This is the third post on women and hypothyroidism. If you like, start with the first post.
Hopefully you read the last post on Nutrition for your Thyroid. This is Step One, for all types of hypothyroidism.
Thyroid hormone conversion deficits
Here I focus on a functional type of hypothyroidism: T4 to T3 conversion deficits. This happens in peripheral tissues, organs, and cells.
With conversion deficiencies, your thyroid gland is often functional. It has the necessary ingredients to produce T4. The problem is that your T4 is not properly converted into active/free T3, which is what your peripheral tissues and cells use. You need enzymes for this conversion, called the deoidinase enzymes. I briefly describe the function of these enzymes, for those of you who like to know the physiology. If your eyes glaze over, skip to the next section.
Your deoidinase enzymes
There are three of them:
Deiodinase Type 1 (D1)
This enzyme converts T4 into T3 throughout your whole body, except for your pituitary gland.
Deiodinase Type 2 (D2)
D2 converts T4 into active T3 only in your pituitary gland. It’s about 1,000 times more efficient than D1. This means that 80-90% of T4 in your pituitary gland gets converted to active T3, but in your tissues and cells it’s only 40-50%.
Deiodinase Type 3 (D3)
D3 converts T4 into inactive (junk) reverse T3 (rT3). RT3 takes up receptor sites for active T3. In other words, it blocks active T3. D3 competes with D1. This is why we measure rT3.
There is no D3 in your pituitary gland. This is yet another reason why T3 levels are higher in your pituitary. Since the signals to make thyroid hormone (TSH) come from your pituitary, TSH can be normal according to your pituitary gland, but not an accurate marker for whole body hypothyroidism.
Why is it important to assess conversion deficits?
If you are hypothyroid because of a conversion problem, then T4 hormone replacement medication may not be appropriate. You may be a cases for a T3-only approach, while you address underlying causes of your conversion problem. Hormone replacement may not be necessary, or be temporary. If there’s nothing wrong with your thyroid gland, then it is completely possible to not be on thyroid hormone replacement permanently. (It is possible to have conversion deficits and Hashimoto’s, and these cases are more complex).
How do you determine if you have conversion deficits?
- You have hypothyroid symptoms.
- Your labs fit one of the following scenarios.
- You have one or more of the conditions listed further down.
Conversion deficit labs look like this:
- TSH levels can be normal or elevated.
- T4 levels are typically fine.
- Free/active T3 levels can be low, or normal.
- Reverse T3 (rT3) levels may be high.
- The ratio between free T3 and rT3 may be low (under 20).
- Often all thyroid labs are normal!
Since your labs can be normal, we need to pay close attention to your symptoms. We need to consider the following conditions, and evaluate if tissue hypothyroid, undetected by labs, is present.
When your D-enzymes are out of whack and cause cellular hypothyroidsim
When D1 is blocked, D3 is increased, and D2 is up-regulated, it’s the perfect storm for tissue hypothyroidism. In Functional Medicine, we find which of these factors is the cause, and work to resolve it. We don’t just offer thyroid hormones and call it a day.
Chronic stress raises your cortisol. Elevated cortisol lowers active T3. Chronically elevated cortisol disrupts your brain-adrenal communication, otherwise known as your HPA axis.
A Functional Medicine approach: Test adrenal hormones and metabolites with the Dutch Adrenal Test, and tailor treatment according to exactly how and when your cortisol is disrupted. Learn to reduce stress, your perceptions of stress, and how to sleep well, which are all imperative to treating HPA dysfunction.*
Many depressed and bipolar patients have thyroid dysfunction as a contributor to their depression. In this study, T3 therapy was more effective than 14 other medications to treat bipolar disorder, and the same was found in the STAR*D Report for depression.
A Functional Medicine approach: Other than supporting T3, we find sources of neuro-inflammation that cause or contribute to depression. We examine your gut function: leaky gut, food intolerance, and gut microbiota. Your gut-brain relationship is vital!*
Pain disrupts D1 and D2, and causes tissue and cellular hypothyroidism. These pain specialists understand this and recommend T3 supplementation to patients with significant pain.
Functional Medicine approach: Find your sources of pain, and treat. We use safe pain treatment and anti-inflammatories.*
Reduced Calorie Dieting
Acute or chronic dieting lowers your cellular T3 levels by up to 50%. This reduces your basal metabolic rate (number of calories burned per day) by 15-40%. After chronic dieting, your thyroid levels and metabolism often do not return to normal levels. Your body can stay in starvation mode for years, making it very difficult to lose weight, or maintain lost weight.
A Functional Medicine approach: First evaluate and treat your insulin resistance, blood sugar imbalances, and leptin resistance. Then lose weight without severe calorie restriction. Next, improve your mitochondrial function in order to burn calories more efficiently.*
Insulin resistance/diabetes/metabolic syndrome/obesity
Insulin resistance, diabetes, and metabolic syndrome reduce T4 to T3 conversion. These are cases in which T4 supplementation alone may not be effective. T3 alone could help.
A Functional Medicine approach: Support T3 only, and treat your insulin resistance with an appropriate diet and exercise approach for you. Improve your carbohydrate and fat metabolism, mitochondrial function, and gut microbiota.*
Leptin regulates your weight and metabolism. You secrete leptin when you gain weight, to signal your brain (hypothalamus) that you have enough energy (fat) stores. Your hypothalamus should then reduce your hunger, increase your satiety, boost your resting metabolism, and increase fat breakdown. Research shows that leptin signaling is dysfunctional in the majority of women who can’t lose weight.
The majority of overweight women are able to produce leptin; however, they have leptin resistance. Your brain senses leptin resistance as starvation, and causes you to increase fat stores, rather than burn excess fat. Leptin resistance results in low cellular T3.
A Functional Medicine approach: Restore your homeostatic and hedonistic metabolic set points. Explore low-carb or temporary ketogenic diets, and ketone supplements. Reduce your rT3 levels. Improve your gut microbiota.*
Women who perform excessive exercise, especially while dieting, have reduced T4 to T3 conversion, and increased rT3, which counteracts the positive effects of exercise.
A Functional Medicine approach: Alter exercise to strength-training, fat-burning approaches, or burst / interval training. Limit sustained aerobic exercise. Avoid excess calorie reduction.
Iron deficiency can reduce T4 to T3 conversion, increase reverse T3 levels, and block the metabolism boosting properties of thyroid hormone. Low iron (iron saturation below 25, or ferritin below 70), can result in low cellular T3 levels.
A Functional Medicine approach: Test iron markers and B vitamins. Supplement absorbable iron and increase iron rich foods. Increase B vitamins if needed. Take vitamin C or eat vitamin C rich foods with iron. Check for small intestine bacterial and yeast overgrowth, which can sequester iron.*
Inflammation decreases D1 activity, and reduces tissue T3 levels. This includes inflammation from physical or emotional stress, obesity, diabetes, depression, menopause, heart disease, autoimmune disease, injury, chronic infections, and cancer.
A Functional Medicine approach: Find sources of inflammation (including stress and dietary sources, as well as gut infections). Treat the sources, and use effective, natural anti-inflammatories.*
A Functional Medicine approach Test toxins and metals, and your detoxification ability. Design a detoxification program for you. Restore your phase 1, 2, and 3 detoxification pathways.*
The bottom line on T4 – T3 conversion
Conversion deficits are not always easy to assess, evaluate, and treat. However; this kind of detective work is what we Functional Medicine hormone specialists are familiar with. In summary, if you have hypothyroid symptoms, and you have one or more of the above conditions, get an assessment for conversion deficits. You may take T3 hormone, or supplements that support T3, while addressing the underlying causes for conversion problems.
*Please know that these Functional Medicine approaches are suggestions, and that in clinical situations, patients may be more complex and may need a more complex approach.