How It Started:

by | Aug 5, 2023 | Thyroid and Hormone Balance

                    Dr Kunz’s approach to Thyroid and Bio-Identical Hormone Balance

For patients interested in Dr Kunz’s approach to this much-misunderstood medical problem, the sections that follow could be helpful. (a brief note: anything stated below as being related to thyroid dysfunction or deficiency applies equally to sex hormone endocrine dysfunction, specifically to testosterone deficiency) Read on.

“Wasn’t a box made that could keep me in it”

This pretty well sums up my philosophy of medicine, or, for that matter, life and thinking in general. This attitude has infused my approach to approaching and treating patients for the last forty-plus years.

I’ll start with a disclaimer and a few words about expertise and qualifications. In this world of conflicting opinions and information overload, we all tend to rely upon the “expert.” Academic institutions bestow degrees and credentials so that a careful and responsible user, buyer, customer, consumer, or patient may know whom to trust for sound, tested, scientifically reviewed opinions and advice.  The medical world has many levels of such credentialing, beyond a basic medical degree. Among them is the Board Certified Medical Specialty of Endocrinology, the diagnosis and treatment of disorders of the glands and hormones of the body.

Although I am a Medical Doctor, Board Certified in Family Medicine, I am not an endocrinologist. My credentials in this area consist not in certification by a recognized medical specialty group, but only in my over 40 years of medical practice, listening intently to the issues of my patients, and having an intense curiosity that has forced me to learn every day newer and better ways to help those who enter my door.

Perhaps not being an endocrinologist has been an advantage. Not being constrained by the standards and restrictions of a particular specialty, I have been able to think and work “outside the box” and to see things that others do not. At least I hope so.

The Ignored Patient

“I’m sick and tired of being sick and tired…” This is the worn-out refrain of miserable patients that every primary care doctor dreads to hear. This complaint is frequently accompanied by a long litany of other mental and physical symptoms. The doctor looks for a place to hide!

“I’ve been to several doctors over the years,” these patients say to me. “ I have told them my story. They have all checked my thyroid with a “TSH test” and said I absolutely did not suffer from low thyroid. They gave me Prozac.”  I have to confess I was one of those doctors for many years. And it wasn’t that I wasn’t paying attention. It wasn’t that I was not trying to help. I most certainly was trying. But according to my training, and from the point of view of the overwhelming majority of doctors who have learned thyroid diagnosis and treatment the traditional way, I was doing the right thing.

After all, what would you do for a patient (usually, but not always, a woman… and, by the way, this is not a sexist remark… women just have much more complex hormonal systems than men) with a laundry list of symptoms concerning nearly every system of the body? Take them by the hand and say, in the most consoling manner, “There, there?” 

Believe me, I have spent over forty years listening to the tearful frustration of hundreds (nay, thousands) of patients who were subjected to condescending platitudes, upward rolling of the doctors’ eyes accompanied by deep sighs and fidgeting, followed by hasty diagnoses, futile treatments, or extensive, expensive, even invasive and risky diagnostic ordeals.

Until the last thirty years, I, too, may have been guilty of the futile treatment or unnecessary diagnostics part.  It is a daunting list of symptoms, after all. A doctor only has three choices: 1) embark on an endless wild goose chase of various diagnostic tests to track down those symptoms that seem most important or, 2) chalk all those varied symptoms up to stress and prescribe – you guessed it – Prozac (or some related drug) or, 3) punt – tell the patient you can’t help and send her away. What are those symptoms that drive patients (and doctors) to distraction?

Here is a rather comprehensive list, organized by system. In The Thyroid Protocol, anyone scoring fifteen or more (each symptom counting “one point”), regardless of other known causes of specific individual symptoms, is more than likely in need of more thyroid hormone. (I’ll explain my logic behind this at the end of this section). 

CONSTITUTIONAL — fatigue (especially excessive drowsiness and extreme need for afternoon or evening nap), weight gain or inability to lose weight, or, conversely, inability to gain weight, inability to increase strength or muscle mass with exercise, or excessively slow recovery from exercise or stress, “tired and wired” syndrome (especially in the afternoons and leading to the evenings – i.e., too tired to function, too wired to rest), awakening in the morning without feeling rested or recovered, temperature intolerance (especially to cold, but sometimes to heat or changes in temperature), fluid retention (especially puffiness in face and under eyes, swelling of feet and lower legs) 

MENTAL/EMOTIONAL — “brain fog” (such as, the inability to hold a phone number in your head, or do simple math comparing prices in the grocery store isle), depression, anxiety, inability to focus/poor concentration (a lot like Attention Deficit Disorder), mood swings

NEUROLOGICAL — headaches (tension or migraine), carpal tunnel syndrome  GASTROINTESTINAL — constipation, bloating, gas, indigestion, heartburn, sluggish bowels, food cravings (especially carbs/sweets/starches) 

CARDIOVASCULAR  — high blood pressure, high cholesterol, palpitations (sudden surges in heart rate or irregularities of rhythm) 

SKIN/HAIR — excessively dry skin (especially shins, forearms, knees, elbows), hair loss or thinning, dry brittle hair, inability to perspire, thin, bendable, or splitting fingernails that do not grow well (in fact, if nails improve on thyroid therapy this is nearly diagnostic of the body’s need for thyroid), thinning of outer half of eyebrows, premature graying of hair 

ENDOCRINE/REPRODUCTIVE— irregular or heavy menstrual cycles, shortened cycles with increased flow, infertility, loss of libido, increased incidence or severity of endometriosis, PMS, galactorrhea (inappropriate discharge of milk from the breasts), symptoms of early menopause, fibrocystic breasts 

ALLERGY/IMMUNITY— increased frequency of colds, chronic nasal congestion, sinus infections, hay fever symptoms, increased frequency of bladder infections, interstitial cystitis 

MUSCULO-SKELETAL— joint stiffness and pain, muscle soreness or stiffness. 

Special mention must be made of FAMILY HISTORY. In adding up the “symptom score”, if a parent or sibling has been diagnosed with a low thyroid condition, this counts as two points! Low thyroid is strongly hereditary.  Why do these symptoms add up to a high probability of low thyroid, when there are dozens of other medical problems that can contribute to this list? The logic is simply this: while there are, indeed, many causes of each or several of the symptoms listed above, to my knowledge – and I have asked this question almost daily for the last three decades – there is one and only one diagnosis that can contribute to every item on this list.

That diagnosis is  HYPOTHYROIDISM.  Therefore, would it not be logical at least to try to treat the one disease that can negatively impact everything on the above list? It’s simple logic that is not routinely followed by medical doctors. The pressure to ignore the obvious is great.  So why has this problem and those who suffer from it been ignored? The answer lies in the history of medical education and the development of knowledge regarding diagnosis and treatment of thyroid disorders (more on this later). But the cynical answer is money.

Hypothyroidism is not a “big money” disease. Unlike heart disease, diabetes, COPD and lung disorders, breast cancer, etc., hypothyroidism is not filling up Emergency Departments and ICU’s with sick and dying people. It’s not stoking research budgets of universities and medical centers with government, charity, and pharmaceutical dollars. It’s not the topic of funding drives, public awareness campaigns, or media events. It’s not generating an impetus for the development of new and more sophisticated technologies or drugs. 

No, hypothyroidism is just a disease that annoys internists, gyns, and family doctors with the endless and unsolvable problems and symptoms of a bunch of complaining women – okay, and a few men. Furthermore, the diagnosis and treatment of hypothyroidism has long been settled in the minds of Western traditional doctors. And the solution cheap and generic, not likely to generate big profits for anyone: thyroid hormone therapy in the form of levothyroxine (T4), triiodothyronine (T3), natural desiccated thyroid, or compounded thyroid preparations.

 In defense of my colleagues, the cardinal rule of medical care is: “First, do no harm.” The fear of “overtreating” hypothyroidism is instilled in every medical student from the time of his first introduction to endocrinology to his every clinical rotation in medicine. We will cover this next. 

The Invisible Epidemic

I really didn’t write this piece to add anything new to the discussion. It’s just a “how I do it” guide for my patients. To get more information on hypothyroidism therapy outside the mainstream of medical orthodoxy, look no further than your local big box book retailer. Go to the medical section. Then go to the area concerned with thyroid.  You will be amazed. There will be five to ten different books covering most of the aspects of thyroid therapy I am outlining in this article. Most of them are written by non-endocrinologists like me or even some educated non-medical doctors. It is a hot topic. 

Thyroid forums and discussion groups populate the internet, frequented by those whose lives are being changed by thyroid therapy, or those who are frustrated by lack of help from the medical community. One such forum in my area seems to be sending a steady stream of patients to me. I appreciate the business but there’s not enough of me to go around.  Personally, and professionally, I believe that hypothyroidism is the number one under- and mis-diagnosed condition in America. I have personally begun thyroid therapy on around four thousand patients in the last 25 years. I currently have over 1500 still under my care for this condition.

What about the other 2500, you say? Well, some have moved, some were helped by thyroid for a while and then no longer needed it (I’ll discuss the once-on-thyroid-always-on-thyroid myth later), and some were not helped or needed to be treated for another problem. To be perfectly honest, thyroid therapy alone helps two out of three patients who come to me with that long symptom list. And for one out of three it’s a “hey-Baby-where-have-you-been-all-my-life” reaction.  I’ll take that track record any day for a group of people that had no hope before.

 So, what’s going on? Why is there so much apparent hypothyroidism among people who are running around with normal TSH levels? There are several theories, none of which will gather the research funding to test any time soon – I refer you to my previous explanation of this situation. Here are a few of my favorites:

Fluoridated water. This is an interesting theory. Fluorine, like its halogen brothers, chlorine, iodine, and bromine is a very strong ionic atom that binds ferociously to, well, anything. Could it be that for many people fluorine replaces iodine in a significant proportion of the body’s thyroid hormone (T “4” and T “3” mean, four or three iodine atoms in the thyroid hormone molecule)? Theoretically, this could cut down the effectiveness of thyroid hormone while still fooling the body into thinking it has enough. Chlorinated water may have the same effect. Don’t get all conspiratorial on me. Fluoride probably cuts down on cavities and chlorine definitely kills bad germs. It’s just a theory that’ll never get investigated – mainstream medicine will have to recognize that there’s a thyroid problem first. 

Genetic predisposition toward “down-regulation” of thyroid metabolism under starvation and deprivation conditions might offer another explanation. This would be an example of a physiological adaptive response inherited from northern European ancestors who were able to survive long cold winters with less food. Certain genetic types automatically reduce their thyroid metabolic rate under stressful situations. This would obviously be a survival advantage if the caribou herds don’t show up on schedule. In today’s society caloric deprivation is rare, but the body could react this way to stress of any kind. 

Bromine in flour. Most commercial flour has potassium bromide added to improve storage and baking characteristics. Same problem as fluorine.

Thyroid resistance theory. This is my personal favorite. We know that Type II Diabetes is a problem of insulin resistance, that is, the body no longer responds to the glucose-lowering effects of insulin. It seems to me that a similar phenomenon is happening with thyroid hormone. It has to do with some type of blocking or inactivation of thyroid hormone at its site of action, the thyroid receptors. 

Receptors to thyroid hormone, like three dimensional switches (think: Fairy Tale Castle, and the oddly shaped crystal key that fits into the secret slot in the stone dungeon wall that opens the secret escape passage), are found in every cell of the body. In fact, they are found in nearly every organelle (the inner parts of cells) of cells in every organ and tissue. Among these organelles are the mitochondria (the energy packs of the cells) and the ribosomes (the protein manufacturing plants). The ubiquitous action of thyroid hormone at these sites explains why deficiency of thyroid activity has such diverse effects. 

I say “deficiency of thyroid activity” rather than “lack of thyroid”, because, as I pointed out before, most sufferers have a “normal” TSH. This means the body’s own feedback mechanism seems to be saying that there is (or ought to be) enough thyroid hormone around to do the job. But there’s not. I’ll explain this feedback mechanism in a later section, “The Endocrine Symphony.” 

Why Thyroid Therapy Is Considered “WRONG”

In the medical world, we like to make a big deal of “evidence-based” medicine. That is, traditionally trained university-bred doctors hold fast to the ethic that all of our opinions and decisions about medical diagnosis and treatment should have a solid basis in scientific evidence. This evidence should be systematically obtained (most preferably by a university-sponsored, placebo-controlled, randomized, double-blind study with a very large number of subjects) and scrupulously documented. It must then be accepted and published in a peer-reviewed mainstream medical journal. Then, and only then, does this data become “EVIDENCE”.

Significant institutional, peer, legal, and economic pressures are exerted on physicians to rely only on evidence-based medicine for clinical decision-making; the major criterion for all physician reimbursement schemes is the presence or absence of academic evidence to support any particular therapy.  Responsible practice and professionalism are laudable goals. But there are other types of data that carry weight along with “evidence-based” medicine, namely, years of experience and personal observation. 

Over a hundred years ago the medical profession was figuring out what the thyroid gland does for the body. They figured it out mostly by seeing what happened to a body when the thyroid was removed (as the great surgeons of Central Europe did in the 19th century to save iodine-deficient patients from suffocation by enlarging goiters).  Thyroidectomy patients eventually died of myxedema, a condition characterized by massive swelling and weight gain with congestive heart failure. This occurred until doctors learned to treat thyroidectomy patients with bovine (cow) thyroid gland. This was later replaced by desiccated porcine thyroid (the forerunner of today’s Armour Thyroid, derived from pork). 

It was found that thyroid fixed everything! Heart disease was attributed to low thyroid, it having already been noted that the coronary vessels of those who died of congestive heart failure from lack of thyroid were clogged with cholesterol.

Low thyroid was recognized as a cause of mental illness; it became common practice a hundred years ago for patients committed to mental institutions with severe melancholia (depression) to be placed on thyroid.  The practice of using thyroid freely for a host of conditions continued up until the latter half of the twentieth century until more modern laboratory testing, specifically the “TSH” test, became the preferred manner by which a doctor could determine whether or not a patient had enough thyroid hormone.

Thyroid was used for fatigue, depression, “the blues”, as an aid for weight loss, for aches and pains, general malaise, and so on. Doctors relied on clinical experience to determine a patient’s need for the hormone and used it freely, sometimes too freely. 

As should be expected, the adverse effects of excess thyroid use were becoming apparent, from nervousness to excessive weight loss, to racing heart and cardiac irregularities, to thinning of the bones. The academic (not to mention legal) pressure to treat medical problems “scientifically” rather than by clinical judgment was great. This academic pressure was aided, in no small part, by the pharmaceutical industry’s push to have its synthetically created levothyroxine (T4) established as the standard of care for thyroid replacement. 

Let me now state that the reason you will hear that it is considered wrong, even malpractice, to give thyroid hormone to someone who has a normal “TSH” (and is therefore “euthyroid”) is that thyroid therapy is believed to be fraught with peril and best left up to the experts.

Two main issues constitute the major pushback I receive from other doctors and prospective patients.  The first is that thyroid therapy thins the bones. All established and accepted research has settled this issue in the minds of every doctor. It has reached the level of unquestioned dogma in the medical community that thyroid therapy is a cause of premature osteoporosis.

The second is that excess thyroid is dangerous to the heart, causing tachycardia (rapid heart rate), palpitations, atrial fibrillation (a potentially dangerous rapid, irregular heart rate pattern), cardiomyopathy (a thickening and damage of the heart muscle), and even sudden cardiac death.  For anyone acquainted with the history of science, questioning of long-established “facts” ought to be the norm rather than the exception.

Regarding thyroid therapy’s thinning of the bones, let me say three things: First, there is little doubt that for persons who are “thyro-toxic” from long-standing Grave’s Disease or other form of symptomatic hyperthyroidism have bone loss. And for a large number of post-menopausal women with other independent risk factors for osteoporosis, being on thyroid therapy is associated with a well-documented risk of loss of bone mass.

Second, (and to the opposite point) this cannot explain the half dozen or more patients I inherited from an older internist (now deceased) from downtown Atlanta over twenty years ago, post-menopausal women in their fifties and sixties who were treated to thyroid levels up to four times the upper range of normal. Some of these women were treated for up to fifteen years.

All of these women felt well. They all had bone density levels – I checked them myself – in the 99th percentile. And, third, I have checked serial bone densities in hundreds of women on thyroid therapy over the last twenty years (especially those whose thyroid levels are maintained at a “higher than acceptable” range). I have yet to see the first one whose bone density dropped significantly. Most did not drop or got better. The very few that did drop did no more than would be expected of any woman of similar age and hormonal status.

Regarding cardiac arrhythmias and heart damage, it is a well-known fact that among patients presenting to the emergency department with atrial fibrillation and other tachy-arrythmias (fast heart rate), hyperthyroidism is the leading cause. One cannot, however, logically infer the opposite, as most doctors do, that just because a patient fits a laboratory definition of hyperthyroidism or “thyro-toxicosis”, cardiac arrhythmias will necessarily follow.  In fact, a more common observation in my practice is that patients who come in with a plethora of hypothyroid symptoms also count palpitations and episodes of racing heart among them. When placed on the appropriate dose of thyroid hormone, these palpitation episodes cease (more on this later).

Let me say here that thyroid therapy will slightly increase the baseline resting heart rate, and I am careful to point out that if the thyroid dose is actually too high, constant rapid pulse, usually in upper 80’s and higher, will be an unmistakable sign. The solution is simple. Decrease the dose. 

Other physicians have shuddered in fear as I have explained my protocol, which often includes increasing thyroid doses to levels unimaginable by their training and experience. What if I get the dose too high and the patient does experience thyroid side effects? I remind them of their own experience dealing with someone who presented with Grave’s disease or thyroid storm or some other hyper-thyroid condition. They have all seen patients who present with thyroid levels many times the normal range, suffering from all the classic symptoms of thyrotoxicosis. They all agreed that, when the condition was treated properly and resolved, i.e., thyroid levels were reduced, their patients did just fine.

So then, if severe and sometimes long-standing thyroid toxicity can be resolved without complications, why not transient, mild excess thyroid?  I have never, in fact, pushed a thyroid dose to anything approximating the level that most internists and family physicians have seen occurring spontaneously in their own practices.

In standard parlance, to be “toxic” from anything, means to be suffering adverse effects. By this definition, the person who gets tipsy from one drink is toxic, while the one who downs three and feels nothing is not. Undoubtedly, the sensitive one will have a low blood level and the other one a “toxic” level. Which one was suffering from toxicity?

This constitutes the crux of why doctors will not treat hypothyroidism. In the medical community, thyrotoxicosis is defined by a lab value of TSH below the accepted range (usually around 0.4). Time after time I have seen patients who have come to me after starting thyroid therapy in the standard way – they had hypothyroid symptoms and their TSH was “high”. In the course of adjusting their dose upward they reached a point where they felt good again, only to have their doctor reduce the dose because their TSH had gotten too low.

The doctor was happy because he had now properly treated the low thyroid condition to normalize the TSH. The patient was miserable because they did not feel normal.  Contemporary western-trained doctors have all been indoctrinated with a basic principle during their medical school and residency training years. That principle is: “Treat the patient, not the lab.” In other words, when your clinical evaluation of the patient himself runs counter to the findings of the laboratory, and some type of therapy is warranted, follow clinical judgment, not lab numbers. In general we do this very well… except where it comes to hypothyroidism.

The Thyroid Protocol

I myself have decided to treat the patient. I have a few thousand who thank me for that. But it will only take one who has a bad outcome and some well-meaning family member or other doctor sees “high thyroid” numbers and attributes it to my therapy to cause major trouble. With the weight of medical history against us, and the lack of current research for us (more on this in “The Protocol” section), thyroid therapy practitioners such as myself do take some risk.  It’s a risk I, personally, am happy to take.

When a prospective thyroid patient comes to my office, the first order of business is to take a complete medical, surgical, and family history. The patient completes a checklist (in previous section) of symptoms that can possibly be attributed to low thyroid, and barring any other obvious medical condition that demands priority over thyroid dysfunction, treatment is often begun on the first visit. Certain baseline examinations and tests are performed and followed at systematic intervals. These include:

  • Height, weight, pulse rate, and blood pressure.
  • Body fat/muscle composition (optional)
  • Examination of the thyroid itself (size, texture, nodules, masses, etc.)
  • Heart exam (especially rate and rhythm)
  • Reflexes (some practitioners have placed great value on specific reflex testing as a means of assessing thyroid activity)
  • EKG
  • Blood work: CBC, complete metolic profile, ultra-sensitive TSH, free T4, free T3, thyroid antibodies (TPO, anti-thyroglobulin), cortisol, Vit B12, Vit D, ferritin, Hgb A1C, basic lipid panel. A complete sex hormone panel including testosterone (total), FSH/LH, estradiol, progesterone. Where indicated, auto-immune and inflammatory studies (ANA, sed rate, C-reactive protein, etc.) are performed. Every one to two years in those with documented borderline or low bone density a dexa scan may also be performed. Starting thyroid hormone is relatively simple. Synthroid (or other T4/levo-thyroxine equivalent such as Levoxyl, Unithroid, or generic T4) is started at the lowest available dose (25mcg daily) and increased every two weeks up to 50 mcg and finally 75 mcg daily.

At this time, (from six to 10 weeks after initiation of treatment) the patient returns to the office for follow-up. Response to therapy is assessed (decreased “brain fog”?, increased energy?, improved sleep?, decreased need for afternoon nap?, improvement in constipation?, etc.). Presence or absence of adverse reactions is also determined (fast heart rate? , tremor?, excess “heat”?, etc).  Depending upon initial response, we make the decision either to increase T4 dose, maintain the 75 mcg dose, or stop therapy. The last option happens only rarely, since the overwhelming majority of patients have either had some positive result, or no change at all. In either of the latter two cases, the dose of T4 is increased, generally to 100-125 mcg in most cases, where peak effectiveness usually occurs. Special note at tbis point: since the first writing of this article I have almost exclusively shifted thyroid therapy over to the “natural” forms of thyroid derived from pork… see below).

Two obvious questions should naturally occur at this point: 1) how do you know when the thyroid dose is high enough for best results, and 2) what do you do if you get some results, but this is not enough, or there are enough negative results to require consideration of another type of therapy? 

The blunt and simplistic answer to the first question is that you increase the T4 dose until one of two things happens, either the low thyroid symptoms disappear, or symptoms of too much thyroid begin to occur (tremor, heat, constant rapid heart rate). This, or course, is too simple, but it is generally still true. It is safe to increase the thyroid dose gradually to a rather high level, sometimes as much as 300 mcg.

We do not use TSH levels to dictate the upper end of thyroid dose. Likewise, we will not necessarily seek to reduce the thyroid dose if either free T3 or free T4 levels are “above normal range”. On the contrary, it is symptoms of hyper-thyroidism that are the signal that thyroid doses should be reduced. Unlike other medications whose adverse effects on the body can happen quietly and dangerously, high thyroid levels make their presence known more or less obviously. The solution? Just cut the dose back.

The patient is the first to know when they’ve got too much. It’s no secret. As for worries about doing harm (this is the objection of most physicians who are uncomfortable with higher thyroid doses), I remind my fellow family doctors and internists of all the thyro-toxic patients they have seen who had thyroid levels many times higher than the “normal” range, often for quite a long time.

After medical (or surgical) treatment, these patients do very well without long term harm.  The answer to .the second question is more difficult, and will be addressed in the next section. But, briefly, it is appropriate to mention here that not all patients respond well to T4 preparations, though their bodies clearly require some thyroid help. These are patients who do well with the T3 form of thyroid hormone. T3 is given either in the form of T3 (triiodothyronine), or one of the natural porcine (pork) forms of thyroid gland extract, Armour Thyroid, Nature-throid, NP Thyroid.

The Physician’s Desk Reference states that forms of natural thyroid have roughly a 4:1 ratio of T4 measured in micrograms to T3.Thus, a 1-grain (60 mg) Armour Thyroid has approximately 37 mcg of thyroxine and 9 mcg of T3. I have found over the years that whenever I have measured T4 and T3 levels in patients changed over to natural thyroid, it seems that only (or mainly) the T3 levels have risen. So, for all practical purposes I use natural thyroid preparations quite often when I’m really mostly interested in just changing T3 levels.)

By the time a patient has reached an appropriate level of thyroid supplementation, they have had at least two rounds of blood work, one at the beginning, and a second at between 8 and 16 weeks of therapy. Other conditions have been excluded such as iron deficiency, B12 deficiency, anemia, blood, kidney or liver disease, diabetes and other metabolic conditions.

From here on out one need only be vigilant for changes in patient energy and general health. Annual thyroid levels, periodic bone density evaluations for women, and routine blood work for cholesterol and usual health maintenance testing will suffice. 

A final word about long term maintenance is in order here. Almost everyone acquainted with hypothyroidism has heard the phrase, “once on thyroid, always on thyroid”. Generally, this means that if one gives a relatively high dose of thyroid, and especially if TSH levels are suppressed, the thyroid gland will become inactive and atrophied, unable to work.

I once thought this was true, but over the last twenty-plus years many patients who needed and responded well to thyroid supplementation have come off treatment (intentionally, and unintentionally) and done fine. To those physicians who disagree that this is possible I usually pose one simple question: “How often have you seen patients who are newly presented to your office who inform you on their “new patient history” questionnaire that they used to be on thyroid therapy?” There are actually quite a few of these.

The explanations are limited… either they didn’t need thyroid therapy in the first place, or the thyroid got well.

Beyond Thyroid – The Endocrine Symphony

What if the patient has a partial, varied, or unsatisfactory result to therapy with thyroid alone? This is where things get complicated and finding the right formula for each individual can be extremely difficult. But all is not hopeless. The budding field of “Integrative Medicine” has much to say about the interactions of the energy-modulating glands of the body (the endocrine system), how they affect one another, how they depend on one another, and how adverse or beneficial changes to one can precipitate improvement in or even stress in another. 

The endocrine glands consist, strictly speaking, of those organs in the body that secrete their hormones directly into the bloodstream to modulate, in a general sense, certain aspects of the body’s energy. The thyroid, with which we’ve been concerned thus far, is for reasons explained previously, the gland with the most important and global energy function in the body. It is charged with providing the “baseline” steady-state energy key to every cell in the body at all times in every stage of development, growth, and ongoing metabolic function.

This property of the thyroid accounts for the almost endless list of symptoms that can be blamed on decrease in thyroid activity. There is little or no cycling of thyroid activity except perhaps some seasonal variation or general increase or decrease of activity in response to chronic or acute stress or lack thereof. 

The next gland(s) that contribute to energy modulation in the body are the adrenal glands. Adrenal glands have a twenty-four-hour day-night cycle. Secretion of cortisol, a well-known stress and energy modulating hormone, peaks in the morning, usually around 8 a.m., and slowly decreases throughout the day until nighttime.

Cortisol levels will rise temporarily during acute stress or injury, and may, during periods of prolonged physical or mental duress, fall out of their normal diurnal pattern. We should include epinephrine (or adrenaline) in the topic of stress, as most people are well aware of this hormone during the panic of “fight or flight” syndrome. Corticosterone and aldosterone and other adrenal hormones help regulate salt and water balance in the body.

Loss of the normal pattern of morning cortisol peak, or inappropriate surges at night or later in the day are signs of adrenal stress, and the topic of many books and articles that are beyond the scope of this paper. 

The sex glands (ovaries in women, testes in men) are also important energy modulators of the endocrine system. In this case the primary function is sex differentiation and reproductive energy. Normally, the female contribution to this energy pattern runs (on average) in 28-day cycles, the predominant hormones being estrogen and progesterone. For men, no cycle occurs, as men and women will universally confirm… testosterone is usually just on.

This brings up an important difference in the frequency with which women seek help for thyroid deficiency as opposed to men. In my experience the ratio of women to men is around 20:1. The persistence of testosterone in much higher levels in the man, its lack of a cycle, and its powerful over all energy –inducing effects explain the relatively reduced impact that thyroid insufficiency has on men. This fact as well as men’s general overall reticence regarding their health that (as opposed to women) keeps them out of the doctor’s office!

We should also include the beta cells of the pancreas in this endocrine list. As the primary modulators of glucose levels, energy storage and release in the bloodstream and in the cells, this powerful hormone plays a minute-to-minute role in the regulation of the body’s energy. While we must include this as a part of the list, we rarely deal with it directly or primarily, except where the patient is diabetic, pre-diabetic, obese, or suffers from hypoglycemia.

The Endocrine Symphony

Taken together, all these hormones and the glands that produce them comprise the instruments of what I call “The Endocrine Symphony”. The analogy has been an important one in my patients’ understanding of their own bodies and the interaction between the sections of the symphony. Each human being is designed to play his own composition. The thyroid sets the undertones, the rhythm, rate, and base of the music. The adrenals come in and out on their 24 hour cycles (and emergency appearances as needed). The ovaries play a complicated 28-day accompaniment.

The conductor of this whole orchestra is the pituitary gland, telling each section to act by sending out “stimulating hormones” at the appointed moments in the musical piece: TSH, already mentioned – thyroid stimulating hormone, FSH – follicle (ovarian) stimulating hormone and LH – luteinizing hormone (triggering ovulation), ACTH – adrenocorticotropic (stimulating) hormone.

The composer of this symphony is the hypothalamus, who sends each bar of the sheet music up to the conductor as he listens to the last one. Perhaps this is carrying the orchestra analogy too far, but it works.

Now, suppose that a large part of one of the sections of the symphony calls in sick one day; the show must go on but most of the string section are out with the boogie woogie flu. The clever conductor instructs several of the brass section and the woodwind section to pick up the string part. Well, Beethoven’s fifth won’t sound, quite right today… but it will be recognizable.

This is how the human body, in all its marvelous intricate design, compensates for low thyroid (or low anything for that matter). If the thyroid is under-functioning, the adrenals work harder. If the adrenals become stressed, hormonal building blocks are shunted away from ovarian hormonal production. Look in any on-line reference material like Wikipedia and search “steroid synthesis pathway” and you will see that adrenal and ovarian hormones are produced along the same physiological “factory line”. When the adrenals take more of the “raw materials” away from the flow, ovaries suffer.

This one illustration alone explains a great deal of the reason why women under stress (or with thyroid insufficiency) experience menstrual irregularities and other female hormone-related problems.  Sometimes in the thyroid protocol it becomes necessary to assess other hormonal function, such as female (or male) hormone levels, or cortisol levels (best done with 24-hr saliva samples to assess the diurnal rhythm). The patient is instructed in proper nutrition and given recommendations for over the counter vitamins and supplements such as iron, certain B vitamins, anti-oxidants like selenium, hormonal precursors like DHEA, progesterone cream, or pregnenolone, natural ingredients with some hormonal effect like angelica (dong quai), Mexican wild yam, black cohosh, ginseng, licorice root, and ginger. Small doses of topical hormone such as bio-identical estrogen, progesterone, testosterone, or small physiologic doses of cortisol may be given. (Now my focus has shifted to an emphasis on the role of testosterone and implanted pellet therapy has become the method of choice. See below)

Complex adjustments of adrenal function using natural and complementary methods is the domain of Integrative Medicine, a complicated and ever-expanding discipline.  I have personally not sought formal certification in Integrative Medicine, but have kept abreast of studies in this area for over twenty years. I frequently seek advice from other clinicians whose entire practices are comprised of this type of care. Most of these doctors are out of the mainstream, that is to say, they are not on insurance plans. Therefore their services are on a cash-pay basis and often out of the range of most patients.

I have chosen to stay within the system, practicing mainstream traditional medicine while devoting a significant portion of my practice to Integrative and Alternative studies. In this way I have continually served as a bridge between health care methods that would otherwise often be at odds with each other (take, for example, mainstream medicine and chiropractic or naturopathy). Lest we be tempted to think that only the university-trained MD or DO has the corner on healing expertise, let me give just one example:

Forty years ago or more, the natural practitioners and herbalists were touting the importance of the digestive tract to the health of the entire body. They were promoting yogurt, foods, and acidophilus milk that would help to bolster the normal good bacteria in the gut. It has only been in the last few that mainstream science (and Madison Avenue marketing) have jumped on the probiotics bandwagon, thank you Jamie Lee Curtis and Activia! 

You see, mainstream medicine is not an exact science. And while it has the benefit of a vast scientific and academic establishment and wields enormous financial and political power, it often overlooks the profound insights of individuals whose experience and knowledge suggest a better way to prevent, diagnose, or cure a disease. And, unfortunately, the pharmaco-FDA-academic complex tends to downplay or even ignore good information that might generate a different form of treatment and thus competition for profitable brands.  I wore a button on my medical school lab coat. I still believe what it said:  “minds are like parachutes… they only function when open.”


As of July, 2015, I have become a participant in the bio-TE program. Briefly, this is a proven system of bio-identical testosterone pellet implants for men and testosterone/estradiol implants for women. As I have stated in the Thyroid Protocol, the endocrine system is like a symphony orchestra, all sections playing their various parts. The bio-TE method provides for safe and effective balancing of the endocrine system. Along with thyroid (or, in many cases, without it) it completes the picture for helping patients to achieve optimal wellness and vitality. (If this sounds like an advertisement, my sincerest apologies… It’s only that I have observed patients for over forty years and felt their frustration of being “sick and tired of being sick and tired”. I’m in this business because I want to help people and I have forty-plus years of caring, experience, and extensive research to prove it). Despite the negative hype, the adverse effects of hormone replacement and balancing therapy are grossly overstated. The benefits of bio-identical hormone therapy via implanted sustained release pellets (particularly testosterone) are overwhelming and worldwide experience and research over the last forty years bears this out. Please consider if thyroid and bio-TE therapy are a fit for what’s missing in your pursuit of healthier living!