Adrienne Clamp, MD: I often consider the adrenal status to begin. The role of suboptimal adrenal function is not very well addressed or recognized. It can wreak havoc and undermine health and wellness if not addressed. When thyroid function appears to be normal and still someone suffers with all the symptoms of hypothyroidism, often adrenal hypofunction is to blame. Diagnosis can be suggested by the history of recent or prolonged stress, or recurrent bouts of serious illness. It is best confirmed by measurement of cortisol levels throughout the day and evening.
The adrenal gland may be overreacting or underfunctioning and testing of the pattern of cortisol secretion helps to sort this out. I moat often do this by having the patient collect salivary cortisol levels at several times during a typical day. Measurement of the other hormones made by the adrenal gland such as DHEA sulfate and aldosterone is also helpful.
Treatment of the adrenal gland dysfunction depends on the pattern. I usually turn to herbal adaptogens first, as well as recommending work on stress reduction by means such as meditation, relaxation, learning different coping mechanisms and psychological counseling, among others. Sometimes hormone replacement is needed and in extreme cases of hypofunction, even low doses of cortisol, though this is typically only after trying the other approaches.
In the case of sex hormone status, I use blood, urine and salivary testing, depending upon the presentation of the patient and whether I am trying to diagnose deficiency, excess or imbalance. I prescribe compounded bioidentical hormone replacement. Using nonbioidentical hormones is like forcing a key that does not fit a lock into it and expecting smooth operation of the lock. I do not think it works well.
There are a variety of ways to address hormonal imbalances. You can pick the most glaring imbalance and work at that first, or you can try to address all imbalances at once. Most commonly, I assess thyroid and adrenal function first -- and often together -- unless a sex hormone imbalance is obvious. For instance, correcting thyroid imbalance will often relieve symptoms of PMS and menstrual irregularity without needing to use progesterone. However, if PMS is present in isolation, without evidence of thyroid dysfunction, then going right to progesterone is often the preferred approach. All that being said, I think I really try to address each person as an individual and not use a "shotgun" or "cookbook" approach.
Mary Shomon:Can you give a quick overview of some of the ways you believe in treating adrenals?
Adrienne Clamp, MD: In cases of excess, I use herbal adrenal adaptogens and lifestyle modifications, as well as phosphatidyl serine, to calm an overactive adrenal response. In the case of hypofunction, I first attempt treatment with adaptogens and if there is positional hypotension (low blood pressure), licorice root. If this doesn't yield good results, I use low dose natural cortisol (hydrocortisone) which may take the pressure off of the adrenal gland and give it some time to recover its function. Cortisol, however is not a benign drug and can have side effects. I usually reserve it for more resistant cases. I also use unrefined Celtic Sea Salt in some cases, especially those with hypotension. Adrenal glandular preparations can also be helpful, though I use them less often -- more from a lack of experience in using them than from a belief that they are not helpful.
Mary Shomon: Can you give a quick overview of some of the ways you believe in treating thyroid conditions?
Adrienne Clamp, MD: I think it is important to use the preparation that the patient feels best on. That being said, I usually begin with natural desiccated thyroid because it most closely mimics the normal thyroid gland. If this is not what the patient feels best on or has objections (for example, those who keep Kosher, or who are vegetarians -- since natural desiccated thyroid is a pork derived product) I use synthetic T4 and T3 alone or in combination. Often compounded T3 is a useful adjunct to T4 when quick-release (manufactured) T3 is not well tolerated or needs to be dosed multiple times a day.
I myself feel best on a combination of natural desiccated thyroid and compounded slow release T3. I do have some patients on T3 alone, but that is more unusual. Again, everyone is different and it often takes some experimentation to find the agent or combination of agents that gives the best result.
Mary Shomon: As a physician with a thyroid condition yourself, what do you think is especially misunderstood about what thyroid patients go through?
Adrienne Clamp, MD: I think that often patients are not taken seriously when they express how poorly they feel. One of the most common things I see is treatment of fatigue and weight gain as laziness and dietary overindulgence on the part of the patient. This is insensitive and not helpful. Patients would not come to a physician if it were that simple.
In my experience, most thyroid patients have a very difficult time being taken seriously if their "numbers" are normal. They are often offered antidepressants and psychotherapy when what they need is optimization of their thyroid hormone levels. When people feel better, they are able to exercise. When they are fatigued, exercise if a difficult task and often makes their fatigue worse.
I have seen many patients who have been told that how they feel is just part of getting older and they should just accept it. I do not think that aging has to be equivalent to feeling poorly. Depression is often a result of just not feeling well, not a neurotransmitter defect. These are a few of the many things I think that hypothyroid patients hear all the time that are simply the result of suboptimal thyroid function.