INTEGRATIVETHYROIDTESTING

Y O U R G U I D E T O

Jean Martain BHSc Nat ATMS The Natural Thyroid Clinic

THE HOLISTIC APPROACH

All rights reserved - copyright of The Natural Thyroid Clinic April 2019

Table of contents 1. Introduction 2. Thyroid blood markers 3. Autoimmune antibodies & inflammatory markers 4. Additional hormone panels 5. Infection screening 6. Thyroid nutrients 7. Additional testing 8. Bibliography

IntroductionThis guide will empower you with the information you need to understand which tests your practitioner may request in order to monitor the progress of your integrative and holistic thyroid treatment. We will look at various functional and pathology tests so you can gain insight into which tests may be useful for general monitoring and which tests you may need to ensure you are addressing underlying triggers and root causes of autoimmune thyroid disease. Some of the tests reviewed in this guide won't be relevant to you as every case of hashimoto's thyroiditis is different. Testing is a crucial first step on your road to recovery to identify your individual triggers. We recommend working with your naturopath to help prioritise which tests may be the most relevant to your individual health case. Standard pathology tests are generally available via medicare with your general practitioner or endocrinologist however many of the functional tests are not medicare rebatable. Your naturopath will help you prioritise which tests are the most relevant to try to limit out of pocket expense. This guide is intended for educational purposes only and is not intended as personal health advice or to be substituted for personal health advice. You should only take medicines including nutritional supplements and herbal medicines as prescribed by a qualified practitioner who has assessed your individual health case.

Thyroid blood markers

Hashimoto’s thyroiditis generally takes some years to progress and can be asymptomatic for a long period of time. It is common for the disease process to have been present for some years before symptoms and diagnosis occur. The main blood test your doctor will order is TSH (thyroid stimulating hormone). This is a measure of how much thyroid hormone your body needs. For example if you have insufficient thyroid hormone the stimulating hormone will be high and if you have too much thyroid hormone the stimulating hormone will be low. This is based on a complex feedback system between the pituitary and the thyroid. The TSH is an accurate measure of your body's need for thyroid hormone over the last month. Thyroid hormone levels provide further insight into how much hormone is available in the body. Thyroid hormones to test: • TSH (Thyroid stimulating hormone) • Free T3 (active thyroid hormone) • Free T4 (inactive thyroid hormone) • Reverse T3 (inactive thyroid hormone) Ratios: Ratio of T4:T3 should ideally be 4:1 T3:Rt3 <10 or FT3:RT3 < 0.2 = may indicate cellular hypothyroidism

- Anti-thyroid peroxidase antibodies (anti-TPO abs) - Anti-thyroglobulin antibodies (anti-TGabs) - Thyroid receptor antibodies (TRabs) - Antinuclear antibodies (ANA) - general autoimmune screen - Coeliac serology (must be measured while still consuming gluten in the diet) Anti-thyroid peroxidase antibodies are the most commonly found antibodies to be elevated in hashimoto's thyroiditis which leads to hypothyroidism. Anti-thyroglobulin antibodies may also be raised. Thyroid receptor antibodies are elevated in graves disease leading to hyperthyroidism. Coeliac disease is commonly associated with hashimoto's and must be excluded in all hashimoto's sufferes. It is essential to measure thyroid antibodies to identify if your thyroid symptoms are due to a dysregulation of the immune system. Measuring TSH and thyroid hormones alone is problematic as autoimmune antibodies can be elevated for many years before hormone levels are affected and symptoms occur. If you have thyroid symptoms and or a family history of autoimmune diseases (eg. lupus, celiac disease, rheumatoid arthritis, graves disease) or particularly thyroid disease then it is CRUCIAL to test your thyroid antibodies.

Autoimmune Antibodies

If you have elevated antibodies or are diagnosed with autoimmune thyroid disease we recommended to test your antibodies regularly to monitor the levels. This will give you insight into how effective your diet, lifestyle, natural medicines and thyroxine are. It is normal to have flares and periods of remission over the course of your journey and understanding what triggers or exacerbates your symptoms are key to controlling the inflammation. You may notice periods of both hyper and hypo thyroid and it's best to manage the dose of your thyroxine with an endocrinologist. Inflammatory markers: • C-Reactive protein (CRP) • Erythrocyte sedimentation rate (ESR) Inflammation is associated with autoimmune disease and the above markers can give an indication of the level of inflammation.

Your practitioner may consider additional hormone testing particularly if you also have PCOS (polycystic ovarian syndrome) or irregular periods: • Oestrogen • Progesterone • Testosterone • SHBG (sex hormone binding globulin) • LH (lutenising hormone) • FSH (follicle stimulating hormone) • DHEA (dehydroepiandrosterone) • Salivary Cortisol (stress hormone) • Fasting Insulin (checks for insulin resistance) • HbA1c (blood sugar handling over the last 3 months) All of the hormones are connected in the body and work together in synergy. The sex hormones are best measured between days 2-5 of your menstrual bleed if you are a female. If you have irregular periods take the test at any time of the month.

Additional hormone panels

Infection screen: • HSV 1,2 (herpes, cold sores) • EBV SEROLOGY IgG and IgM (glandular fever) • Varicella zoster (Chicken pox, shingles) • Hepatitis C - Viral Hepatitis C Antibody Screen • Helicobacter pylori urease breath test • Stool PCR (tests for parasites) • Urine culture (if urinary tract infection) • Respiratory PCR (if respiratory tract infections) • Functional gut testing (bacteria, parasites, fungus, viruses, inflammatory markers) Screening for infections is one of the most critical factors on your thyroid journey. Many of the infections listed above have been associated with triggering molecular mimicry in autoimmune disease (eg. the body thinks that the infection looks the same as thyroid tissue and begins to attack the thyroid)! Knowing if you have an underlying infection enables you to tailor your treatment to remove it so that the immune system can restore balance. Some of these tests are available on medicare and some are not. It's best to discuss which tests are useful for your particular presentation with your naturopath, doctor and endocrinologist.

Infection screening

Nutrients: • Urinary Iodine (must be the first void of the day) • Vitamin D (immune modulator) • Iron studies (crucial for energy and carrying oxygen in the body) • Red cell selenium (essential for conversion of thyroid hormones) • Plasma zinc (involved in thyroid hormone metabolism, gut health, mood and immune health) • Red cell folate and active B12 (cofactors for mood and healthy DNA repair, methylation, energy production) • Elevated CoQ10? (this can't be used in the mitochondria if insufficient T3, this can indicate cellular hypothyroidism even if your FT3 is "normal") • Organic acids (meaures metabolites of nutrients) • Lipid studies (thyroid hormone regulates LDL receptors, hypothyroid = less receptor numbers and activity leading to less clearance of LDL) Ensure you do not take nutritional supplements for 3 days prior to testing for a more accurate measure. If you are taking thyroxine you should continue to take your medication as you normally would. Thyroid testing is best done at the same time of day for progress monitoring as thyroid hormones vary over the day with diurnal rhythms.

Thyroid nutrients

Other tests: • Homocysteine (elevated in hypothyroidism, B6, folate and B12 deficiency, MTHFR polymorphisms, lead toxicity) • Thyroid ultrasound (gives us insight into the chronicity and function of the gland itself, also identifies the presence of nodules) • Kidney and liver function (e-GFR, creatinine, electrolytes, LFT) • Heavy metals (known to disturb thyroid function and irritate the immune system, best done as a hair mineral analysis to identify metals stored in body tissues which reflects cumulative exposure levels rather than current exposure) • Creatine kinase (marker for muscle inflammation and found to be elevated in hypothyroidism)

Additional testing

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Bibliography continued Ventura, M., Melo, M., & Carrilho, F. (2017). Selenium and thyroid disease: From pathophysiology to treatment. International Journal of Endocrinology, 2017. https://doi.org/10.1155/2017/1297658 Natural Thyroid Masterclass – Health Masters Live Brenta G - Why Can Insulin Resistance Be a Natural Consequence of Thyroid Dysfunction? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175696 /pdf/JTR2011-152850.pdf Holtorf K - Peripheral thyroid hormone conversion and its impact on TSH and metabolic activity http://docserver.ingentaconnect.com/deliver/connect/aarm/21657971 /v3n1/s3.pdf?expires=1517652902&id=0000&titleid=72010396& checksum=C8B4962225B5367F8EE2781AD2440707 Hoshiro M - Comprehensive study of urinary cortisol metabolites in hyperthyroid and hypothyroid patients (Abstract) https://www.ncbi.nlm.nih.gov/pubmed/16402926 Ichikawa Y - Altered equilibrium between cortisol and cortisone in plasma in thyroid dysfunction and inflammatory diseases (Abstract) http://www.metabolismjournal.com/article/0026-0495(77)90016- 6/abstract

Bibliography continued Iranmanesh A - Dynamics of 24-hour endogenous cortisol secretion and clearance in primary hypothyroidism assessed before and after partial thyroid hormone replacement https://www.researchgate.net /profile/Michael_Johnson53/publication /20862211_Dynamics_of_24Hour_Endogenous_Cortisol_Secretion_ and_Clearance_in_Primary_Hypothyroidism_Assessed_before_and_ after_Partial_Thyroid_Hormone_Replacement/links /0deec534d8dffc378f000000.pdf Somppi TL - Non-Thyroidal Illness Syndrome in Patients Exposed to Indoor Air Dampness Microbiota Treated Successfully with Triiodothyronine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5545575/pdf/fimmu- 08-00919.pdf Taniyama M - Urinary cortisol metabolites in the assessment of peripheral thyroid hormone action: application for diagnosis of resistance to thyroid hormone (Abstract) https://www.ncbi.nlm.nih.gov/pubmed/8257864 deLuis DA - Helicobacter pylori infection is markedly increased in patients with autoimmune atrophic thyroiditis (Abstract) https://www.ncbi.nlm.nih.gov/pubmed/9649006 Di Crescenzo V - Human herpes virus associated with Hashimoto's thyroiditis (Abstract) https://www.ncbi.nlm.nih.gov/pubmed/24008857 Fallahi P - The role of human parvovirus B19 and hepatitis C virus in the development of thyroid disorders (Abstract) https://www.ncbi.nlm.nih.gov/pubmed/27220938

Bibliography continued Thomas D - Herpes virus antibodies seroprevalence in children with autoimmune thyroid disease (Abstract) https://www.ncbi.nlm.nih.gov/pubmed/18473192 The Natural Autoimmune Masterclass – Health Masters Live Clinical Diagnostics 2 Immunology and Autoimmunity -Mediherb Hypothyroidism in Natural Medicine: Under-Recognised or Over- Treated? – Metagenics Lab tests online https://www.labtestsonline.org.au/