’s not true. I think that’s also a disservice. We often think so many things are healthy, but maybe they’re not healthy for us.

This is why this tailored approach is so key. Essentially, we eliminated a couple things. As a gut health coach, she was already healthy per se. She had blind spots. We all do. In 48 hours, her hair loss stopped. That’s incredible.

I’ve had other clients with female pattern baldness and a long time of postpartum hair loss, where in one week it stops. You can hear all these inspiring stories on the podcast. It’s incredible because you’re hearing it from the horse’s mouth.

To me, that is exactly what I would have wanted going through my own alopecia journey. I would have wanted the support, the clear results, not just pictures, but clear testimonials of that this works. At the end of it, it does. Diet and lifestyle work. It just needs to be tailored to you.

Dr. Eric:

When you work with someone, is it 1:1? Is it in groups? Is it a combination?

Johanna:

It’s hybrid. We do have personal sessions. Then we also have group coaching sessions. You have the online course that you can access anywhere 24/7. It’s up to you to do the work. As you would go to school and graduate, you can’t graduate until you take the test and do the homework. It’s that type of thing, where yes, there is effort on your part. It’s not too much. It’s about two hours a week, which isn’t a lot.

From there, you start implementing. You start seeing the changes. It’s automatic within the first or second week. A lot of these ancillary conditions start to fall off. Whether it’s excess weight gain, excess inflammation, joint pain, knee pain, migraines, the tingling, the burning, the itchy scalp, which a lot of times is associated with scarring alopecia. A lot of these things which are associated with our current conditions start to fall off.

That is the beauty of it. We are starting to support the body. That is exactly what it’s been craving. We just weren’t listening.

Dr. Eric:

This has been an awesome conversation. Anything else that I should have asked you that I didn’t ask you? Any last words of wisdom before we wrap up?

Johanna:

I would say to anyone out there: If you ever feel like you want to try, you want to get back on the horse, it’s never too late. You can heal this. You can heal it for you or a loved one. I offer consultations. Come meet me at AlopeciaAngel.com. We have lots of free resources, a free training that I offer. I’m happy to help.

I want to get the word out that healing is possible. You have many more options than just accepting your hair loss or medications. That is the bigger picture here. I want everyone to know they can heal naturally, and it is possible.

Dr. Eric:

Your podcast is Alopecia Angel. Can they connect with you on social media?

Johanna:

They can. I’m everywhere. Instagram, YouTube, TikTok.

Dr. Eric:

Thank you so much, Johanna. This was a great conversation. Check out Johanna’s website and podcast. It was a pleasure speaking with you.

Johanna:

Thank you so much. The pleasure was mine.

In this episode, Dr. Eric Osansky takes a deep dive into the relationship between cortisol and thyroid health. While many people knows that stress can impact the thyroid, Dr. Eric explains that the connection goes far beyond simply “being stressed.” He explores how cortisol influences thyroid hormone production, T4-to-T3 conversion, thyroid hormone sensitivity, immune function, and the development of autoimmune thyroid conditions such as Graves’ disease and Hashimoto’s thyroiditis.

Dr. Eric discusses how chronic stress can contribute to thyroid dysfunction through multiple mechanisms, including impaired thyroid hormone conversion, increased reverse T3, thyroid hormone resistance, immune dysregulation, intestinal permeability (leaky gut), blood sugar imbalances, and disrupted sleep. He also explains why people with hyperthyroidism and hypothyroidism may experience very different cortisol patterns, reviews the available testing options—including saliva testing, serum cortisol, and the DUTCH test—and shares practical strategies for restoring healthy cortisol balance through nutrition, stress management, sleep, nervous system regulation, and targeted supplementation.

The episode concludes with practical advice on evaluating adrenal health and addressing one of the most overlooked pieces of thyroid recovery: managing the body’s stress response. If you want a clearer, more balanced understanding of the thyroid-cortisol connection and how stress influences autoimmune thyroid conditions, you’ll get a lot out of this episode.

Click Here to listen to it on the Save My Thyroid podcast

Dr. Eric Osansky:

Let’s discuss the thyroid-cortisol connection. A question I sometimes get asked is: Can stress really affect my thyroid? It seems like stress is used as an excuse for many different health conditions.

The short answer is yes. It’s a lot more complex than most people realize. The goal of this episode is to dive a little bit deeper into the thyroid-cortisol connection. I did speak about stress in the past. I have spoken about stress on past podcast episodes. I want to dive a little bit deeper but still make it easy to understand.

Let’s start out by briefly discussing the role of cortisol. Cortisol is produced by the adrenal gland, specifically the adrenal cortex. It helps regulate how you adapt to stress. It also plays a role in blood sugar balance along with insulin. It helps with controlling inflammation. It plays a role in immune system function. It regulates blood pressure, even energy production. It controls how your body uses glucose for energy.

We have acute versus chronic stress. I have discussed this before, too. Acute stress is a good thing. We have the perception that stress is all bad. Fight or flight mode is important. Acute stress is not necessarily bad. Our body was meant to adapt to acute stressors. It’s really the chronic, long-lasting stress that could be a really big problem. It can disrupt multiple systems. There is a big difference between surviving a stressful event, an acute stressor, and then living in a constant state of chronic stress.

You have also heard me and others talk about the HPA axis, which is the hypothalamic pituitary adrenal axis. You have the hypothalamus, which communicates with the pituitary gland. The pituitary gland communicates with the adrenals. This actually communicates with the HPT axis, the hypothalamic pituitary thyroid axis. Similar. You have the hypothalamus communicating with the pituitary gland, which communicates with the thyroid.

Most listeners here are familiar with TSH, thyroid stimulating hormone. That is what communicates with the thyroid gland. That is a pituitary hormone. ACTH is also a pituitary hormone. It’s what communicates with the adrenal gland. Some will say the thyroid gland is the master gland. Really, it’s the pituitary gland that is the master gland.

When it comes to cortisol affecting thyroid function, first of all, it plays a role in T4 to T3 conversion. The thyroid gland produces mostly T4 and a little bit of T3. T4 is mostly produced by the thyroid gland. T4 is largely inactive. You have T3, which is the active form of thyroid hormone. You have T4 converting into T3. That is how most T3 is produced. T3 is what actually binds to the thyroid receptors.

There are a number of factors that could affect this T4 to T3 conversion. Most of this conversion takes place in the liver. About 20% of this conversion takes place in the gut. If you have issues with your liver or your gut microbiome, that could affect the conversion.

Chronic stress can also affect this conversion. If you are dealing with chronic stress, you very well might see an increase in what’s called reverse T3, which is the inactive form of T4. Remember, we have T4 converting into T3, which is the active form of thyroid hormone. T4 can also convert into reverse T3, which is the inactive form. That blocks free T3.

It’s also important to mention for those with hyperthyroidism, whether it’s Graves’ or toxic multinodular goiter, it usually does result in an increase in reverse T3. I’m not a big fan of testing reverse T3 in those with hyperthyroidism.

We need to talk about how cortisol can affect thyroid hormone sensitivity. There’s what’s called thyroid hormone resistance. It’s similar to insulin resistance, which you have probably heard of. You have too much insulin, but it’s not getting into the cell. There is thyroid hormone resistance, which is similar. On a blood test, T4 and/or T3 will look normal, or they might look elevated, yet you might be experiencing low thyroid symptoms because not enough thyroid hormone is getting into the cells.

Chronic stress can decrease the cellular sensitivity to thyroid hormone. Essentially, chronic stress can be one of the causes of thyroid hormone resistance.

There is also the relationship between cortisol and the immune system. This is important to mention because most thyroid conditions are autoimmune in nature. Most hypothyroid conditions are Hashimoto’s. Most hyperthyroid conditions are Graves’. Chronic stress dysregulates the immune system and increases pro-inflammatory cytokines. As the name suggests, they promote inflammation. These are associated with thyroid autoimmunity.

Chronic stress can also contribute to what’s called the loss of immune tolerance. Immune tolerance is the immune system’s ability to distinguish self from non-self. These are some of the mechanisms in which chronic stress can affect the immune system.

Another way is it can decrease secretory IgA, which lines the mucosal surfaces of the GI tract. It’s not a specific leaky gut marker, but if someone has low secretory IgA, usually they have a leaky gut. When I dealt with Graves’, I had low secretory IgA. Very commonly seen in people I work with.

Let’s talk more about hyperthyroidism and cortisol, and then hypothyroidism and cortisol. Hyperthyroidism, as you know, typically accelerates metabolism. Most people with hyperthyroidism will have elevated resting heart rate, palpitations, and other symptoms. Not everybody has classic hyperthyroid symptoms, but most people do.

You get increased demand for cortisol. You also get increased cortisol metabolism. On a blood test or a saliva test or dried urine test, you might see cortisol elevate, but not always. When I dealt with hyperthyroidism, specifically Graves’, I had low cortisol levels. You will usually see cortisol metabolism increase because your overall metabolism is increasing. When you are doing a DUTCH test, you can usually expect to see increased cortisol metabolism.

The cortisol levels could be high, but they could be low. You might experience fatigue. You might not. There is the “wired but tired” presentation. You might have anxiety, heart palpitations, insomnia. All of these are pretty common with hyperthyroidism. You might also feel tired, even though you have that increased metabolism.

When I dealt with Graves’, I did not feel tired. I definitely felt more wired than tired. Some people feel both. They feel wired, but at the same time, they feel exhausted. Looking back, it’s now been quite a long time. I’m pretty sure I had a good amount of energy throughout the day. Everybody is different.

When it comes to the research, specifically with Graves’ and chronic stress, there is definitely research showing that stressful live events can be a potential trigger. It doesn’t say it like that in research. “Stressful life events often precede Graves’ onset.”

Keep in mind, stress isn’t necessarily the only trigger in most cases. Most people have multiple triggers. In my case, I’m pretty sure stress was a trigger. It wasn’t just emotional stressors, but I have discussed elsewhere that I was overtraining. I wasn’t listening to my body. That was putting some stress on my adrenals. There are other factors. Genetics is a factor. Food, infections, environmental toxins and toxicants. I have spoken about the importance of gut health.

Reinforcing my story is when I dealt with Graves’, I did an adrenal saliva test. I was pretty surprised how bad it looked. I had very low cortisol levels; low DHEA, which is another adrenal hormone; low secretory IgA. Stress management was important. Proper sleep was important. I also took some adrenal support, which I will talk more about shortly.

There are other things we need to look into, like blood sugar dysregulation. Cortisol has a role in maintaining stable blood sugar. It does this by raising circulating glucose levels, which is important. We don’t want chronically elevated glucose, but glucose provides fuel to our bodies. It does play an important role.

Cortisol acts as an insulin antagonist, so it reduces the ability of the muscle and fat cells to pull glucose out of the blood, which temporarily restricts glucose uptake. It remains available for its immediate use.

It plays a role in sleep disturbances. It’s a catch-22. Poor sleep can worsen cortisol patterns. Without question, if you have high cortisol, it can negatively affect sleep. Low cortisol can as well. If you have morning low cortisol, it could be a compensatory effect on sleep.

Either way, blood sugar imbalances, cortisol imbalances, definitely those are some of the more common causes of sleep disturbances. If you have issues falling asleep, waking up in the middle of the night, definitely these could be related to blood sugar and/or cortisol issues.

If you wake up in the middle of the night, blood sugar is something to look into. If you have issues falling asleep, it is probably less blood sugar, but it could be cortisol. It could be related to sugar. You might have elevated cortisol levels at night, but there certainly can be other causes, too.

Poor sleep in turn can negatively affect immune function. Also, poor sleep can also negatively affect blood sugar. If you have problems balancing your blood sugar, it could be related to adrenals or sleep. Poor sleep affects adrenals. It’s all a vicious cycle.

The impact of cortisol on the gut. Stress and intestinal permeability, which is a leaky gut. I spoke about that decreased secretory IgA, which usually indicates a leaky gut, which is part of the triad of autoimmunity, the three-legged stool of autoimmunity. Genetics. One or more environmental triggers. That increased intestinal permeability or leaky gut. That could be a factor in the development of Graves’ or Hashimoto’s.

Prolonged chronic stress can negatively affect the diversity of the gut microbiome, which is not good. Really, you need to focus on stress management, but you also need to focus on the gut. By focusing on stress management, that will also help with the gut. You will probably need to do other things as well, but you need to do a good job of managing stress, if you want a diverse gut microbiome.

I already mentioned the impact on thyroid autoimmunity: Chronic stress can increase proinflammatory cytokines, decrease immune tolerance, decrease secretory IgA.

Let’s talk a little bit about the cortisol-hypothyroid connection. Some of this is going to be repetitive. I already spoke about the T4 to reverse T3 conversion that can be caused partially by chronic stress. I also mentioned liver and gut health being important. As a result, you might see that increased reverse T3 in the blood test. You also might have altered thyroid receptor sensitivity, so you might get that thyroid hormone resistance in some cases. Not in all cases. Not everyone with chronic stress will have thyroid hormone resistance, but something to keep in mind.

When we talk about cortisol and Hashimoto’s, that connection between chronic stress and autoimmunity. I mentioned multiple times now that immune dysregulation, loss of tolerance. The mechanism when it comes to chronic stress and Graves’ and Hashimoto’s is really similar.

The symptoms of hypothyroidism will be usually different. There might be some overlap. Definitely fatigue is more common with hypothyroidism, low thyroid. It could also be related to adrenals and other factors. A lot of people with low thyroid will have brain fog, weight gain, depression, reduced resilience with stress.

It’s also worth mentioning that weight gain can be caused by thyroid hormone imbalances, but also cortisol imbalances, too. Someone who has hyperthyroidism may have increased metabolism, but if they have issues losing weight, it might be a cortisol issue. Similar with Hashimoto’s, it could be both. You could have low thyroid, and you balance the thyroid. You still have issues with losing weight because cortisol is an issue.

Why some people feel hypothyroid despite normal labs. Of course, you want to look at optimal ranges, TSH, thyroid hormones. Many times, we need to look beyond the thyroid. Adrenals and cortisol can play a role with this. I like looking at adrenals. I am not one who just wants to guess. We could guess. Most people will have adrenal issues. I want to see the patterns. I am going to talk about testing next. We want to look at cortisol. We want to look at DHEA. We want to consider that someone might have thyroid hormone resistance that is related to chronic stress.

Let’s go ahead and talk about testing. When I dealt with Graves’, I mentioned I did an adrenal saliva test. I still do a lot of adrenal saliva testing that looks at cortisol throughout the day, what’s called the circadian rhythm of cortisol. Cortisol should be highest in the morning and gradually decrease throughout the day. Most saliva tests will look at DHEA. Some will look at secretory IgA. The one I recommend does. It looks at 17-hydroxy progesterone, which is a precursor to cortisol. I do like saliva testing. If you are going to focus on adrenals, I’d say a saliva is the way to go.

There is also dried urine testing, the DUTCH test being the most popular. That looks at the circadian rhythm of cortisol as well. It also looks at cortisol metabolites. I don’t know how helpful it is. You can see the elevation in cortisol when someone has hyperthyroidism. If someone has low thyroid, many times you will see low cortisol metabolism. I wouldn’t say it’s necessary to look at that.

The DUTCH test, I recommend if we want to look at hormones and hormone metabolism, like how you are metabolizing estrogen. I am more interested in how people metabolize estrogen than cortisol. If someone is hyper, I’m going to assume in most cases that it will show that elevated cortisol metabolism. That’s not always the case. It’s not as easy to guess how one’s estrogen metabolism looks.

You could do blood testing. Blood testing usually just will get a morning serum cortisol, which could provide some value. The problem is cortisol responds to stress. If you’re someone who gets stressed out when going to a lab, that could affect cortisol.

Even with saliva testing and dried urine testing, if you’re stressed out the day of collection, you might not want to do the test. If you do saliva testing, every now and then, it can be difficult to generate enough saliva. That could be stressful and raise cortisol. Maybe you want to practice first before collecting the saliva samples. Just keep that in mind. If you have a headache or an argument with your significant other on the day of collection, that could affect cortisol.

With getting the blood draw, the blood draw itself can sometimes cause cortisol to spike. That’s why if someone has elevated cortisol levels in the blood, maybe it really was elevated, but maybe it was because they were stressed out when getting the blood draw.

There are some benefits of blood testing. I mentioned ACTH, similar to TSH. They are different hormones. TSH communicates with the thyroid, and ACTH communicates with adrenals. ACTH, typically you’re looking at in the blood.

There are also adrenal auto antibodies, similar to thyroid antibodies. These auto antibodies mean you have an autoimmune condition like Addison’s. The blood testing is usually where you want to look for these. If you are suspecting a condition like Addison’s or Cushing syndrome, not to say that saliva testing and/or DUTCH testing can’t be valuable to some extent, but you probably want to do some blood testing as well.

As far as supporting healthy cortisol levels, prioritizing sleep is definitely really important. Many times, it’s another catch-22. Many people want to get sleep, but they can’t sleep. If you have hyperthyroidism, and that is causing insomnia, then of course you want to balance the thyroid hormone. You want to try to address the cause of the problem. If someone has insulin resistance that is causing sleep issues, you need to address insulin resistance, which can sometimes be challenging. I have discussed this on previous episodes.

When it comes to stabilizing blood sugar, diet plays a big role. Eat plenty of protein. Avoid plenty of sugar and processed foods. There is usually an inflammatory component that you want to address, too.

Intermittent fasting. A lot of people have questions about intermittent fasting and insulin resistance. It can be beneficial, but you want to be cautious. I just released an episode about intermittent fasting.

Stress management is very important with cortisol. Blocking out time. I recommend starting out with five minutes per day, just to get into the routine of stress handling. Once you’re in that routine, you can increase the duration. To me, it doesn’t matter what you do as long as it’s something that is activating the parasympathetic nervous system.

I bring this up because a lot of people will say, “I exercise, and that is my form of stress management.” Walking is a type of exercise, and that can activate the parasympathetic nervous system. If you’re running or doing aerobic exercise or weightlifting, this is more of a sympathetic activity. I’m all for exercising. I do cardio. I do a lot of resistance exercise and walking. I don’t count that as my stress management routine.

Some type of mind/body medicine, be it meditation, deep breathing, yoga. Some people need extra support, like vagus nerve support. Mind/body medicine also supports the vagus nerve. You could do things like humming or singing out loud or vigorous gargling or cold exposure. I mentioned I’m not a big cold plunge person, but I do cold showers. The only thing is now, as I record this, it’s in the summer months, so the shower is not as cold as it is in the winter.

Some people need nervous system retraining. You might have dysregulation of the nervous system because of past traumas that you’ve had. There are a number of factors that can cause nervous system imbalances. It might very well go beyond stress reduction. Mind/body medicine and vagus nerve exercise do help support the nervous system, but you might need to go beyond those. I mentioned Primal Trust and the Gupta Method. Those are ones I like and am familiar with that you might want to look into.

There are other factors which I have discussed in other episodes. Nutrient deficiencies can affect adrenals, like B vitamins, Vitamin C. Infections can affect adrenals. Mold can affect the endocrine system, including adrenals. Chronic inflammation from numerous sources. Toxic exposures. A lot of factors could affect adrenals.

When it comes to supplements, I mentioned B vitamin complex. Vitamin C, magnesium. I do like adaptogenic herbs. You need to be careful. I have spoken in the past about ashwagandha, which I love, but not a good fit for everyone. If you have hyperthyroidism, you want to be cautious. If you are following an AIP diet, ashwagandha is part of the nightshade family. There are other herbs. Rhodiola is another popular herb.

Licorice root is one I took. Not really considered adaptogenic necessarily. Having low cortisol, that’s something to consider. The only thing is it can raise blood pressure, so work with a practitioner if you are thinking about taking licorice root. If you already have high blood pressure, you don’t want to take it for too long.

You don’t want to take these herbs really long-term if you do take them at all. There is calming agents like relora, phosphatidylserine, which usually if someone has higher cortisol levels. Time and place for adrenal glandulars.

Supplements alone usually aren’t going to solve the problem. Diet, lifestyle, stress management, getting proper sleep, all of those are arguably more important than supplementation.

That’s all I want to discuss when it comes to the thyroid-cortisol connection. Remember that both hyperthyroidism and hypothyroidism can play a role when it comes to adrenals. We spoke about how cortisol can play a role.

Chronic stress can affect cortisol and thyroid autoimmunity, leading to conditions such as Graves’ and Hashimoto’s. It’s usually a piece of the puzzle, but it’s a big piece of the puzzle. If you’re not blocking out time for stress management, it will be difficult to heal. It sounds simple. Block out time for stress management. I realize for many people, it’s not that simple, but it is essential.

If you’re not managing your stress, if you’re not working on stress management. Let’s face it. In many cases, we’re not going to eliminate our stressors. We will always be dealing with stressors. It really comes down to the perception of stress. If your perception of stress isn’t good, that is when you will have those cortisol imbalances. If you’re able to manage your stress effectively and change your perception of stress, that will greatly help and make a big difference.

Supporting cortisol is not just about fixing adrenals. It’s about restoring balance throughout the entire stress response system. We do want to restore the health of your adrenals, but it also affects other bodily systems—the immune system, the gut—in a negative way.

If there is one takeaway, make sure to get in that routine of blocking out time for stress management. Choose something you’re willing to do. You don’t have to do the same thing every single day. You can mix things up. That’s perfectly fine. Once you’re in that routine of five minutes per day, hopefully you will increase it to 10, 15, 20 minutes per day. Not every day. Maybe some days, it’s still five minutes a day. Other days, you do 15-20 minutes, even more than that.

Hope you found this episode to be valuable. As usual, look forward to catching you in the next episode.

In this episode, Dr. Eric Osansky welcomes back Dr. Angela Mazza, a triple board-certified endocrinologist specializing in thyroid health, metabolic medicine, and integrative endocrine care. The discussion centers around two topics Dr. Mazza has recently published journal articles on: iodine and thyroid nodules. Together, they explore why iodine remains one of the most controversial nutrients in thyroid medicine and why individualized care is critical when determining whether supplementation is appropriate.

Dr. Mazza explains the delicate balance of iodine intake, discussing why both deficiency and excess can create thyroid problems. She also shares her approach to iodine testing, addresses common misconceptions about iodine supplementation, and discusses special considerations for Hashimoto’s thyroiditis, Graves’ disease, pregnancy, and breastfeeding. The conversation then shifts into thyroid nodules, where Dr. Mazza explains the most common causes of nodule formation, the role of inflammation, estrogen, insulin resistance, environmental toxins, and genetics, along with how toxic nodules differ from non-functioning nodules.

The episode wraps up with an in-depth discussion on goiters, radiofrequency ablation (RFA), thyroid cancer, and modern alternatives to surgery. Dr. Mazza also explains how she evaluates thyroid nodules using ultrasound and shares her perspective on personalized treatment approaches. If you want a clearer, more balanced understanding of iodine, thyroid nodules, and goiters, you’ll get a lot out of this episode.

Click Here to listen to it on the Save My Thyroid podcast

Dr. Eric Osansky:

Welcome back, Dr. Angela Mazza. Very excited to chat with you again. Hope you have been doing well. Really looking forward to doing a deep dive into iodine, thyroid nodules, and goiters. How are you doing today, Dr. Angela?

Dr. Angela Mazza:

I’m doing really well. Thanks so much for having me on your podcast. I’m excited to be back again.

Dr. Eric:

I am going to read your bio just in case someone hasn’t heard the previous interviews I’ve done with you. Then we will get into the conversation.

Dr. Angela Mazza is a triple board-certified endocrinologist specializing in thyroid health, metabolic medicine, and anti-aging care. She is certified in neck ultrasound and biopsy and is one of the few physicians in central Florida performing radiofrequency ablation, also known as RFA, for thyroid nodules.

Dr. Mazza has served as an investigator on major endocrine clinical trials and has authored publications and international presentations. She is the founder of Metabolic Center for Wellness in Oviedo, Florida; host of The Thyroid Talk podcast; and author of Thyroid Talk: An Integrative Guide to Thyroid Health, dedicated to personalized integrative endocrine care.

One question I have for you. Whenever I mention RFA, I usually mention you. Do you notice anybody getting confused between RFA and radioactive iodine? I always try to make it clear. I was just having this conversation. Maybe there should be a different name. When thinking about ablation, radioactive iodine is ablating the thyroid. I always clarify it’s not the same.

Dr. Angela:

It’s really confusing for a lot of people. That ablation can mean a few different things. I will have patients come to me asking about radioactive iodine. This is different. Unfortunately, the term “radioactive iodine ablation” was around before RFA. You’re right. We should probably make distinctions with that. Two different animals.

Dr. Eric:

I’m having you back on because, as we discussed prior to pressing record, I have been following you. I have been seeing all these journal articles you’ve written. I wanted to get updated information from the person who is putting out the research. I was very impressed by your journal articles on iodine and thyroid nodules, so that’s why we will be focusing on those.

Let’s start off with why did you decide to write the journal articles? Thyroid nodules is understandable because you do RFA and see a lot of people with thyroid nodules. What motivated you to write specifically the journal article on iodine?

Dr. Angela:

When I lecture, there will be questions that come up about iodine from other practitioners. There is a little bit of misunderstanding.

I will also say that whenever I am seeing a new patient who has a thyroid nodule or some sort of thyroid issue, guaranteed, I look through all supplements. I’m sure you do the same thing. I ask people to bring in all regular supplements, and I look at all of them. It never fails that someone who has or thinks they have a thyroid issue is on some sort of thyroid support. Sometimes, these thyroid support products have very high levels of iodine. We will talk about the extremes of that.

Between practitioners and patients asking about iodine, I figured it is obviously an important topic, and there are a lot of misunderstandings. Let’s make it easier. We don’t want people not to have enough iodine. We don’t want people to have too much iodine. It’s moving past those extremes of thyroid care because you and I know that it’s really about individualized care. Iodine is no different than thyroid hormone replacement or thyroid treatment or a thyroid protocol for a person. It has to be individualized. That was my goal for writing the article.

Dr. Eric:

There is definitely a lot of confusion. You have different sides of the story. You still have some practitioners recommending large amounts of iodine supplements. You have other practitioners who recommend for those with thyroid patients to completely avoid iodine. There are different perspectives when it comes to Hashimoto’s versus Graves’ as well. It’s confusing because someone could go on YouTube or another social media platform and find five different videos with five different perspectives.

Dr. Angela:

What’s the right one?

Dr. Eric:

Supplement with Lugol’s solution, says one. Another one says stay completely away.

I am not opposed to iodine these days. It is obviously important. I was on the high dose iodine bandwagon years ago with Dr. David Brownstein.

Dr. Angela:

Right.

Dr. Eric:

I was one of the ones who took high doses of iodine. Quite frankly, I did okay with it. I didn’t experience any side effects. As you see patients, you realize everybody is different. There are some people who might be able to get away with large doses of iodine. Others who can’t.

The question is do we need massive amounts, 50mg doses, or 25mg doses, of iodine? Even if we can’t tolerate it, is it actually necessary?

I don’t know where you want to start. If you want to talk about your approach or some of the common myths and misconceptions people have about iodine. I’ll let you take the lead and go wherever you want to go with this.

Dr. Angela:

I think you hit the nail on the head. When you have been taking care of thyroid patients long enough, you say that the same thing could cause a real problem. That high dose of iodine could set someone into a bad place. Even dealing with patients with thyroid nodules, it can actually cause issues.

If we want to talk about why iodine is important, it’s because it makes up the bulk of the thyroid hormone. We can’t have thyroid hormone if we don’t have iodine. The theory around when people use high doses of iodine is if a little bit is good, more should be better. But there is this U-shaped curve of the sweet spot for iodine.

If we want to talk about a bunch of myths out there, starting with if some is good, more is better. That is probably a myth that we want to talk about.

Another thing is if you have Hashimoto’s, should you avoid it altogether? It is individualized. This is an oversimplification of a more complicated question. Even natural iodine supplementation isn’t necessarily harmless.

When we talk about seaweed or kelp, that is a natural form, but it can have a huge array of iodine in it. If you have some kelp flakes, it might be 50-100mcg. If you have a whole sheet, it can go up to 1,000-1,500mcg. There is quite a nuance when it comes to iodine.

We have to take it in context of the person. My patient in front of me, I have not only to get their good history, get an idea of what their dietary intake is, but what are the other medicines they are on? Are they on medicines like amiodarone? It is used for cardiovascular patients as an antiarrhythmic. But it is super high in iodine. It hangs around in the system for a very long time. It might not cause a problem right away, but it can cause either hyper or hypo.

When we have too much iodine, it can cause one of two issues. It can either shut down thyroid hormone replacement for a while because the system gets overloaded, or it becomes such a rich substrate for making thyroid hormone that the thyroid can become overactive. We don’t necessarily know what is going on with our patient right away. To give them a huge dose of iodine is not necessarily the wisest thing to do.

If you are dealing with a pregnant patient or a patient who is breastfeeding, her iodine requirements will be higher than a person who is not.

I like to get a good picture of a background for a patient from that context.

Testing gets into another question. Is there a really good test for iodine? In functional medicine, we like to test, not guess. There is not a great test for iodine. Serum testing isn’t very accurate. Probably the best is if you did a 24-hour urine collection for iodine, which that can be pretty tedious. I don’t like putting patients through a 24-hour urine collection, especially if you will do it frequently. It’s a pain in the butt to do.

What I generally do, and it’s not perfect either, is I will get a random urine for iodine to creatinine. That helps me extrapolate out what a 24-hour urine would be. I don’t necessarily make a kneejerk reaction off of that either. Ideally, we want that to be between 100-250. If something is a little bit higher or lower, I question a little bit more.

Just the other day, I had someone come in, and I did a random urinary iodine to creatinine. It was off the charts, 1,200. The urinary iodine will only give you a few days to a week idea. It’s not a long-term idea of iodine intake. She happened to have had a CAT scan within that week. CAT scans do deliver a high dose of iodine.

Do we want to stay away from CAT scans if we have a patient with thyroid issues? No, because they’re necessary for certain things, as far as imaging and diagnosis. It’s generally a short-lived thing. It gives you an idea of what is going on.

If you have someone who is coming in on a regular basis, and their random urinary iodine is really low, you talk to them. They may have a very low salt diet. You can get a gestalt of what is going on with them. Maybe that is the person you want to tell to maybe do an iodine supplement a few times a week to supplement for iodine.

That is my general approach to iodine. It’s all very individualized. It’s not necessarily if we check it one time, that is the be all, end all. That person doesn’t have to be on iodine for the rest of their life. My main concern is I don’t want to cause an issue in someone who already has a thyroid issue.

Dr. Eric:

Understandable. What are your thoughts on the iodine loading test?  

Dr. Angela:

I think there is a lot of value to an iodine loading test. It can be pretty cumbersome. If you have a high dose of iodine, then reevaluate from a urinary excretion standpoint. I tend not to do them. If you will do anything, because you will have to do it repeatedly to get an idea on a regular basis of what someone’s iodine is generally going to be. That’s why I go for the random.

Dr. Eric:

You’re right. The inconvenience of the collection is one thing. I should have specified. Are there concerns with taking the 50mg tablet of iodoral prior to that? There are people taking 50mg daily of iodoral compared to that one single tablet before. Could that one tablet cause problems with the loading test?

Dr. Angela:

Probably not that one tablet. We get into the same thing with the contrast. Probably not one dose will cause too much of an issue. If it is, it probably will be temporary.

Dr. Eric:

You said the contrast with CT scans is also not a big concern.

Dr. Angela:

I never promote imaging that isn’t necessary. If someone has to have imaging done, I am not going to say don’t do it because of your thyroid issue.

Dr. Eric:

Have you come across cases of hyperthyroidism or Hashimoto’s that seem to be induced by iodine? If so, what seems to be the most common causes?

Just to give my background, I have probably had at least a few patients per year who, at least according to the health history, they will bring it up to me. They started supplementing with high dose iodine, not just taking it once. I don’t think I had anybody say they did an iodine loading test and then developed hyperthyroidism or Hashimoto’s. Instead, they were taking high dose iodine supplements for a while.

Also, I’ve had a few patients with amiodarone where that caused hyperthyroidism. Not a lot. I can probably count on a single hand how many people. It does happen. I don’t think I’ve had anybody who had the iodine contrast come to see me because they developed hyper or hypothyroidism.

In your experience, when someone comes to you with iodine induced hyperthyroidism, is it the same thing, where they have been experimenting with higher dose iodine?

Dr. Angela:

Usually. It can be either end of the spectrum. I’ll have patients who were actually undiagnosed with Hashimoto’s, and they’re sent to me for evaluation of hypothyroidism. They had been taking some sort of high dose iodine supplement. They shut down their thyroid function. Luckily, for most cases, that resolves as you take away the iodine.

If you think about it, with autoimmune thyroid issues, especially Hashimoto’s, making thyroid hormone in and of itself is an oxidative process, an inflammatory process. If you are giving iodine, it’s causing inflammation if you don’t have enough selenium or glutathione to combat that reactive oxygen species that is going on. It can cause an issue.

I learned the hard way with thyroid nodules and hyperthyroidism. I had a patient who I was following for thyroid nodules. I always check a complete thyroid panel on my patients with thyroid nodules. Her thyroid levels were normal when I first saw her. Then I did a follow-up. Her TSH was .02, T4 was okay, and T3 was high. This wasn’t an overactive nodule before. Digging in, it turned out. It’s not always right at the surface that they are adding a supplement in. The patient said, “Oh yeah, I added in some Lugol’s solution.” Now, not only are you hyperthyroid because of this nodule that has become overactive, but this nodule has grown.

Unfortunately, taking the iodine away didn’t cause the nodule to get smaller. She did return to a normal thyroid state. I learned the hard way about the supplements, even in just the thyroid nodule follow-up.

Dr. Eric:

In this situation that you just described, the iodine caused the thyroid nodule to be a toxic nodule? Or was there a different cause?

Dr. Angela:

It caused the thyroid to become overactive. It caused the thyroid nodule to grow.

Dr. Eric:

It caused the thyroid nodule to get larger and caused hyperthyroidism. Okay. I understand. When she stopped the iodine, her thyroid hormone levels normalized, but the nodule didn’t shrink.

Dr. Angela:

Yeah.  

Dr. Eric:

How about goiters? I want to talk to you about goiters. If you have hyperthyroidism or hypothyroidism, you could have a goiter. An iodine deficiency could also be a cause of a goiter through causing hyperthyroidism. If you had to put a number on it, what percentage of goiters care caused by an iodine deficiency? This may be a guess on your part.

Dr. Angela:

The number is pretty low. It would have to depend upon where you practice. If you are in a place where there is iodine deficiency, it being a cause of goiter would be higher. I tend to see more goiter related to some sort of underlying autoimmune thyroid issue. The TSH is hypertrophic in hypothyroidism. If you have hyperthyroidism, which the most common cause is Graves’, that stimulation of TSH receptor causes thyroid enlargement and inflammation.

I think it would have to depend. If you ask an endocrinologist in the Midwest, they might say a much higher number. It’s pretty low for where I’m at in central Florida.

Dr. Eric:

Okay. I am going to stick with this topic because it does happen. Even if they don’t have a goiter, but they have a thyroid issue. Maybe it’s a goiter or a thyroid nodule or hyperthyroidism without a goiter or nodule. They do a urinary iodine test, and they are pretty deficient according to urinary iodine testing. Would you say to increase food sources without going overboard with the kelp? How would you recommend for them to correct that?

Dr. Angela:

There are a couple different ways. Kelp flakes, put it on your salad a few times a week. If you do choose to do a supplement, potassium iodide, even a few times a week. Any sort of supplement, you don’t need every day, if you think someone is low on iodine. There is no harm in rechecking. That is my route. If we can do dietary, that would be my preference. If you have a good supplement, that’s good.

Dr. Eric:

Do you test everybody for iodine deficiency? Does it depend on the person?

Dr. Angela:

I test everyone, so I have an idea. I’m still going to try to get a detailed personal history. Get an idea of what their lifestyle dietary intake is.

Dr. Eric:

Let’s say you test someone, and their iodine looks normal. Are you at all cautious about giving someone with Hashimoto’s or hyperthyroidism/Graves’ a multivitamin with iodine in it? Whatever amount it has. It can have anywhere from 50-75mcg, sometimes 150-200mcg. Are there any concerns? Or does it depend on the person? Most people can tolerate it, but every now and then, there might be someone who is more sensitive to iodine.

Dr. Angela:

Great question. I have done a few different ways. You want them to get the benefit of the multivitamin. If it’s someone who I’m a little concerned about, especially some with underlying autoimmune, do the multi. Only do it every other day.

It is tough, too. You can’t find a lot of multis without iodine in them. It’s hard. Even the same thing goes for the thyroid supports. They’re not available, but you still want someone to get the benefit, especially if you’re feeling like they’re micronutrient deficient. You want them to get the multi. That’s why I say do it every other day if you can, and then recheck.

Dr. Eric:

Now, someone who is pregnant with Hashimoto’s or hyperthyroidism, and you are giving a prenatal. I don’t know of any prenatal that doesn’t have iodine. Even if there was a prenatal that existed without iodine, iodine is also important for the baby. You want to make sure the baby has sufficient iodine. This is one of these risk versus benefit scenarios. How do you approach pregnant women when it comes to iodine, not separate supplementation but simply a prenatal or having regular food sources of iodine?

Dr. Angela:

I would go with the prenatal vitamin in that case. Her needs are higher. You have some buffer with that.

Do I check urinary iodine levels in pregnancy? Not as much. I’ll follow thyroid function tests really strictly, at least through week 24, and then a little bit less. Since I’m following thyroid function so closely, I don’t overtest on the iodine then.

If she’s breastfeeding afterwards, her needs go up even higher. Breastfeeding, I tend to check a little more the urinary iodine, just because I want to make sure she has enough because her needs are so high.

Dr. Eric:

I’m asking these questions because especially in the case of someone who is pregnant, I don’t want them to completely restrict iodine from the diet. “There is iodine in my prenatal; I won’t take a prenatal. I will avoid all food sources of iodine.” I’d like to think most endocrinologists won’t tell a pregnant woman to stop iodine completely.

Dr. Angela:

I would hope not.

Dr. Eric:

Thyroid nodules. You also wrote a journal article on thyroid nodules. Not a surprise since you deal with a lot of thyroid nodules. Like you said, one of the few practitioners in central Florida who does RFA. Why do people develop thyroid nodules in the first place?

Dr. Angela:

That’s the question that drove me to write this article. I take care of new patients daily with thyroid nodules and thyroid biopsies. Pretty much every single person asks me why they got this nodule. I didn’t have a great answer to this question in the past. Over time, I did some research and dug into it a little bit more, especially considering the frequency that we’re finding of thyroid nodules.

I used to say it was related to iodine deficiency or too much iodine. We know that’s probably not a huge chunk of thyroid nodules. Yes, we get concerned about thyroid cancer because we don’t want to miss thyroid cancer. There are genetic abnormalities that can cause thyroid nodules.

Probably far and away the biggest cause of thyroid nodules is inflammation going on in the body that drives thyroid nodule growth. Whether it’s estrogen related, because we find a lot of thyroid nodules in women, and it can be related to changes and fluctuations in estrogen. It can be related to things we’re exposed to. We’re exposed to how many different chemicals on a regular basis.

The thyroid itself is super sensitive. It’s important, but it’s influenced by so many things. When there is something like an endocrine disruptor that can drive the growth. It can be related to history of radiation exposure.

There are a lot of things that can drive thyroid nodule growth. If you had to narrow it down to one big group, it would be something that drives inflammation.

The other question I get a lot is the concern about GLP-1s and thyroid nodules and thyroid cancer. The concern about thyroid cancer and GLP-1s has been around for a while. That was based off of rat studies. When we look back at the current state of affairs, we know that GLP-1s don’t cause thyroid cancer, but decreasing inflammation and weight loss can actually decrease thyroid nodules and thyroid cancer risk.

Dr. Eric:

In that respect, GLP-1s might benefit some people with thyroid nodules.

Dr. Angela:

In some people, yeah.

Dr. Eric:

But they don’t directly cause thyroid cancer? There is no evidence of that.

Dr. Angela:

No.

Dr. Eric:

That’s good to know. How about insulin resistance? Blood sugar imbalances, insulin resistance. There is some evidence showing-

Dr. Angela:

Definitely. I put that into the inflammation bucket, if you will. Along with insulin resistance, we tend to see obesity. There are hormones that come from our adipose tissue. Lectin feeds back and can cause elevations in TSH, and that TSH can drive thyroid nodule growth from that respect. Without a doubt, insulin resistance and obesity fall into the inflammation category for me.

Dr. Eric:

Toxic nodules. What are toxic nodules, and how are they differentiated from regular thyroid nodules?

Dr. Angela:

Toxic nodules can be really frustrating, for lack of a better explanation. Toxic nodules are overactive nodules. You might also hear “autonomously functioning thyroid nodules.” They are nodules that have developed different genetic mutations that don’t allow it to listen to the signal to shut down, like the rest of the thyroid. It can actually take over function for the whole thyroid, essentially shutting down the rest of the thyroid. What the thyroid nodules have is this really rich blood vessel supply that is in turn feeding that nodule.

Do they necessarily become very large? Not always. There can be small toxic nodules. With RFA, we can treat them well. There can be larger toxic nodules. They can cause compressive symptoms in addition to the symptoms that go along with hyperthyroidism, like anxiety, sleep problems, palpitations, weight loss, those sorts of things. They can be super frustrating. They don’t tend to respond to all our good functional medicine tricks.

Dr. Eric:

Do they have the same causes as far as inflammation?

Dr. Angela:

They can. They tend to have a genetic mutation that drives it a little more than a regular nodule.

Dr. Eric:

You said that they do respond pretty good to RFA in most cases?

Dr. Angela:

They do. The caveat is how large they are. Smaller thyroid nodules, we can treat them very easily with one session of RFA. Sometimes, larger overactive nodules, we need 1-2.

When we look at studies that look at RFA and toxic nodules, there are two key tricks. You have to get the nodule to at least 80% of its size. Whether you are starting out with a nodule that is 10ml or 5ml—we tend to think in terms of volume with nodules—or 25ml, it has to be at least 80% the size.

When you are dealing with something, the delta is a lot bigger to get it smaller, and that blood supply I mentioned, really important when we are dealing with a toxic nodule is we want to zap the blood vessels that are feeding it. If you don’t get those blood vessels, then it’s tough to get that toxic nodule under control. You want it smaller in size, but you want to decrease the vascularity.

Dr. Eric:

Is it the same with cancer? When I had you first on the podcast, I am going by memory here, so I might be wrong. I don’t think at the time, RFA was approved for thyroid cancer.

Dr. Angela:

Right.

Dr. Eric:

When I had you on the Thyroid Summit I had in the past, I’m pretty sure for certain types of thyroid cancer, you said that RFA has been approved or at least has been shown to help with thyroid cancerous thyroid nodules.

Dr. Angela:

I think you’re right. Since then, we do have an indication for thyroid cancer nodules.

The difference with RFA for thyroid cancer, it has to be a fairly smaller size, about 1.5 centimeters. It has to be in an area where it is easily accessible. You not only have to ablate the nodule, but you have to ablate the entire surrounding area. If the nodule is right against the capsule of the thyroid, there is no space to ablate around it. You’re essentially going to ablate the capsule. It has to be in a certain area within the thyroid, and you have to obliterate the whole thing, including the area around it.

For the right nodules, it’s a great option. It’s great for people who can’t have surgery, don’t want surgery, or are not a good candidate for surgery.

Some of these nodules, the other option is observation. Just watch the nodule. Check it every six months. Check it every year on the long end. Part of the problem with that is if you are the patient, and you know you have cancer, do you just want to watch it? Even though capillary thyroid cancer, which is the most common cause of thyroid cancer, is slow growing, I don’t know. I think it is disconcerting for people to know they have cancer and not do anything about it.

Dr. Eric:

It’s great that there is another option because still probably most endocrinologists would recommend thyroid surgery. Just remove the whole thyroid gland. For those who maybe surgery is not an option, just because of other health issues, or maybe they want to save their thyroid and don’t want to get the whole thyroid taken out, to attempt RFA or at least get evaluated by someone like you and see if they are a candidate and give that a try to potentially save their thyroid.

Dr. Angela:

I think it’s a great option for the right nodule or cancer.  

Dr. Eric:

Getting back to toxic nodules. Is there a way to diagnose toxic nodules other than doing an uptake test? Is that really the only way?

Dr. Angela:

I can tell you in the past 10 years, I have not ordered one single radioactive iodine uptake test. Using an ultrasound in the hands of a skilled ultra sonographer, you can see with the vascularity.

Say you just have one nodule. That narrows it down. You can see the vascularity. You have already ruled out Graves’. Even if you have two nodules, you can look at the vascularity and compare one nodule to the other, and you are able to narrow down if it is one nodule that is overactive or two. Sometimes, that can happen. It is a little more rare. Ultrasound is a great technique of localizing a toxic nodule without the use of radioactive iodine.

Dr. Eric:

We had this conversation, too. I know I told you in the past I am not a fan of the radioactive iodine uptake test or treatment. I was surprised by your response. You said, “I’m not a big fan either.”

Dr. Angela:

No.

Dr. Eric:

I never asked you about the toxic nodules and how you diagnose. Honestly, I haven’t seen other endocrinologists or anyone else diagnose a toxic nodule just with the ultrasound. Maybe they take the easy way out or whatever their reason is for doing the uptake. Maybe it’s more profitable. We don’t have to get into that.

The point is, I have been asked that question. Honestly, I wasn’t sure if an ultrasound can actually diagnose toxic nodules. You confirmed that is the case, which is great. The challenge is if you are working with an endocrinologist, maybe they are not as skilled as you are.

Dr. Angela:

True.

Dr. Eric:

They might say, “No, this is the only way,” or perhaps it is the only way they know how to diagnose a toxic nodule.

Dr. Angela:

I have had patients come to me for RFA, and they don’t want to have to do the uptake scan. I’m okay with that. Honestly, a toxic nodule doesn’t technically even need a biopsy because the chance of it being cancer is close to zero.

If you’re going to do an RFA, we have to have the biopsy beforehand. If anybody is thinking about that, we do need a biopsy for that.

Dr. Eric:

Makes sense. On the topic of nodules, how about cold versus hot nodules? That also ties into the uptake test. That is the justification that some endocrinologists use. We want to do it just to see if it’s a cold or hot nodule. I might be wrong, but I think if it’s a cold nodule, it’s a little bit greater chance of being malignant, maybe 5%. Still very low. You can also look at the ultrasound characteristics of the nodules and get an idea if there is a malignancy. It’s not perfect, but neither is the uptake test.  

Dr. Angela:

No. That cold nodule being a little more suspicious, yeah, that’s fallen to the wayside. You’re exactly right.

Back to the uptake scan. It depends upon the institution you’re having it done at and who is reading it. It’s very misleading. They will say, “Oh, at 10 hours, it’s this percentage.” You could have that same person go to another place, and it will be read completely differently. There is little standardization.

Dr. Eric:

Good to know. If someone is listening to this and already got the uptake test, it’s not the end of the world. You got it. You did it. That’s fine.

If someone is on the fence, “I really don’t want to get it, but my endocrinologist is pressuring me to do it,” in both of our opinions, it’s not necessary.

Dr. Angela:

Right. I always encourage patients to be proactive. If you feel like you want a second opinion, there is no harm in getting one.

Dr. Eric:

Exactly. It’s funny. I don’t want to say I criticize endocrinologists a lot. I get nightmare story after nightmare story from people I work with. Probably moreso those with hyperthyroidism and Graves’ than those with Hashimoto’s.

Usually with Hashimoto’s, giving thyroid hormone replacement. They sometimes don’t see the endocrinologist because the primary just gives the thyroid hormone.

With hyperthyroidism/Graves’, nightmare story after nightmare story. I say the same thing. You can always get a second opinion. The second opinion might be the same as the first because they are just recommending antithyroid meds, radioactive iodine, or thyroid surgery. Most of them do recommend the uptake test. They tend to give similar recommendations.

Dr. Angela:

Unfortunately, yeah.

Dr. Eric:

They won’t dig deeper if they can’t work with someone like you. It’s frustrating because you’re obviously open-minded, which is why you’re on the podcast. A return guest on the podcast. Unfortunately, it seems like most endocrinologists aren’t open-minded. Someone else might have to get a third or fourth opinion before they find someone who connects with them.

Dr. Angela:

You have to feel good about your options. We are trying to train physicians and educate providers on a regular basis. Hopefully, someday, things will be better.

Dr. Eric:

Hopefully heading in the right direction. This might be the last question with nodules. As far as addressing underlying causes like inflammation, estrogen imbalances, things like that, where do castor oil packs fall? I get that question, too. Can I use castor oil packs for nodules, even goiters? Do castor oil packs actually help? Is it woo woo?

Dr. Angela:

I get this question a lot, too. I wrote something up on it.

Dr. Eric:

Be honest. If it means hurting people’s feelings and being like, “In my experience, they just don’t work.” I don’t know what your answer is going to be. Maybe you think they’re great. Be up front. Let us know.

Dr. Angela:

I will say that I have not seen them help anyone. If it’s part of your normal routine, and you feel like it is helping you feel better in general, there is no harm in them. I can also tell you that there are not any studies or data on them either.

There is a lot of things out there. Does spirulina help? Dill? Frankincense? We don’t have any studies to show. Are they harmful? No.

Dr. Eric:

If someone wants to do castor oil packs, by all means-

Dr. Angela:

You’re not causing any harm.

Dr. Eric:

Goiters. What are some of the causes of goiters? Is it similar to nodules? Is there an overlap of causes with goiters? Hyperthyroidism and hypothyroidism can cause them. Let’s talk about that.

Dr. Angela:

Any sort of thyroid enlargement far and away is more related to underlying autoimmunity for the most part. Hashimoto’s, that stimulatory effect of TSH on the thyroid. For Graves’, it’s that increased inflammation within the thyroid and TSH receptor activation.

Again, if you look in different areas of the country or the world, where iodine deficiency is more common, you may see more goiters. The tough thing is, and I think we touched on this earlier, as far as treating the underlying cause for goiter or thyromegaly, does that always make the situation better from a cosmetic or compressive standpoint? It depends where we are on the spectrum of its formation honestly.

There is a lot of fibrotic changes that went along with the underlying autoimmune issue. The chances of it getting smaller is less. If it’s a fairly new process, especially with Graves’, it came on suddenly, the chance of that thyromegaly going away is higher. Those are the big things.

There are rarer things, like infiltrative processes like sarcoidosis that can cause thyroid enlargement, too. Far and away, it’s more of an underlying autoimmune issue.

Dr. Eric:

If it happened around the time that someone developed Graves’, there is an increased likelihood of that goiter decreasing over time.

Dr. Angela:

Yeah.

Dr. Eric:

I did have a mild goiter when I dealt with Graves’. That did resolve.

Dr. Angela:

They tend to go away in that circumstance very nicely.

Dr. Eric:

You can get a goiter related to the TSH stimulation with Hashimoto’s, moreso than the underlying autoimmune process, compared to Graves’?

Dr. Angela:

It’s a combination. What we tend to see over time is the TSH stimulation. That infiltrative process that goes along with Hashimoto’s, that lymphocyte infiltration, it starts to affect the architecture of the thyroid itself. It can cause some fibrotic changes that can cause some enlargement. Over time, it shrinks down.

If we are at the end game, if you will, of Hashimoto’s, they tend to have a very atrophic looking fibrotic thyroid.

Dr. Eric:

Here is a question as far as someone that I have been working with who has a history of Graves’ on antithyroid meds, methimazole. In my opinion, it can exacerbate the goiter. I’d love to get your opinion. On the antithyroid meds, she more recently is really hypo. Her last TSH was 24. Prior to that, it was over 3, which is more on the hypo than hyper side. In the past, when she first dealt with Graves’, her TSH was depressed, less than .01. She keeps on fluctuating between hyper and hypo. As we discussed, either one can cause a goiter. The underlying autoimmune process also can cause a goiter.

In her case, obviously, I am trying to do things. She is working with an endocrinologist for the methimazole. I am working on the autoimmune component, trying to improve her health. It seems like it’s a difficult time getting that thyroid normal with the methimazole.

I am throwing you a curveball here because you didn’t expect this question, but I am sure you can handle it. One thing I brought up to her, as the goal is ultimately to get to the point where you are not on any thyroid hormone medication, is if someone in her case, where she keeps swinging back and forth, while trying to work on improving her health, I mentioned block and replace therapy. This is not commonly recommended in the United States. Sometimes, it is. Her endocrinologist shot it down.

I wanted to get your opinion on that. Again, if you’re not a fan of it, let me know. We didn’t prepare this question. I usually don’t recommend it. I don’t have prescribing rights, so I was just telling her to ask her prescribing doctor about block and replace therapy. The extreme swings between hypo and hyper. I wanted to ask that question.

Dr. Angela:

That’s a really good question. Most patients with Graves’ also have antibodies for Hashimoto’s. Whatever process is taking the lead at the time drives the train, if you will.

First thing. When I see a patient swinging back and forth on methimazole, that always makes me question the dose itself. What will happen a lot of the time is when you’re on methimazole, with all the good functional stuff, too, you have to stay ahead of the curve with the methimazole. You can’t wait for the TSH to change before you start cutting back.

Say she started out with undetectable TSH and high T3 and T4. Say her endocrinologist started her on 30mg of methimazole, which is a pretty standard dose. When we check the labs the next time, if the T4 and T3 are even in the mid or approaching the higher range, even though the TSH is still suppressed, we have to start cutting back at that time. That’s part of the process.

To answer your question about block and replace, I have only done it a handful of times. We get to a point where one immune process takes over. Then we are left with one or the other. In that case, it’s more of a dosing problem. I don’t usually have to go to block and replace.

Dr. Eric:

I usually don’t recommend it either.

Dr. Angela:

For someone who is swinging back.

Dr. Eric:

It’s pretty common, where someone is on a higher dose of methimazole. They become hypo, and then the doctor will reduce the dose. Maybe either they will still be hypo, or maybe they will swing to hyper, depending on how low the dose. I do see those fluctuations pretty frequently.

Here, it’s been going on for a while. She is not on a real high dose now of methimazole. I think she is on 10 or 15mg, which is not a low dose, but it’s in the middle. 10mg is on the lower side.

I didn’t even mention what block and replace therapy is. It’s taking antithyroid medication, but giving some thyroid hormone replacement.

Dr. Angela:

On top of it.

Dr. Eric:

In her case, she has recently been more hypo. Again, she decreased the methimazole. Then she has become hyper again.

For the goiter, it’s a unique situation for her because she has a larger goiter. I figured that’s not helping to have those extreme swings, where she is extremely hypo and then switches to hyper. That’s the only reason. I’m with you. Most of the time, I am looking to refer them back to an endocrinologist, and if someone is super hypo, reduce the dose of methimazole. I didn’t know your perspective on block and replace, but it sounded like you’ve done it a few times. Again, it’s not-

Dr. Angela:

It’s really complicated.

Dr. Eric:

Makes sense. Wrapping up goiters. Thyroid hormone balance is important. The autoimmune component and inflammation is important. RFA, is that an option for larger goiters?

Dr. Angela:

It’s not FDA-approved treatment. It gets tricky if patients are trying to get insurance to cover it. It becomes an option if you say you have one side that is a lot larger. With a thyromegaly, if the left side is a lot larger, you can treat that left side to match the other side. That is pretty doable.

You can really do RFA on one side at a time per session. Say someone had symmetric thyromegaly. You could still only work on one side versus the other side. You’d have to wait six months to work on the other side. It will be lopsided. As long as patients are on board with that.

It gets tricky with the insurance covering for just that. Usually, they will want to know if it’s a thyroid nodule or thyroid cancer. You could even get away with nodular replacement. If we just say it’s for thyroid enlargement, they don’t always cover that.

Dr. Eric:

You have seen it work for larger goiters.

Dr. Angela:

Yeah.

Dr. Eric:

It will be one side at a time, so the person must be comfortable having the asymmetric thyroid for six months. Everybody is different. When you say, work on it and then work on it again six months later, is it multiple sessions working on one side?

Dr. Angela:

Depends upon how large it is. It would just be one session. It takes a good six months to a full year to some patients to see the full effect of one session of RFA. Essentially, you’re causing some cell destruction. The body itself has to take up those destroyed cells and essentially think about a ball shrinking down on itself. That takes time. You start seeing changes within a few weeks, but we don’t see the full effect of one treatment of RFA until at least six months.

Dr. Eric:

It’s not the same with nodules though, right? People would see changes quicker with thyroid nodules, or is that also a process?

Dr. Angela:

It’s still a process, too. Some people notice it right away, and the nodule responds really quickly. We always do an ultrasound at three months, six months, and a year. Sometimes, three months, we’re good. Some nodules take a little bit longer.

Dr. Eric:

One more question. We’ll then wrap it up unless you have anything else to add. Do you do a thyroid ultrasound on every thyroid patient you see?

Dr. Angela:

I tend to. Even if it’s Hashimoto’s, I want to know the extent of any sort of thyroid destruction. It helps me correlate where we’re at with thyroid antibodies. Patients always ask, “Can I get off of thyroid medicine? What are my chances?” That helps me figure it out. I also don’t want to miss a nodule that’s there.

Dr. Eric:

I understand. I don’t know if I told you this story, but when I was diagnosed with Graves’, the endocrinologist I saw didn’t think I needed an ultrasound. She palpated my thyroid and didn’t think there were any nodules. At the time, I didn’t have health insurance, so she might have been more sensitive to that. I was willing to pay, so I asked her for one. “I know you feel like there’s nothing there, as far as nodules go, but I still want to pay for the ultrasound for peace of mind.” She was right. In all fairness, she did the ultrasound, and I had a smaller goiter but no nodules.

I was curious because in my case, the endocrinologist- Same thing with working with other people. A lot of endocrinologists will, but some won’t. I was just curious what you do.

Dr. Angela:

If you talk to some endocrinologists, they will say, “We will find nodules that were never going to cause a problem and cause unnecessary biopsies.” I’d rather know it’s there than not know.

Dr. Eric:

I agree. All right. This was awesome. We could easily talk for another hour. Anything that you were hoping that I would ask you about iodine or thyroid nodules or goiters that I didn’t ask you?

Dr. Angela:

No, I think we ran a full spectrum on these topics. One thing I hope people take away is that everybody is different. Everybody’s options are different. Thyroid health is personalized medicine; it has to be personalized.

Dr. Eric:

Can you remind people where they can find you?

Dr. Angela:

Sure. Our website for the clinic is MetabolicCenterForWellness.com. You mentioned my book Thyroid Talk: An Integrative Guide to Optimal Thyroid Health. I have a YouTube channel. I’m on Instagram and LinkedIn. That’s about it. That’s enough.

Dr. Eric:

This was wonderful. Thanks, Dr. Angela. Always a pleasure speaking with you. I’m sure the audience learned a lot. I learned some things as well.

Dr. Angela:

Wonderful, thanks so much, Dr. Eric. Keep doing all the good work you’re doing.

Dr. Eric:

Thank you so much. You do the same.

 

In this episode, Dr. Eric Osansky explores a common question he receives from people with hyperthyroidism: Can I incorporate intermittent fasting? While fasting has been praised for benefits such as weight loss, blood sugar regulation, reduced inflammation, and improved metabolic health, Dr. Eric explains why those with hyperthyroidism and Graves’ disease need to approach fasting differently than the general population.

Dr. Eric reviews the most common fasting methods, including overnight fasting, 16:8 intermittent fasting, alternate-day fasting, water fasting, and fasting-mimicking diets. He explains how hyperthyroidism creates a catabolic state characterized by increased metabolism, muscle breakdown, and weight loss, making prolonged fasting potentially problematic for some people. He also discusses the important roles of adrenal health, cortisol balance, blood sugar regulation, insulin resistance, and stress when determining whether fasting is appropriate.

Throughout the episode, Dr. Eric emphasizes the importance of individualization. While fasting may offer benefits for certain people, especially those with stable thyroid levels and insulin resistance, it may be counterproductive for others who are actively hyperthyroid, losing weight, struggling with adrenal dysfunction, or experiencing significant symptoms. If you want a balanced, practical perspective on fasting and hyperthyroidism, you’ll get a lot out of this episode.

Click Here to listen to it on the Save My Thyroid podcast

Dr. Eric Osansky:

Intermittent fasting has become incredibly popular over the last decade. Some people swear by it for weight loss, blood sugar balance, inflammation, even longevity. But if you have hyperthyroidism, including Graves’ or toxic multinodular goiter, the question is: Should you be fasting?

The answer isn’t necessarily yes or no. In some cases, fasting can be helpful while in others it can slow down your recovery.

What you need to keep in mind is that when it comes to fasting, most of the fasting advice is directed toward a general population. There isn’t a lot out there when it comes to hyperthyroidism and fasting, at least not in the research. People with hyperthyroidism, they do have unique consideration.

Remember there is not a one size fits all approach. If you’re reading a book on intermittent fasting, for example, or watching YouTube videos, keep in mind that the people who are talking about it usually are not dealing with hyperthyroidism. That does make a big difference.

Let’s briefly talk about the different types of fasting. I won’t go into great detail here. You can learn more about this elsewhere.

The most basic type is an overnight 12-hour fast, where you stop eating at 7pm and then eat the next morning at 7am, for example. You can vary that. Maybe you stop eating at 6pm and eat at 6am. You could do a 14-hour fasting window. Very popular is 16-8 fasting, where you’re fasting for 16 hours, and you have an 8-hour eating window.

There is alternate day fasting. There is 24-hour fasting. There is multiple-day fasting. There is water fasting.

There is also what’s called fasting mimicking diets. The goal is to replace the benefits of intermittent fasting without restricting the eating that is associated with traditional fasting. Essentially, it allows a limited intake of specific nutrients to help sustain the body. Usually, you are following this diet over a five-day period. Many times, people will do it once a month for a few consecutive months.

As far as why people are interested in fasting, there are numerous benefits. The #1 reason is weight loss. People want to lose weight. When I dealt with hyperthyroidism, I did not want to lose weight. I was losing too much weight. I would have not been a good fit for intermittent fasting. There are some people with hyperthyroidism who aren’t losing weight. That is one of the potential benefits.

Blood sugar regulation. If someone is dealing with insulin resistance, type 2 diabetes.

Inflammation. Some will talk about fasting, including intermittent fasting, for reducing inflammation, especially if someone has autoimmune conditions. It could be a piece of the puzzle. I would keep your expectations in check. Fasting alone is probably not going to completely eliminate the inflammation. Maybe it will reduce it to some extent. Maybe not. Depends on the person.

There is what’s called autophagy, which is cellular cleanup, improving metabolic flexibility, which is the body’s ability to shift between burning glucose and fat for energy. Those are probably the main benefits. I’m sure there are others. Giving your digestive system a rest would be a potential benefit of intermittent fasting.

Why is fasting more challenging with hyperthyroidism? The reason is because hyperthyroidism is considered to be a catabolic state. Catabolism means you have increased muscle breakdown, typically weight loss, and increased metabolic rate. If you have an elevated resting heart rate, like I did when dealing with Graves’.

Sometimes, it’s strange just because you figure if you have that increased metabolism, you will lose weight. A lot of people do lose weight. Weight loss is very common. But there is a decent amount of people who don’t lose weight, even if they have an increased resting heart rate. They also might be losing muscle mass, even if they are not losing weight. The classic hyperthyroid case, you not only have the increased metabolic rate, but you also have muscle breakdown as well as weight loss. I fell under that category when I dealt with Graves’. Not everybody does.

The concern with fasting, if you are in that state of catabolism already, that fasting may already further increase the tissue breakdown in people with hyperthyroidism who are losing weight, losing muscle. When you have hyperthyroidism, you might need more calories. The key is not just getting more calories, but with any health condition, make sure you are eating healthy foods, nutrient dense foods.

A problem with fasting, even intermittent fasting, is some people aren’t getting enough calories. If you are doing a 12-hour fast or a 14-hour fast, you are probably fine. Even if you are doing a 16-8 fast, it might be okay. Over the years, I have had people do 20-hour fasts every single day. Only a four-hour eating window. When that’s the case, they are probably not getting enough calories or nutrients or protein.

Anything over 16-8 is a bit extreme if you’re doing it every single day, especially if you’re dealing with hyperthyroidism. Not to say 16-8 is acceptable for everyone. You need to be careful if you’re dealing with hyperthyroidism, which you probably are if you’re listening to this.

Remember, everyone is different. Not everyone has classic hyperthyroid signs and symptoms, including weight loss. If that’s the case, maybe you can get away with the 16-8 fast. Maybe you could get some benefits from a 16-8 fast. If you are losing a lot of weight, a lot of muscle, with that increased metabolism, then 16-8 or even 14 hours might be too extreme for you. Everyone is different.

In addition, we need to look at the adrenals, blood sugar. When it comes to cortisol and hyperthyroidism, a lot of people with hyperthyroidism have cortisol imbalances. I know I did when I dealt with Graves’. I had low cortisol, but some people have high cortisol. The only way to know for sure is by testing.

Blood sugar imbalances are very common. You could test not just fasting glucose; that’s what most doctors do. It’s great if you test fasting glucose, but you also want to test fasting insulin and hemoglobin A1C, which is the average blood glucose over a period of 2-4 months. I wouldn’t look at any one of these alone. Do all three. There are other blood sugar markers. At the very least, do fasting glucose, fasting insulin, and hemoglobin A1C.

In some cases, some people will get what’s called a continuous glucose monitor (CGM), which is constantly looking at glucose levels throughout the day. Usually, you tie it into an app. I have tried that out for a few weeks. Working with a practitioner is a good idea if you’re using one. Usually, you will need a prescription for one anyway. These days, there are companies where you can purchase on your own. Many times, you will need to work with someone.

Cortisol imbalances are a big issue. The reason is stress is a big factor. Chronic stress is a big factor. The reason I am bringing this up is because intermittent fasting can be a stressor as well. Not everybody perceives it as being a stressor. It’s one of these things where it could be a physiological stressor, especially if you are doing extreme fasting. I mentioned someone who is fasting 20 hours a day with a four-hour eating window, or an 18-6 fast, where you fast for 18 hours and eat for six hours. That could put stress on your body.

From a psychological standpoint, the perception of stress also could be difficult. If you only have that 4-6-hour eating window, psychologically, some people might be fine with that. That could also affect stress from an emotional standpoint.

If you are dealing with something like insulin resistance, fasting without question can improve insulin sensitivity in people. You also need to consider the impact it has on your adrenals.

You also need to see how you feel. If you’re doing intermittent fasting, even if you are doing a 16-8 fast, and you’re experiencing increased anxiety, increased shakiness, palpitations. I know these are common symptoms with hyperthyroidism. I’m saying if it seems more extreme with the fasting. Getting disrupted sleep. Any exacerbation of symptoms when you start fasting, maybe that’s telling you that it’s a little bit too extreme. You want to listen to your body.

I already mentioned a few situations when you want to be cautious about intermittent fasting when you’re dealing with hyperthyroidism. If you’re having extremely elevated thyroid hormones, or even if they are moderately elevated, they don’t have to be off the charts. Even without looking at your thyroid hormones, if you’re losing weight and muscle, it may not be a good idea to do longer fasts.

If you’re one of those people with hyperthyroidism where you’re not losing weight, maybe even having difficulty losing weight, but still moderate to severely hyperthyroid, which it doesn’t make sense but does happen in some cases, if your thyroid hormones are extremely elevated, you also might want to be cautious about doing intermittent fasting. 12-14 hours is okay for most people, but going beyond that, I would work with a healthcare practitioner.

I already mentioned if you’re having weight loss, especially significant weight loss, I lost 42 pounds total when I dealt with Graves’. I mentioned muscle wasting. If you’re having blood sugar imbalances. If you’re having insulin resistance, intermittent fasting could help in some cases. If you are having hypoglycemia, low blood sugar, it’s probably not a good idea to incorporate intermittent fasting.

Listen to your body. If you’re having increased anxiety, sleep issues. There are other common scenarios, like if someone is pregnant, then you probably don’t want to do extreme fasting. I wouldn’t say 16-8 fasting is extreme, but I would definitely work with a practitioner if you plan on doing that and are pregnant. If you are pregnant, you want to make sure you get enough nutrients for you and the baby that you get through food. If you are only eating 4-6 hours a day, even eight hours a day, that still might not be enough if pregnant.

When is fasting considered reasonable for those who have hyperthyroidism? If your thyroid levels have stabilized, if you are not actively hyperthyroid- I am not giving recommendations and saying if everything looks good, go ahead and fast. But that’s one scenario where fasting might be okay.

Adrenal health. Healthy adrenals. Doing an adrenal saliva panel or maybe a dried urine test, like the DUTCH test. Looking not just at a single cortisol level but cortisol levels throughout the day. Blood sugar, looking at glucose, insulin, hemoglobin A1C.

You should also have a healthy relationship with food. Fasting should not become another source of stress. If you’re stressed out because you’re fasting, and I mentioned this earlier, it could be physiological stressors, but it could be emotional stressors. The fasting itself could be a stressor. That is probably not a good idea if that increases stress.

When it comes to specifically Graves’, there are some practitioners out there who talk about fasting helping with autoimmunity, with the immune system response. It could reduce inflammation, modulate the immune system. Fasting can have these benefits.

Autoimmune hyperthyroidism is different. I don’t want to keep on repeating myself. If you’re dealing with Graves’, yet you’re losing a lot of weight, you’re losing a lot of muscle, your adrenals aren’t great, then everything comes down to risk versus benefit. Fasting might still offer some benefit with the autoimmune component.

I don’t even want to say it’s a piece of the puzzle. I talk about how diet is a piece of the puzzle. For example, when I dealt with Graves’, I didn’t do any fasting. My situation is different than yours. If someone is dealing with Graves’, and they are having difficulty losing weight, then maybe in that case, fasting would be okay. It also depends. If your adrenals are not in great shape, it could be an increased stressor. Of course, I will be biased because I am a natural healthcare practitioner, but I recommend working with someone and not doing this on your own.

Hyperthyroidism is complex. Autoimmunity is complex. Autoimmune conditions such as Graves’ are complex. Especially when it comes to Graves’, it’s finding and removing triggers: food triggers, environmental toxins and toxicants, gut infections, chronic stress, correcting nutrient deficiencies, healing the gut. All of these are important. If all you do is intermittent fasting, you are not going to reverse Graves’.

I will say that many people over the years have reversed Graves’ without intermittent fasting. I can’t say that fasting is necessary in most people with hyperthyroidism and Graves’. It could offer some benefits in some situations, but you want to be careful. Work with someone. Remember that fasting alone is definitely not a treatment for Graves’ or any other type of hyperthyroidism.

I would say start out more conservatively. If you haven’t done anything when it comes to fasting, or even if you have, if you have been doing extreme fasting, cut back. I would recommend for those who haven’t done anything to start with a 12-hour overnight fast. If you have been fasting for 20 hours a day, and you don’t want to cut back to 12 hours, maybe 14 hours. Finish dinner at 6/7pm. Eat breakfast at 6/7am. If you were to stop eating dinner at 6pm and eat breakfast at 8am, which is 14 hours, most people can handle that as well.

Everyone is unique. If someone has hypoglycemia, you might not want to do that. Not everybody with hypoglycemia is the same.

Start with a 12-hour fast. Consider gradually progressing to 13-14 hours. Pay careful attention to any symptoms you’re experiencing. If you’re experiencing any increase in symptoms. I mentioned specifically anxiety, palpitations, poor sleep, increased fatigue. Obviously things like dizziness are not good. Listen to your body. Don’t try to tough it out when it comes to fasting.

Keep in mind there are alternatives. Focusing on eating nutrient-dense foods, plenty of protein, healthy fats, fiber. Reduce snacking. Maybe rather than doing a fast, have specific eating windows. Don’t snack. Have three meals per day. Make sure all the meals that you eat are nutrient dense, healthy meals.

Block out time for stress management. Prioritize sleep. These are all important. Many people can achieve really good health benefits without doing aggressive fasting. As I mentioned, I don’t know if I would consider 16-8 fasting to be aggressive, but it depends. Someone with active hyperthyroidism, especially if you are losing weight, muscle mass, then I would say 16-8- When I dealt with Graves’, 16-8 fasting would have been too aggressive for me. Not everybody is in that same situation, but a lot of people are.

If you’re experiencing moderate to severe hyperthyroidism, especially weight loss, muscle loss, be cautious when it comes to fasting. Like I said, you also have to look at other things like blood sugar markers, adrenals.

I am not against fasting. This solo episode might give you the impression that I am not a big fan of fasting. I have done 16-8 fasting. Most nights, I am usually doing 14-hour fasts. At least 12-14 hours. Sometimes, I do 16-8 fasts. I did it more frequently in the past. Now, I just listen to my body. A few years ago, I would stop eating at 6pm and eat again at 10am the next morning. If I’m hungry, I won’t wait just to go 16 hours. I will eat if I’m hungry after 12 hours or 14 hours.

Focus on healing right now. You don’t need to fast in order to heal. Maybe later on, you introduce it. Or start with 12 hours and gradually increase to 13, 14 hours.

My point is, don’t force fasting. Don’t fast because it’s popular, and you have friends who are doing it or hear about others doing it.

I’ll wrap things up. Fasting is not necessarily good or bad for people with Graves’ and other types of hyperthyroidism. If you have active hyperthyroidism, if you’re losing weight, if you’re losing muscle, have unstable blood sugar levels, blood sugar imbalances, compromised adrenals, you want to be careful about doing more than 12-14 hours’ worth of fasting.

A 12-hour overnight fast is a reasonable starting point. Just because fasting can be beneficial for some people doesn’t mean it’s beneficial for others. The question isn’t whether fasting is healthy. The question is whether it’s healthy for you, based on where you are in your hyperthyroid healing journey.

I also put together a few questions people might have. One question some people have every now and then is: Can fasting lower thyroid hormone or thyroid antibodies? I will say there is some evidence that restricting calories extremely can actually lower thyroid hormones. It’s not the way you want to go about it. You don’t want to do extreme fasting. That’s not addressing the cause of the hyperthyroidism. In some cases, fasting might be able to help lower thyroid hormone levels. It’s not going to do much from an autoimmune component as far as lowering thyroid antibodies.

Can fasting help with weight gain in Graves’? Maybe. It depends. Not everybody is the same. If someone is having insulin resistance and Graves’, maybe. I would say work with a healthcare practitioner.

Is fasting different for Hashimoto’s’ versus Graves’? Those with Hashimoto’s usually aren’t losing weight. Many people with Graves’ are losing weight, but a lot of people with Hashimoto’s have adrenal imbalances and blood sugar imbalances. If it’s blood sugar imbalances like insulin resistance, maybe it’s okay. If it’s hypoglycemia, maybe not. If someone has compromised adrenals regardless of whether they have Graves’ or Hashimoto’s or a different autoimmune condition, you want to be cautious.

You can learn more about diet by reading my book The Hyperthyroid Healing Diet. I don’t talk a lot about fasting in it, but it’s in there a little bit. My Healing Graves’ Naturally newsletter, SaveMyThyroid.com/GravesNewsletter.

Like I said, I will always recommend working with a healthcare practitioner, usually a natural one. If you go to your primary care doctor or your endocrinologist, they are probably not going to be big fans of fasting. In all likelihood, they will tell you that diet won’t make any difference when it comes to your hyperthyroid condition. You probably don’t want to bring up diet at all to your endocrinologist.

I am not against intermittent fasting, especially in a healthier state. If you are healing, you want to be cautious.

Thanks again for tuning in. Look forward to catching you in the next episode.

***

Hopefully, you found this solo episode on fasting and hyperthyroidism to be helpful. Over the years, I have had a number of people ask me about water fasts on hyperthyroidism. Three-day fasts, if not five-day fasts.

I don’t usually recommend this for some of the same reasons I mentioned during the episode. If someone is losing a lot of weight, you don’t want to do this. Even if you are not losing a lot of weight, it puts a lot of stress on the body.

Everything is risk versus benefit. If someone is in a healthier state, they are dealing with insulin resistance, maybe the benefits very well might outweigh the risks. Even if someone is not losing weight, maybe you have problems losing weight. If your adrenals aren’t in great shape, then I’m not sure if you want to do a three-day water fast, let alone a five-day water fast.

24-hour water fast? I wouldn’t do them regularly. It’s different if you’re in a better state of health. That’s why people are trying to incorporate water fasting and juice fasting to try to get into a healthier state, to help benefit their health. You definitely want to be careful. Work with someone.

If you are working with me, just to be up front, I wouldn’t recommend a three-day water fast or regular 24-hour fasting. If you are looking to do those, you wouldn’t want to work with me because I won’t tell you to do those types of fasts.

Fasting and insulin resistance. I spoke about this a little bit during the episode. If someone has insulin resistance and hyperthyroidism, and they are not losing weight, intermittent fasting, 12-14 hours is something to consider. 16-8, maybe in the case where someone is not losing weight.

It depends on the state of your adrenals, which is why I would recommend doing an adrenal saliva test or dried urine test to look at the circadian rhythm of cortisol. That would be a situation where I would at least consider it.

If someone has insulin resistance and hyperthyroidism, whether it’s Graves’ or toxic multinodular goiter, and they are struggling to lose weight, and maybe their adrenals don’t look too bad, maybe doing a 16-8 fast is something they could do. Keep in mind it doesn’t work with everybody. Fasting can sometimes work wonders, but sometimes there are other things you need to do.

With insulin resistance, there is an inflammatory component, so you might need to do other things to reduce inflammation.

Fasting as a source of stress. I mentioned this already. Tying it into the adrenals. Fasting itself could be a stressor. I mentioned if you already have weakened adrenals, you might want to be careful about fasting.

Also, fasting itself could be a stressor in some people. Some people are excited about fasting. They think about this positively. Others learn about fasting and are not happy about it, but they are doing it to try to lose weight or general health benefits. Maybe they heard it can help with the immune system, which I’ll discuss next. Especially if you have a negative mindset toward fasting, and then you’re doing it, just like you have a negative mindset toward AIP or any diet, it could be a big emotional stressor.

It could be a big physical stressor, too, if your body is not ready for it. If you are losing weight and/or your adrenals are compromised.

I am not trying to talk negatively about fasting, but I am warning you. I have done 16-8 fasting. I regularly do 12-14-hour fasts. I know people who do more extreme fasting, and it’s benefited them. You just want to be careful. Hyperthyroidism is different than many other health conditions.

Finally, can fasting benefit autoimmunity? There are practitioners talking about the benefits of it. I discussed this a little bit during the episode. All I’ll say is it could in some cases benefit the immune system. I also can’t say it’s necessary.

There are a lot of things out there that can add benefits. Doing hyperbaric oxygen might have benefits. That is a little bit more extreme because you’d have to go somewhere or buy your own hyperbaric oxygen chamber. Fasting is simple and easy. Could put stress on your body, but it is definitely easier than some other things.

I wouldn’t say it’s absolutely necessary. I have had a lot of success over the years helping people with hyperthyroidism, Graves’, toxic multinodular goiter, without recommending fasting. I can’t say that I’m going to recommend fasting. I’ve mentioned this already. Everyone is different. There definitely are benefits of fasting and caloric restriction. Most of the studies on fasting and caloric restriction are more animal studies. It doesn’t mean there are not benefits with humans. Like I said, really be careful. If you really are thinking about it, work with someone.

The problem is, if you work with someone, it probably won’t be someone who is too familiar with hyperthyroidism. I honestly don’t know anyone who focuses on hyperthyroidism and also has a lot of experience with fasting. You might be on your own. If you are working with someone who has a lot of experience with fasting, they could do some of their own research.

If you work with someone who has a lot of experience with fasting, not with hyperthyroidism specifically, and they tell you, “I’m not sure. Maybe I wouldn’t do it in your situation,” that’s a red flag. If someone who is an advocate of fasting is telling you that maybe you shouldn’t fast, you want to be cautious.

With me, I am neutral. I am not against fasting. I am just cautious. If you work with someone who recommends fasting on a regular basis, and they are not sure in your situation, then you might want to think twice about doing it, at least while healing. Maybe in the future, you probably could do it. While healing, maybe don’t do it.

That’s all I want to talk about with regard to fasting. As usual, hope you found this information to be valuable. Look forward to catching you in the next episode.

In this episode, Dr. Eric Osansky welcomes thyroid patient advocate, speaker, and bestselling author Rachel Hill to discuss her book, The Positive Thyroid Pregnancy Book. Drawing from both her personal experiences and years of supporting thyroid patients, Rachel shares practical guidance for navigating fertility, pregnancy, and postpartum health while managing hypothyroidism and Hashimoto’s thyroiditis. While her focus is primarily on hypothyroidism, much of the conversation applies to anyone dealing with thyroid or autoimmune thyroid conditions.

Together, they explore some of the biggest challenges thyroid patients face when trying to conceive, including infertility, miscarriage risk, thyroid antibody management, medication considerations, and optimizing thyroid hormone levels. Rachel also discusses the importance of tracking thyroid labs throughout pregnancy, reducing thyroid antibodies before conception when possible, supporting gut and immune health, balancing blood sugar, addressing nutrient deficiencies, and understanding the role of hormones, diet, exercise, and environmental toxins in fertility and pregnancy outcomes.

The conversation concludes with practical advice on prenatal supplements, postpartum thyroid health, building a supportive healthcare team, and advocating for yourself throughout the entire pregnancy journey. If you want a clearer understanding of how to prepare for a healthy pregnancy while managing a thyroid condition, you’ll get a lot out of this episode.

Click Here to listen to it on the Save My Thyroid podcast

Dr. Eric Osansky:

I am super excited to chat with Rachel Hill, who is the multi award-winning thyroid advocate, speaker, and best-selling author behind The Invisible Hypothyroidism and four thyroid patient books. In this conversation, we will be talking about her book The Positive Thyroid Pregnancy Book. Rachel, thank you so much for joining us.

Rachel Hill:

Thank you so much for having me on. I’m really excited to discuss a really important topic today.

Dr. Eric:

Same here. You’ve written a number of different books. The question I’m about to ask is, why did you write The Positive Thyroid Pregnancy Book? I assume it’s your own experience, but there is also not a lot of information out there when it comes to thyroid and pregnancy. Were those two of the biggest motivating factors? Maybe there were other reasons, too.

Rachel:

I’d say you hit the nail on the head there. I have one called The Patient Expert about navigating a new diagnosis. One about relationships with your spouse, friends, and family. For me, writing has to come from an organic place. It’s often a representation of where I am in my own thyroid journey.

I now have two sons who are six and four. When I went through my own pregnancies, it was an overwhelming time of not knowing where to turn for this information. I think there are one or two books out there. They can be quite clinical. They are written by doctors, brilliant doctors, but they are not easy for someone who is perhaps brain fogged, fatigued, with these typical thyroid symptoms. It’s not easy for us to digest. They can be really long books.

I wanted to create something that had all of the essential information but without all the fluff and jargon. Just the need-to-know information that we thyroid patients can go ahead and implement.

My work is always there to be utilized alongside your doctor, functional medicine practitioner, chiropractor, whomever you’re working with. I want thyroid patients to feel empowered to know what they can do specifically and what questions to ask in the doctor’s office. How to advocate not only for themselves but for their unborn child when they are pregnant.

Writing The Positive Thyroid Pregnancy Book is something I pieced together over 3-4 years of going through a couple of pregnancies that were incredibly different. One with a thyroid condition well managed, and the other one was the complete opposite. It gave me a lot of personal experience to use as well that will hopefully not only help the thyroid patients but give them validation for what it is we go through.

I really wanted to put some difficult experiences into something useful. It was important to me that it was a positive book to read, hence the name. When you Google “hypothyroidism pregnancy,” thyroid in general and pregnancy, fertility, it’s doom and gloom. At least when I was Googling, “chances of miscarriage,” you end up going down this terrible black hole. It’s not positive information that comes up.

When we get to the truth of it, thyroid patients can have children. We just need to know this crucial information in order to help support ourselves with the best chances of getting there. That’s why I created it.

Dr. Eric:

Wonderful. Glad you did create the book as well as your other books. Let’s start by discussing some of the biggest challenges women with thyroid conditions experience when they are trying to have a healthy pregnancy. If you want to tie it into some of your own experiences, I’m sure you have seen a lot of different experiences from other women who were pregnant with hypothyroidism/Hashimoto’s.

Rachel:

The single biggest struggle that we have is falling pregnant. A lot of people don’t realize how important their thyroid gland is for their fertility.

Second to that is being able to hold onto the pregnancy. I experienced a miscarriage as my first pregnancy, which was a trigger for me feeling like, “Okay, I need to understand more of what I can do, more of what is going on,” and delving into that research. I found so much that thyroid patients don’t know. It’s not easily accessible, or at least it wasn’t before I wrote this book.

Understanding the T4 synthetic medications, like levothyroxine or Synthroid, they work for a lot of people, but they don’t work for everyone. When I say “work,” we’re not just talking about getting your thyroid test results normal. We are talking about actual symptoms and your quality of life and whether your thyroid test results are optimal as opposed to normal, fine, or in range, all these phrases we all hear. That alone can be the biggest step we can make to combating fertility struggles, pregnancy loss.

It’s such a simple thing, yet a lot of us don’t know to ask those questions to get a copy of our own test results and look at them and understand them. When it comes to the biggest issues that we face, that pregnancy loss, falling pregnant, they’re often the biggest ones. It’s just about how we can then navigate that and understand what we can ask to overcome those.

Dr. Eric:

Thyroid hormone replacement, I’m glad you brought that up because a lot of women are on levothyroxine. Some women do fine with it, and some don’t. You need to convert that T4 into T3. That’s a big problem.

Do you have a preference? It is individual, but I don’t know if you personally take levothyroxine or if you like desiccated thyroid. Is desiccated thyroid safe to take during pregnancy? There is also some debate. If you ask conventional medical doctors, they would say no, that you need to be on levothyroxine. I’d love to know your thoughts about what is safe, what is optimal during pregnancy when it comes to thyroid hormone replacement.

Rachel:

I always say there is no one best thyroid medication. It’s the one that works best for each person. When we say that it works best for you, we are looking at optimal thyroid hormone levels as well as symptom relief and overall quality of life.

For me, I am currently on Armour Thyroid plus a small amount, 25mcg, of levothyroxine on the side. This is not very conventional. It was something that I was almost hesitant to share when I first made that switch because a lot of people are very opinionated on thyroid medication options.

When I was diagnosed almost 11 years ago now, I was started on levothyroxine. I felt awful. I was gaining more symptoms, gaining weight. My mental health was down the drain. I then explored the route of natural desiccated thyroid medications. I started off self-sourcing that from Thailand because here in the UK, it’s incredibly hard to get, if not impossible, through our national health care system.

When I knew, and this is something I talk about a lot in the book, that I wanted to start a family, it was important for me to move from self-sourcing medication to having it prescribed. It was never something I wanted to do long-term. It was more a stopgap to get my health back enough that I could function at work.

This is something we don’t hear a lot about. There are thyroid patients who are not optimally treated where it impacts their work life, relationships, absolutely everything. Once I was well enough to be able to digest and understand this thyroid research, I could find a private doctor here in the UK to prescribe.

I have been on Armour Thyroid up to seven years. Levothyroxine was added in after my first pregnancy. The Armour Thyroid was no longer optimizing all my levels on its own. My free T3 was great. TSH was fine. But my free T4 was quite low. We tweaked and tried things, and adding that small amount of T4 in is what got me to my happy place, where I am optimally treated now.

Going forward, that has to be closely and consistently checked in with, moderated. Needs can change over time.

Through my first pregnancy, I was just on Armour Thyroid. Textbook pregnancy, very easy, very straightforward, no major issues. Second pregnancy came along. By this point, I was on both Armour and levothyroxine. My levels would drop very quickly. I think it happened three or four times by the time I was six months pregnant. The Armour didn’t need adjusting until I was about seven months pregnant. The levothyroxine was all over the place. That was a lot harder to keep on top of.

For that reason, as well as many of the guidelines I referenced during the book as well, I am a big advocate of women having their thyroid levels tested every 4-6 weeks throughout pregnancy. We all react so differently. Each pregnancy can be individual. Each woman is individual. Each thyroid condition is individual. You never really know how your body is going to react.

I am an example of a woman who had two very different reactions and needs in terms of those thyroid medication adjustments. Obviously, for people who are just on levothyroxine alone, they do often find they need that medication increase almost as soon as they find out they are pregnant. That need increases.

In terms of medication options, I am a big advocate of each person finding what works for them, in their pregnancy as well. You will find more conventional doctors are not as keen on using T3 medications. They will argue that it doesn’t pass through to the baby, that T4 is what’s needed for the baby to grow.

I would argue that T3 is important for Mom to feel well, that Mom also has to have energy, good mental health, and be able to focus and feel well throughout her pregnancy. I am not a fan of the one size fits all that we often see in the thyroid world.

It is worth knowing that you might get pushback from certain doctors if you aren’t someone who does well on levothyroxine. Ultimately, if you feel like you need T3 medication, it’s important to get stabilized on that before falling pregnant. You want to get stable and settled on that before a pregnancy. Once you are pregnant, it’s much less likely that a doctor will suddenly change your thyroid medication.

There are a lot of things to consider. Ultimately, we want to find what works for each person in order for you to feel well and grow a happy, healthy baby and have a happy, healthy pregnancy.

Dr. Eric:

Agreed. When it comes to testing, what do you recommend testing? Just TSH, free T4, free T3? Anything else?

Rachel:

Thyroid antibodies. Being a thyroid advocate for Hashimoto’s and hypothyroidism, there are antibodies. TG and TPO are the two that can be really helpful. Before getting pregnant, checking if you have Hashimoto’s, which over 90% of those with hypothyroidism do. If possible, trying to reduce those thyroid antibodies.

Unfortunately, there is no one magical thing that works for everyone with that. We often have to try different things. Some people are really stubborn. If you’re able to reduce those before you fall pregnant again, that can help with fertility. Monitoring them throughout pregnancy can be helpful. Checking them every month is probably not necessary. A couple times throughout your pregnancy is fine.

What most people find, and I had this as well, is Hashimoto’s and thyroid antibodies often go really low, if not down to zero, when you’re pregnant. There is a change that happens, Th1 to Th2, that happens when you’re pregnant. This often puts a lot of health conditions into remission. They flare back up when you’re post-partum. That’s normal. As I talked about in the book, knowing how to prepare for yourself and not getting angry at your body when that happens. Since it’s expected to happen, knowing what to do is often the best way forward.

Throughout the pregnancy, TSH, free T3, free T4, absolutely should be checked all the way through. Aiming for them to be optimal as opposed to just within range will support your pregnancy as much as possible.

Dr. Eric:

Any reason to look at reverse T3 before or during pregnancy?

Rachel:

I am more mixed on this one. It can be helpful in showing up if there are other stresses going on in the body. When you’re pregnant, I would hope or promote that people do things to keep that low anyway. Pregnancy is a stressor. Seeing that rise throughout pregnancy wouldn’t be surprising.

I like to focus on what we can do instead of the things we can’t control. Anyone who has gone through pregnancy will tell you there is a lot you can’t control. It’s not about wanting to control everything. It’s about understanding what is reasonably in your control that you can do that won’t add further stress at the same time.

Dr. Eric:

Makes sense. With the antibodies, you mentioned that if you can, you want to try to lower and normalize them before pregnancy. As you mentioned, with immune shifts, they might normalize during pregnancy anyway. If someone has elevated TG and/or TPO antibodies and are trying to conceive, even if they are not successful in lowering or normalizing them prior to conceiving, they could still conceive and have a healthy pregnancy, correct?

Rachel:

Yeah. The thing with wanting to lower them is your risks of miscarriage are higher if you have high thyroid antibody levels. I always recommend, if you can give it time, to give it 6-12 months to try to lower them through various things.

We know selenium supplementation can help. Vitamin D has been shown as well. I am not a fan of supplementing with things we don’t necessarily need. We don’t want to give ourselves problems by having really high levels of Vitamin D, for example. That won’t help. If you are doing blood tests and can see there is room to top that up, and we are already low in it, that can help.

In terms of diet, going gluten-free, that reduced my thyroid antibodies. It didn’t even measure past a certain number. It said more than 1,300 for my TPO. I got them all the way down to 40 just by going gluten-free.

Blood sugar balancing. Reducing alcohol. Going dairy-free can help. Gluten is the biggest one. Optimizing your thyroid hormone levels alone can help with thyroid antibody levels. Improving your gut health. Keeping your nervous system and adrenals in check. There are so many things you can try. I often describe it like a big jigsaw puzzle. There are often a few different pieces that we can slot in, and that gives us results.

As I said before, there is no cookie cutter approach of what can help reduce thyroid antibody levels. It’s some sort of trial and error and some digging into what triggered your thyroid condition in the first place. That can often unearth areas we can work on and improve as well. Naturally, when you’re feeling less stressed, those thyroid antibodies tend to drop down anyway.

Look at reducing them before pregnancy. It gives us a better chance of holding onto a pregnancy and falling pregnant in the first place and having that healthier pregnancy throughout those nine months.

We do have to appreciate that a lot of people spend years trying to lower them, and they haven’t found anything that has worked either. Women hear all about this biological clock. As much as I do want to promote that women can also have a career and do other things, that we are not just here to produce children, we do need to be aware of the biological clock if we want to optimize our fertility.

It does drop off from as early as 28 years old. For a lot of people, they are not having children in their 20s, so if they get into their 30s and may want to delay it longer for the sake of trying to reduce thyroid antibody levels, there has to be a balance struck between what is reasonable and when perhaps it is time to go forward and see if it still happens for you.

I talk about this in the book. There is no perfect time. Your thyroid health is just one side of it. There are other parts in your life that you are weighing when it is time to start or expand your family. It’s a really personal decision. We have to figure out what makes the most sense for us.

Dr. Eric:

When trying to prevent miscarriages, having healthy thyroid hormone levels, doing your best to lower thyroid antibodies. Anything else that women can do, like optimizing sex hormones or any other tips you can give to prevent miscarriages from happening?

Rachel:

There is a phrase we hear a lot, estrogen dominance, in our community. Whether that is strictly a health issue within its own right is hotly debated. I was someone who did have high levels of estrogen throughout my cycle when I shouldn’t have. My skin was so oily, my hair was falling out, I had frequent migraines. At the time, I was working with a functional medicine practitioner. Whether people debate that is a real thing or not, what she did with me in terms of improving, it is embarrassing. People don’t talk about it. Things like your gut health, bowel movements, it certainly helped me, and it improved my fertility.

I went from not regularly ovulating. My cycles were 10 days long, then 40 days, then 20 days, all over the place. Working on supporting that natural flow of hormones, where your estrogen is building up for the first half of the cycle, and then progesterone is taking front and center. Working so we are seeing more of that natural shape, the curves we want to see, definitely helped me regulate my cycles.

Instead of focusing on just estrogen or progesterone being a certain number, which is tricky because they fluctuate throughout the month, so it’s hard to know where that should be. Focusing more on having regular healthy menstrual cycles, aiming for that 30-40-day regular cycle, getting to know what is normal for you will reflect what your hormones are doing for you than zoning in on a specific hormone.

When I’d gone from these irregular cycles to seeing them being 28-30 days every month, being able to pinpoint when my body is ovulating, once you understand your cycles, and you can take a basal body temperature reading to help with this, there are many other ways that you can track your cycle. It helps you with your fertility.

People don’t understand that you’re only actually fertile for a few days each month. That alone can help you pinpoint the window that you are going to be fertile that month and hopefully get you on the journey to becoming a parent.

I am hesitant to zone in on specific hormones. Working with a practitioner who knows how to help you get to the point of understanding your cycles and where possible regulating them more and understanding the flow, that can be incredibly helpful. That is where I stand with those things.

Dr. Eric:

I don’t know if you have the answer to this, but are you aware of any research about exposure to endocrine disrupting chemicals? We are exposed to a lot of toxicants and microplastics. I’m sure they affect fertility, but I don’t know if increasing miscarriage rates has been researched.  

Rachel:

Not super specifically. When they talk about endocrine disruptors, that can impact your hormones and your thyroid and cycles. I would suspect there is a link in that way. I think there is. Space to talk about this stuff and give people tips on how to maybe reduce exposure in certain ways. I wouldn’t want people to stress so much that that stress is impacting their fertility or a chance for pregnancy.

There is that balance. I talk about this balance in terms of diet and exercise. You don’t want to ignore that stuff completely, but there is a balance that we want to find where it is helping us instead of hindering us.

Dr. Eric:

Let’s talk more about diet. You mentioned gluten-free. Of course, you want to eat whole, healthy foods as much as you can. There are diets like AIP. A lot of people with autoimmunity follow a carnivore diet. There is debate on how much protein you should have in general. If you could touch upon some of these topics. There is no perfect diet that fits everyone.

Do you recommend a certain amount of protein for women who are pregnant? When it comes to diets, are there concerns about restrictive diets? I recommend AIP a lot. It’s restrictive, but it’s also nutrient-dense. We could make that argument with carnivore. Are there any concerns you have about any of these diets? If you could talk about protein and fat needs for pregnant women.

Rachel:

Like you said, I don’t recommend any one diet for everyone. We have to find what works for us. We react differently to different foods, especially thyroid patients. Gluten, dairy, they are the big ones. Eggs, all grains, soy. That could be anything from a digestive issue to something more subtle, like headaches or fatigue, which could take a while to pinpoint down to food.

When it comes to diets like the AIP diet, you probably have more to say as a practitioner on this than I do. I understand it to be more of a temporary diet that you would do for a certain amount of time to reduce inflammation, to help give the gut time to heal, to get back to a good place, to identify trigger foods. If foods are causing digestive complaints, headaches, skin rashes.

In terms of an example, with AIP, when you’re pregnant, you probably want to be eating a lot of whole foods, a lot of variety. Those sort of restrictive diets would be done before you’re pregnant and/or trying to conceive. I talk in the book about having this 6-12-month period of getting all your ducks in a row, getting your health in as best a place as possible, so you can go into pregnancy with your mind and body prepared for it and with as good a chance as possible of having a positive experience.

With those more restrictive diets, they are not recommended once you become pregnant. By all means, if you do need to do those for a certain amount of time to reduce your thyroid antibodies and give your gut time to heal. Gut health is such a big part of this thyroid jigsaw puzzle for so many of us. That can be helpful.

Fiber and protein needs. I don’t follow a specific amount. Here in the UK, they currently recommend 30g of fiber a day, which I don’t think is that much. When you see it in front of you, there is room to improve that.

When it comes to protein, national recommendations aren’t a thing over here. What I do know, and what a functional medicine practitioner told me years ago, which completely changed my approach to food and feeling satiated, blood sugar balance, when building a plate of food, aim for it to be 1/3 protein, 1/3 carbs, 1/3 healthy fats. If you can increase protein and healthy fats on your plate, great, but do not have more than 1/3 of carbs on your plate as you’re looking at it. That then more or less creates a meal.

You can do it with your snacks as well. If you are going to have an apple, you probably want to have olives or nuts alongside as well. That will give you more energy to keep you going for longer, stay focused, keep the headaches and fatigue at bay. You will hopefully also look after your gut and address things like constipation. You are more likely to have constipation and brain fog and fatigue.

Sometimes, making these principles safe to look at when you’re building a plate of food can be one of the best ways forward. What people who are already tired or brain fogged don’t need are complicated changes to their day to day. I am a big fan of making these really easy to look at and form day to day instead of things being another roadblock. That is my approach to things like protein, healthy fats, and fiber, not just through pregnancy or trying to conceive.

There are some easy dietary changes you can make day to day. We know about reducing ultra processed foods. We know most of us are not eating anywhere near enough fiber. With simple changes like swapping out regular white basmati rice for brown whole grain rice, or the same with pasta. Over here, we have a lot of lentil pasta. Really easy swaps, naturally gluten free for people who can’t have gluten. They can make such a positive impact on your gut health, bowel issues, fatigue, headaches. A big advocate.

We are not drinking enough water for the most part. It’s such a common thing. It’s free. People forget it all the time. It’s one of the biggest ways you can improve your mental focus and energy. People don’t realize how dehydrated they are.

Dr. Eric:

Agreed. What about exercise? Too much, too little during pregnancy when dealing with a thyroid condition?

Rachel:

One thing I learned was to listen to my body to figure out not only what was working and not working throughout each stage of pregnancy but also day to day. Your hormones are fluctuating so much. One week your body will go through a lot of growth to grow the placenta. The baby goes through a rapid period of growth. You’re more tired and hungry. Sometimes, we don’t only need to consider what is working for us in terms of a trimester or pregnancy in general. It can fluctuate day to day.

I would have an aim of going swimming twice a week. I went to a prenatal yoga class once a week. I walked every day. As pregnancy progressed, the walks became shorter and shorter because of pain setting in when you get more pregnant. I used to do salsa dance classes. I couldn’t keep them up because my center of gravity was changing as the belly grows. I almost tumbled and fell over a few times. I had to pause it after pregnancy.

There are things we can do in terms of keeping an eye on day to day. One day, you might be able to go for a 30-minute walk. The next day, you can only manage five minutes. Maybe keeping a log of these things. Is this more of an overall trend? Do I need to get my iron checked? So many people who are pregnant and thyroid patients all have low iron levels, which can make exercise hard. Or is it just my body is doing a lot more growth this week? Am I not sleeping well? Getting to know your body can be so important.

If you’re exercising while pregnant and having heart palpitations, dizziness, back pain, long lasting fatigue, thyroid flares, which is a period of your thyroid symptoms flaring up, those are signs that the current exercise may not be working for you. It could be too strenuous. It could be that you’re doing too much. It could be the time of day. When I was pregnant, I felt best late afternoon, so that was when I would get my exercise in or go swimming. All these things are really important.

As long as you are keeping your body moving throughout pregnancy, that will do so much more for your health rather than writing all exercise off or pushing and doing too much. Yoga, walking, swimming, all of those are perfectly safe for most pregnant people. If you were lifting weights or doing strength training before pregnancy, that is often okay to continue during most of pregnancy.

You are more likely to injure yourself once you’re pregnant because of the hormone relaxing. It relaxes a lot of your body and joints. We have to keep things like that in mind. Ultimately, when your energy is going up and down, you just need to check in and tune in with your own body and listen to what is and isn’t working.

Some exercise is better than nothing. If you’re having a hard day, some simple yoga stretches or a walk around the garden can still be beneficial for your physical and mental health.

Dr. Eric:

You spoke a little bit about the immune system. We chatted about how the antibodies might normalize during pregnancy because of Th1/Th2 balance. Also, a lot of women do experience post-partum thyroiditis. Is there anything women can do not to completely prevent post-partum thyroiditis from developing but minimize it?

Rachel:

In terms of post-partum thyroiditis, it is most often triggered by that immune change, as far as I can understand. Continuing through pregnancy the things that might keep your Hashimoto’s under control if you have been lucky to get to that point can help. Things like learning to regulate our nervous system, looking after our adrenal health, things like that can go quite a long way. Not just for managing or trying to avoid post-partum thyroiditis, but also the thyroid crash that happens when you’re post-partum.

If you have practices in place that help you feel calm and the opposite of fight or flight nailed down pre-pregnancy, hopefully throughout pregnancy, post-partum, those things alone can go a long way to helping you get your health back to a more stable place.

I personally had my functional medicine practitioner on speed dial. When I’m post-partum, my thyroid antibodies will probably go crazy. I imagine things like iron will drop after giving birth. I had all these ideas. My thyroid levels will go up and down. I had her ready to contact.

I was actually pleasantly surprised when I had everything tested six weeks post-partum that everything had settled nicely on its own. It wasn’t until I was six months post-partum that things started to go awry.

When I spoke to her, she said I probably did quite a good job of trying to do things to support keeping my body in a place where it feels safe throughout pregnancy and post-partum. Once that bundle of joy is here, and they are keeping you up throughout the night, and they are screaming during the day, your body turns to what is more familiar. That regulation of feeling like you have things down day to day tends to change. She says she sees it more at that six-month mark.

I had a conversation with Dr. Izabella Wentz about this as well. She said the same thing. It seems really common. I would say it’s helpful to have that plan in mind. What can I do to promote this during pregnancy and post-partum?

If things do go pear-shaped, you can only do so much. Pregnancy and giving birth is such a huge stressor on our body that we have to be kind to ourselves and remember we can only do so much. That’s okay. Give yourself grace. Know what those next steps are going to be. That alone can give your body a lot of comfort and knowing that you have thought ahead, and there is a plan if you need it.

Dr. Eric:

How about supplementation during pregnancy? I assume you recommend a prenatal vitamin. Do you recommend anything else? Does it depend on the person? Are there any essentials for supplementation?  

Rachel:

A good quality multivitamin that delivers all of those key nutrients that your body needs when you are growing a pregnancy, including omega-3 fatty acids and DHEA. They often get missed out. Those are important for mom and baby throughout pregnancy. That is usually where we start.

From there, a lot of people often need extra iron. We don’t want to be supplementing iron if we don’t need it. A lot of people have high levels and don’t have a clue. Throughout pregnancy, you want to be running everything through your providers.

I recommend having more of a health care team throughout pregnancy. You might have a primary care doctor. You might have a functional medicine practitioner, a naturopath, something like that, alongside. Here in the UK, we have midwives as well. It can be helpful to have this team to bounce all of these ideas off of different people who have different inputs and specialties and the ability to test different things.

When you are looking at iron, vitamin D, make sure to test before you take.

Folate. Methyl folate specifically. You want methylated folate because a lot of people don’t do anything with regular folate. Those are important.

It’s more important to be supplementing the right things when you are optimizing your fertility. You don’t want to fall pregnant and realize your iron is quite low. That can take ages to build back up in your blood. That can take months to get to an optimal place.

Things like Vitamin D as well. Zinc. You need healthy iron, Vitamin D, and zinc to have good fertility. This goes for men as well.

In terms of supplementation, I fully recommend people get a full workup when they are thinking about starting a family and improving that before conceiving. When you fall pregnant, it’s about keeping up with what your body really needs.

Testing your thyroid levels throughout pregnancy. Key vitamin levels like Vitamin D, B12, iron, ferritin. That can be checked in probably every few months to keep a close eye on it.

If you are particularly fatigued, check those things sooner. It’s easy for doctors to write off tiredness and brain fog as normal pregnancy symptoms, but it could be low thyroid, low vitamin levels. We benefit a lot from being clued in on this. This is why I want to empower other thyroid patients to know what to ask for, so those things aren’t being missed.

Dr. Eric:

You brought up a few important points. Omega-3 fatty acids. If it’s not in the prenatal, and women are not eating fish on a regular basis, there is a good chance she is not getting enough. You need EPA and DHEA for the brain health of the baby.

You mentioned methylated folate because a lot of these prenatals still have folic acid. That’s important.

Iron, you don’t want to be low on iron. You want to be careful because too much iron can cause oxidative stress.

What you briefly mentioned is the importance of the male. We are focusing on the female during this conversation, but that is another conversation, too. Sometimes, when women have problems conceiving, it’s not always related to the woman. It could be the health of the man.

You want to do everything you can to prepare for a healthy pregnancy on both sides. Eat a healthy diet and optimize nutrients and reduce toxic load. Same thing with the endocrine disrupting chemicals. A lot of what relates to women when preparing for a healthy pregnancy probably also relates to men, too. Would you agree?

Rachel:

Definitely. It’s 50% from both, isn’t it? It’s equally as important. That’s something we are only starting to understand more now. I saw some interesting research that said that conditions such as morning sickness and preeclampsia could be linked to the sperm quality. If you are having a horrible time with morning sickness, you probably need to have a word with your partner about what he did to his sperm.

The omega-3 fatty acids, zinc, especially, really important for sperm quality. And Vitamin D. Here in the UK, it is estimated that as many as 90% of us are low in Vitamin D because we don’t get a lot of sunshine unfortunately. A lot of people don’t have a clue. A lot of people don’t realize.

It’s easy to write tiredness off or feeling like you lack focus and that mental clarity. It’s easy to write that off as having a busy life or not sleeping well or getting older. It’s important to ask these questions and get these things checked out if you are thinking about starting or expanding your family. It is something that can be simply treated that avoids issues and heartbreak further down the line.

I touch on this briefly in the book. It is more from a female point of view. There are things that men can do as well to improve their sperm quality, so we can mitigate any issues that might come from there.

Dr. Eric:

You already sort of answered this question I was going to ask about working with a team. You mentioned your primary but maybe a functional medicine doctor and a midwife. When it comes to women who are thinking about doing a home birth, if they had the right team in place, is that something that is safe to do for someone with hypothyroidism?

Rachel:

The short answer is yes. The longer answer is we are still different. It depends on how your pregnancy is going. When you are pregnant, you will be classified as low risk or high risk for other issues or complications coming up during birth.

For me personally, I chose to give birth at a hospital but in the midwife-led unit. They don’t monitor you with a lot of equipment. It’s monitoring you based on the signs you are giving. It is offering the environment you would have if you were having a home birth but with that added security of knowing there are medical professionals there. There are midwives, not doctors. That is where I felt most calm. If things do take a turn, because we can’t be in control of everything, at least I am next door to the hospital if I need it.

In the same way, being able to be in a room that was dimly lit. We were able to play calming music. We were able to be in control of the environment. I felt that was going to give me the best chance possible of having a straightforward birth that wouldn’t require intervention. If things aren’t progressing well because your oxytocin can’t pick up and keep progressing labor at a different speed. That was important for me.

For other people considering a similar birth, a home birth can be possible. It will depend on your situation. If your doctor classifies you as high risk, because your thyroid condition is hard to stabilize or something comes up in your pregnancy like preeclampsia or someone who can have an issue with their liver, lots of things can crop up. Your doctor might be less comfortable with you giving birth outside a medical setting. Then that will definitely play a part.

Having a thyroid condition doesn’t automatically mean you will have more complications or you are high risk, especially if you are being closely monitored. You are monitoring and optimizing your thyroid levels. As long as all those things are in place, for the vast majority of people, they don’t need an involved birth plan.

Dr. Eric:

We covered a lot. You go into greater detail in your book. For more information, check that out.

Before we wrap up, there are a lot of things I could have asked you. Anything you really wanted to talk about that I didn’t ask you? Any final words of wisdom?

Rachel:

I think we have covered all the key areas. My #1 piece of advice for anyone in their thyroid journey is continue to be your own thyroid health advocate. Continue to ask questions. Learn through resources like this podcast and books. However best it is you can take in that information. Continue to advocate for yourself, and learn what you can ask in the doctor’s office. Learn what you can do yourself.

Whether you are pregnant or way past that stage in your thyroid journey, learning how to advocate for yourself is crucial. It will make the difference between whether you have good quality of life or whether you struggle. Having optimal thyroid treatment and a good set of practitioners, and how active you are in your own health care. That alone is the #1 thing we can do, and that is the key message in everything I do.

Dr. Eric:

Where can people learn more about you, Rachel?

Rachel:

You can find me online under TheInvisibleHypothyroidism.com. That is my blog where I started 11 years ago. I have around 500 articles and blogs on there now, covering all aspects of living with thyroid disease.

I am active on Facebook and Instagram. I have four books on Amazon. My Substack newsletter is something I am really passionate about at the moment. I am continuing to focus on particular topics that I think thyroid patients need to know more about. It’s a weekly roundup. I include thyroid research, developments, interesting podcast episodes that thyroid patients would find interesting. I collate that in a weekly broadcast. I also focus on particular topics, so we can keep learning together.

What is so great about existing in this thyroid sphere is that we are constantly learning more and more stuff. There is always more we can do or share with others. Come and find me. Join the community. We have a lot to learn from one another.

Dr. Eric:

Thanks so much. This was a great conversation. Really appreciate everything you do for women with thyroid conditions. Check out Rachel’s book on pregnancy and her other books as well. Thank you so much for this conversation, Rachel.

Rachel:

Thank you so much for having me.

***

Dr. Eric:

That was an excellent conversation with Rachel Hill, discussing how to have a positive thyroid pregnancy. Preparing for a healthy pregnancy. She definitely goes into greater detail in her book. Of course, you want to eat healthy, reduce stress. You want to take 6-12 months prior to conception to optimize your health, according to her.

Quite frankly, there are things you can’t do during pregnancy, such as detoxify. I would agree that at least six months prior to conception, do what you can to optimize your health. If you aren’t eating healthy, you don’t want to wait until you’re pregnant. You want to try to eat as healthy as you can prior to conceiving.

Same thing with reducing stress, getting sufficient sleep, reducing your toxic burden is huge. Once you’re pregnant, you can’t do things to detoxify. You can do a lot when you’re not pregnant. If you’re drinking water out of plastic bottles now, now is the time to stop, not when you’re pregnant. That could also affect conception and fertility.

She also mentioned the male. The male could also be preparing. I know a lot of men may not want to change their diet and do these other things, like avoiding endocrine disrupting chemicals. All these things can be helpful.

Thyroid medication. She personally took Armour Thyroid. I will talk about antithyroid medication. Preparing for a healthy pregnancy relates to both hyper and hypothyroidism. With thyroid medication, obviously Armour doesn’t relate to hyperthyroidism. I thought it was important to have this conversation because some women are under the impression that they have to take levothyroxine, that it’s not safe to take Armour, NP thyroid.

I can’t give recommendations. I am not recommending for women to switch from Synthroid to Armour. This is ultimately between you and your health care practitioner. My point is if you speak with an endocrinologist, they are probably not going to speak highly about Armour or NP thyroid. You probably will need to speak with another practitioner who is willing to prescribe these.

Antithyroid medication. I am not a huge fan of antithyroid meds, but there is a time and place for them. You want healthy thyroid hormone levels during pregnancy. If you have low thyroid hormone, it makes sense to take thyroid hormone replacement, even if you don’t want to take it. Something you should consider for the health of your baby.

Same thing if you have elevated thyroid hormones. I know you don’t want your baby exposed to PTU, which will be prescribed during the first trimester, not methimazole or carbimazole. In a perfect world, you wouldn’t take it. If you are hyper, especially moderately to severely hyper, you want to do something. Unmanaged hyperthyroidism isn’t a good thing.

Lowering thyroid antibodies prior to conceiving. She mentioned how you want to try to do that. That ties into what I will discuss next, which is preventing miscarriages from occurring.

We also had a conversation about how because of the immune system shifts during pregnancy, the antibodies might normalize during a first trimester because many people with Hashimoto’s are what’s called Th1 dominant. Many people with Graves’ are Th2 dominant. A lot of times, you get the switch from Th1 to Th2 dominant during the first trimester.

If someone has Hashimoto’s, the immune system will calm down, and the antibodies may lower or normalize as a result. With Graves’, sometimes the opposite happens, where things flare up. It’s not perfect. Some people with Hashimoto’s may flare, and some people with Graves’, it may calm down. There is still a lot we don’t know.

When it comes to preventing miscarriages, having healthy thyroid hormones is important. Healthy thyroid hormone is more important for conceiving in the first place. Not to say that it can’t play a role in having a miscarriage, but she did mention the antibodies. I have seen this, too, not just with Hashimoto’s antibodies, but Graves’ antibodies, having elevated TSIs doesn’t mean you will get a miscarriage, but it increases the risk. You could still have a healthy pregnancy with elevated thyroid antibodies, but there is an increased risk factor.

She spoke about estrogen dominance. Keep in mind that estrogen dominance doesn’t just mean high estrogen. It could mean low progesterone. That is a big reason for miscarriages, women having low progesterone. When we think of low progesterone, one reason is adrenals. You need healthy adrenals to have healthy progesterone.

There are also the endocrine disrupting chemicals that I mentioned and other toxins and toxicants. You can’t avoid everything, but when it comes to cleaners, cosmetics in your home, you could use as many natural cleaners and cosmetics. Drinking water out of plastic bottles, if you are doing that, if you are buying plastic water bottles by the case, I definitely would recommend taking a break from those. Ideally, a permanent break, at least on a day in, day out basis. Definitely could affect fertility and potentially can play a role with miscarriage.

As we discussed, neither one of us has done the research. I don’t know what research is out there when it comes to endocrine disrupting chemicals and miscarriages. It wouldn’t be a surprise if that could be a possible factor.

Preventing post-partum thyroiditis. There is no perfect thing you can do. One thing is at least according to the research, supplementing with selenium. I think it’s 200mcg. I am not sure. I’d have to double check. You also want to be careful because you may have selenium in your prenatal. Usually, it’s not a lot. You might have 50mcg. If you supplement with 200mcg, that is 250mcg. You do want to be careful about selenium toxicity.

I have another episode where I spoke about this. I think I interviewed someone a few years ago. It might have been Dr. Betty Murray who brought this up, too. She spoke about post-partum thyroiditis. Selenium could potentially prevent that from happening.

We also spoke about diet during pregnancy, like AIP, carnivore. It sounded like she recommended following these diets prior to getting pregnant. You may be restricting too many foods. If you are eating a wide variety of meat and vegetables and fruits, it’s not like you need to eat grains and legumes. Eggs are nutrient dense. It’s nice if you like eggs and could eat eggs. They are nutrient dense, extra source of protein. Maybe follow a paleo type diet.

If you are carnivore, you are not having plant-based foods. If you are getting a lot of nutrients through meat and animal-based protein, you don’t have to eat veggies and fruits. Another reason why you should speak with a practitioner.

Supplements during pregnancy. Definitely want to make sure you are getting enough omegas and natural folate like methyl folate, not synthetic folate. You want to test for iron and Vitamin D.

We didn’t mention iodine. I can’t believe I forgot to ask her about iodine in a multivitamin. My perspective is you want to make sure you have enough iodine. You don’t want to take separate iodine supplements, but iodine is important for the health of the baby. Most prenatals will have iodine though. I am not saying to take extra iodine. I don’t think there is a prenatal out there that doesn’t have iodine; that is because it is important. If there is a prenatal without iodine, I am not sure if I would recommend taking that one. It is up to you. You don’t want to be iodine deficient. Especially if you have hyperthyroidism, even if you have Hashimoto’s, there is concerns with iodine. Prenatal, definitely take one with iodine.

In general, talking about hyperthyroidism and pregnancy. Like I said, there is a lot of overlap. The difference is the symptom management aspect between hyperthyroidism and hypothyroidism. If your thyroid hormone levels are low, you might want to consider thyroid hormone replacement for the sake of the baby.

With hyperthyroidism, if you have elevated thyroid hormone, that is not good. You are not really supposed to take bugleweed or higher doses of L-carnitine. Unfortunately, I don’t have a perfect solution when it comes to the symptom management aspect of hyperthyroidism.

When it comes to Graves’ and Hashimoto’s and pregnancy, you will still do things to find and remove triggers and support the gut. But there are restrictions. You might not be able to do everything you can while pregnant that you can when you’re not, like certain herbs.

Really important topic. I think I covered this a number of years ago in a solo episode, but I wanted to get someone who is more of an expert than myself, so I did. Rachel wrote a book on pregnancy. Definitely check it out if you are thinking about conceiving or are currently pregnant.

Thanks again for tuning in. Hope you found this episode to be valuable. Look forward to catching you in the next one.