The Thyroid: Testing and Treatment with Emma Sutherland and Dr. Miranda Myles

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The Thyroid: Testing and Treatment with Emma Sutherland and Dr. Miranda Myles

In this week’s timely podcast, Dr. Miranda Myles and our ambassador Emma Sutherland delve into the world of thyroid, liver and metabolic health as they discuss how to support clients experiencing metabolic imbalance. Dr. Miranda shares her clinical experience in identifying thyroid imbalances and how to determine what pathology tests are required and when, and importantly, how to interpret them in support of a client’s presentation. Emma and Dr. Miranda also cover differential diagnoses associated with metabolic health including the impact of stress, cortisol, iron deficiency and adrenalin. 

This podcast is content-heavy and definitely one you will want to take notes on to make sure that you can apply as much to practice as possible. 

Covered in this episode

[00:32] Welcoming Dr. Miranda Myles
[01:30] The role of the thyroid
[03:55] Nutrients required for thyroid hormone metabolism
[09:04] The actions of T3 and T4
[10:20] The clinical relevance of reverse T3
[14:13] Elevated reverse T3 could indicate a liver problem
[15:47] Treatments for reducing elevated reverse T3
[17:27] Reverse T3 case study
[20:53] Optimal results from a full thyroid blood panel 
[27:46] Symptom picture of subclinical hypothyroid
[30:14] Is tracking basal body temperature a good indication of thyroid issues?
[33:46] Connections between gluten and elevated thyroid antibodies
[39:39] Environmental toxins and thyroid dysfunction
[44:32] Building a successful practice
[46:13] Thanking Miranda and closing remarks


Key takeaways 

  • Thyroid function disorders are the second most common endocrine condition in women of reproductive age. 
  • The thyroid modulates the body’s metabolic rate, or basal metabolism.  
  • For optimal thyroid function, nutritional adequacy in iodine, vitamin A, vitamin D, selenium, iron, tyrosine and zinc is essential.  
  • Iron deficiency symptoms can mimic hypothyroidism and should not be overlooked. 
  • Increased production of reverse T3 may be associated with increased cortisol, adrenaline, and iron deficiency, and may present as hypothyroidism or subclinical hypothyroidism. 
  • Basal body temperature measurements each morning below 36.3 degree celsius may suggest hypothyroidism and would warrant further pathology tests. 
  • Gluten consumption has been associated with an increase in thyroid cell destruction as gliadin protein is similar to transglutaminase, an enzyme found in the thyroid that can lead to autoimmune destruction of thyroid tissue. Gluten consumption has also been associated with inflammatory response and intestinal hyperpermeability, increasing the risk of an autoimmune response.  

Resources discussed in this episode

Dr. Miranda Myles and the Fertile Project
The Australian Thyroid Foundation
Australian Government Department of Health: Thyroid Dysfunction
Study: The Diagnosis and Management of Thyroid Nodules: A Review (Durante, et al., 2018)
Study: Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline (De Groot, et al., 2012)
Study: Efficacy of artichoke leaf extract in non-alcoholic fatty liver disease: A pilot double-blind randomized controlled trial (Panahi, et al, 2018)
Study: The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto's Thyroiditis: A Pilot Study (Krysiak, Szkróbka, & Okopień, 2019)
Study: Relationship between Urinary Phthalate and Bisphenol A Concentrations and Serum Thyroid Measures in U.S. Adults and Adolescents from the National Health and Nutrition Examination Survey (NHANES) 2007–2008 (Meeker & Ferguson, 2011)
Study: Endocrine disruptors and thyroid autoimmunity (Benvenga, et al., 2020)

Transcript

Emma: Hi, and welcome to FX Medicine where we bring you the latest in evidence-based integrative, functional, and complementary medicine. I'm Emma Sutherland, and joining us on the line today is naturopath and acupuncturist Miranda Myles

Miranda is the principal practitioner and owner of the Fertile Project, an integrative and functional-medicine practice combining acupuncture, naturopathy and TCM under one roof. Miranda also has extensive experience treating a wide range of hormonal issues and conditions, including thyroid health, which is what we're going to dive into today. 

Welcome to FX Medicine, Miranda, thank you so much for joining us.

Miranda: It's an absolute pleasure, Emma. We have been trying to get this together for quite a while. So, it's a delight to finally be here.

Emma: It is, yes.

Miranda: Yes, great.

Emma: Yeah. Now, worldwide, thyroid disorders affect 10 times more women than men, which I find astounding, and thyroid dysfunction is the second most common endocrine condition that affects women of reproductive age. And according to a paper on clinical practice guidelines from the Endocrine Society, thyroid antibodies are present in 5% to 15% of women of child-bearing age. And as clinicians, we tend to see, I feel, quite a lot of subclinical thyroid disorders. 

So, today, I want to really delve into what testing we should be doing, what impacts the conversion of T4 to T3, the clinical relevance of reverse T3, and so many other thyroid factors. 

Now, Miranda, you have such extensive clinical experience in this area. I wanted to start with some basic pathophysiology. Now, what is the role of the thyroid, can you explain to us?

Miranda: Really really simply, the thyroid gland produces thyroid hormones that are involved in regulating the body's metabolic rate. So, we think about your basal metabolism, but from a practical perspective, it's actually far far deeper than that. It's involved in controlling our hearts, our musculoskeletal system, our digestive system, bone maintenance, and, really really important, brain development. 

So, when we're talking from a fertility perspective and during pregnancy, in the baby's first trimester, the baby relies solely on maternal thyroid hormones for its growth and development. Right? So, the baby's own thyroid doesn't plan to kick in until 12-weeks gestation. So, it's so so important that women have their thyroid sorted prior to pregnancy. And as you said, 10% to 15% of women in reproductive years and 1 in 5 women will develop thyroiditis during pregnancy. Yeah.

Emma: Yeah, there're really high statistics. And as clinicians, I think that's why we just see this so frequently. 

Miranda: Yes.

Emma: But can you let us know what nutrients are involved in that thyroid hormone metabolism? Because we're going to do a lot of deep diving today but I want to just sort of set the scene with some basics.

Miranda: Yeah. So, it's quite a complex process, right? So, the first thing that happens is that the thyroid gland traps iodide, right, the iodide ion, and it actively transports the iodide from the blood into the cytosol. And the thyroid gland contains most of the body's iodide. 

At the same time that that's going on, the Golgi apparatus are making this thyroglobulin, which is a long protein chain of lots and lots and lots of amino acids. And one of the main amino acids within that is tyrosine. Okay? So, we've got iodide that's been trapped and we've got tyrosine that's attached to this thyroglobulin molecule.

Then what happens is the iodide can't actually bind to the tyrosine in that form, it needs to be iodinized basically. So, it gets converted from iodide into iodine, okay? And the nutrient that does that is iron, okay? So, so far, we've got tyrosine, we've got iodide or iodine, and we've got iron. 

Emma: Yes.

Miranda: And so, that iron changes the iodide into iodine, so, it's an oxidation process that's done by a peroxidase enzyme. And then the iodine is able to attach to the tyrosine molecules on the thyroglobulin chain, okay? So what we’re...

Emma: It's like a symphony, isn't it? It's like a dance, all of these little steps that build up. But one of the first thoughts that came to my mind was, “Boy, I know a lot of iron-deficient women.” So...

Miranda: Exactly. And I think that's one thing that is really really commonly missed in clinical practice, the connection between iron and thyroid. And, of course, some of the symptoms of iron deficiency is fatigue, shortness of breath, cold sensitivity, cold hands and feet, and they are exactly the same clinical deficiency symptoms of thyroid issues. So, I really do believe that's one of those things that is missed clinically, the importance of that iron in being able to convert that iodide to iodine so that we can make the thyroid hormones in the first place.

Emma: Yeah, I think that is such a great clinical pearl to take on board today. Amazing, yeah.

Miranda: And then it even keeps going after that because then, of course, what we're making is we're making T4. So, basically, that process makes T1 and T2 and then T1 and T2 join together to make T3. And then two T2s join together to make T4, so, that's where we get T3 and T4, right? 

And then basically, of our total thyroid hormone pool, we make anywhere between 80% to 93% of our thyroid hormones as T4. And that's basically inactive. 

Emma: Right. 

Miranda: And then we make around 7% to 20% as active T3. Then we need to convert the T4 to the T3, and we need selenium for that process and we need zinc for that process. Then we need to be able to transport the thyroid hormones around the body and we need another protein transporter called transthyretin, which is vitamin A dependent.

So, and then vitamin A also affects our thyroid-hormone receptors on our cells, as does vitamin D. So, it's more than just iodine, which I mean everyone sort of thinks the thyroid, "Oh, let's make sure we've got a whole heap of iodine going in," but it's so much deeper than that. And quite frankly, I would not prescribe high-dose iodine without having some sort of clinical relevance and clinical reason for doing that. Yeah, because we can, obviously, cause problems with that.

Emma: Yeah, and I think, yeah, we could dive into the iodine story down the track as well. But I would agree, high-dose iodine is a big no for me as well. 

But I love that description that we need the iron to convert the iodide into iodine, that selenium and zinc are required for the conversion of T4 to T3 and the transport is vitamin-A-dependent. It just shows us how much is involved in this thyroid picture. And it's not as simple as it looks.

Miranda: Absolutely.

Emma: What about the role of T4 and T3, and then thyroid antibodies and, of course, the reverse T3? What are the actual roles of those in metabolism or in the body?

Miranda: Well, yeah, so, as I basically said, T4, it's effectively inactive but we need to have that really good T4 thyroid hormone pool so that it can convert to the active T3. And then T3 can attach to the receptor sites and do whatever it is supposed to be doing to that particular cell. Right? So, we have thyroid hormone receptors on just about every single cell of our body. Okay? 

Emma: Yeah, fascinating.

Miranda: So, the actions of T3 are very very broad. And then our deficiency symptoms are equally as broad. So we need T3 for ovulation, we need it for fertility, we need it for the basal metabolic rate, making sure our body is actually functioning, is actually doing what it should be doing. 

Reverse T3 is a really interesting one. So, it stirs up a bit of controversy, don't you think, Emma?

Emma: Well, that's why I do want to really cover this today because I think it is a little controversial. So, let's talk about it.

Miranda: All right. So, when we're converting T4, right...so, the conversion of T4 to T3 happens in the liver. And I'm not sure that everyone's aware of that, either. 

So, around 40% of our available T4 is converted into T3. And, during normal circumstances, about 20% of that T4 goes to reverse T3, which, as you know, is like an inactive version of T3. So, that reverse T3 is being produced all the time and our body, when it's at a low level, our body kind of goes, "Yeah, cool, great, we've got a little bit of reverse T3. No worries, let's just clear it from the system, no big deal."

However, reverse T3 does have, in my opinion, a very very important role from a stress perspective. So, reverse T3 is produced in higher amounts during times of stress, during times of fasting or starvation, or any sort of illness, such as liver disease, or weird fatty diets that people are not feeding their bodies properly. And it's simply your body's way of shutting down metabolism, of preventing you from burning fat, preventing you from using your carbohydrates. 

Because, if we think about the role of stress, stress is all about survival, right? It's about running from the woolly mammoth. The last thing you want to be doing when you're in a stressful situation is burning through all of your fat stores, because you don't know when your next meal is going to be. Right?

So if you've got a woolly mammoth on your tail, you're under extreme stress. You are trying to get to safety. You don't want to be either, A, pooing, B, having to stop to change your tampon, C, having a baby, or D, needing to stop and eat some food. So, your whole metabolic process shuts down, slows down. And that's so that, when you get to safety, you still have a reserve. Does that make sense?

Emma: Yeah, it does make sense. And I think the underpinning is that cortisol and stress levels have so much to do with this reverse T3 situation and that increased conversion to reverse T3.

Miranda: Just on that, with cortisol, so, this happens if your cortisol is either high or low, right? It also happens if your adrenaline is high, and it happens, again, if your iron is low. And again, it happens when your iron's low because you don't have enough iron to keep making your thyroid hormones. So, it all just shuts down, shuts down, and shuts down. And how that can then present is a hypothyroidism, even a subclinical hypothyroidism, where you have all of those hypothyroid symptoms, difficulty losing weight, unexplained weight gain, cold sensitivity, hair thinning, hair drying, loss of hair, all of those really common symptoms then start to present because of this elevated reverse T3.

Emma: Yeah, yeah. But when and how do you see reverse T3 being a useful metric in clinical practice?

Miranda: Because when I see reverse T3 elevated on a blood, like elevated in testing, it alerts me to something else is going on. Right? It alerts me to, "Why is this person's reverse T3 elevated at this point in time? What's going on for them? Is it that this isn't a thyroid issue per se? Is this a stress issue?" And it changes your clinical practice. Because if reverse T3 is elevated, remember, that it happens in the liver. Right? So, the conversion of T4 to T3 or the conversion of T4 to reverse T3 is happening in the liver.

So, straight away I go, "Okay, is something wrong in the liver?" So, do we have, you know, non-alcohol fatty liver disease, for example? Right? Or is the liver just not very happy at the moment? Is something going on from that metabolic perspective? Or is it a stress response? Because if it's a stress response or something happening in the liver, then it's not the patient's thyroid per se, the thyroid is not the problem.

Emma: Yeah, so, then you're barking up the wrong tree trying to treat a thyroid issue when...yeah. And, in fact, it's either most likely a stress issue or a liver issue. 

And I wanted to share this 2018 double-blind randomised control trial on non-alcoholic fatty liver disease and globe artichoke. Now, I don't think many practitioners will actually realise that non-alcoholic fatty liver disease is the most common cause of chronic liver disease worldwide.

Miranda: I don't think people realise that either.

Emma: No, it's astounding. And this study demonstrated that a daily dose of 600 milligrams of artichoke leaf extract for a 2-month period resulted in lower ALT and AST levels, increased hepatic vein flow, and a reduction in cholesterol, LDL, and triglyceride level. 

So, when we're talking about this situation with the thyroid and reverse T3, what herbs or nutrients do you use to treat elevated reverse T3 that is actually driven by liver dysfunction, not cortisol but liver dysfunction?

Miranda: Yeah, yeah. So, nothing to do with cortisol. So, I use a lot of the lipotropics to get...because what we're trying to do is get the fat then, the fat accumulation, out of the liver. And I really focus nutritionally as well here. So, I'm using things like acetyl-L-carnitine, taurine, glycine, inositol, choline, even vitamin C and selenium, and even some folate and B12. But my main sort of focus is that carnitine, taurine, glycine, inositol, and choline nutrients there. 

Then herbally, absolutely globe artichoke. I don't know, I think globe artichoke is sometimes really underestimated in what it does as well. Like it's so amazing for constipation as well. And when you've got this non-alcoholic fatty liver disease, then all sorts of digestive complaints can happen. And globe artichoke is brilliant for that.

And then I put in some beautiful things like St. Mary's thistle and schisandra. You know, schisandra for the cellular replication, the liver cell replication. So, they're sort of the things that I really love using from that lipotropic perspective. 

Emma, can I share with you, I just want to share with you a case.

Emma: I'd love to.

Miranda: There's...and it was a male, interestingly, that I was treating. He came to me with what seemed to be thyroid issues, very much pear-shaped and just not feeling like he could lose weight appropriately for what he was eating. And we went on this big long journey, we found that his reverse T3 was through the roof. It was actually one of the highest I had seen and it really...

Emma: So, what kind of number though are we talking? Because I'd love to hear some numbers.

Miranda: What number?

Emma: Yeah, roughly.

Miranda: Okay, so, he was at over 700. And, at one point, he had been at 869. 

Emma: Wow.

Miranda: And ideally, we really want that reverse T3 to be below 300. His T3 was quite good, his T3 was at 5.6 and his TSH was completely normal. 

So, we're looking at this process going, "All right, what's going on here?" and we went through the whole process of, "Is it cortisol? High cortisol or low cortisol?" He's a very successful businessman, so, there was a lot of stress. 

But ultimately, what we found, which sort of surprised all of us...So, we actually did a DUTCH Plus on him, right, and because he was basically suffering, essentially, what we would relate as a female condition. Right? So, I went, "You know what, let's see what oestrogen's doing, let's see what your liver and your bowels are doing with oestrogen." And they were all beautiful, his liver was doing a beautiful job with oestrogen. So, I kind of thought nothing else of it. 

And then I went, "You know what? Just because that's fine doesn't mean his liver is fine." And what we did finally discover was that he had non-alcoholic fatty-liver disease and it was caused by haemochromatosis, he was depositing so much iron in his liver but nobody had ever found that. He's 40 and no one had found that there was a haemochromatosis there. 

And that was really one of the things that I went, "Okay, this presented like a thyroid issue, it presented like a cortisol issue, but it was actually a liver issue, a non-alcohol liver dependent."

Emma: That is a really fascinating case, isn't it? And it just goes to show that you have to keep peeling the layers of the onion back to get to the root cause. 

Miranda: Absolutely.

Emma: We are all practising functional medicine of some kind and it is about the root cause.

Miranda: That's right. And if we hadn't kept going, we would still be sitting here going, "Oh, well, why isn't the reverse T3 going down if we're treating stress and cortisol?" and we would still be stuck in it had we not investigated more into what the liver was doing.

Emma: Yeah, some fantastic tips there. I love the lipotropics for the liver support, the carnitine, taurine, glycine, choline, and inositol. And, of course, those beautiful herbs, globe artichoke, St. Mary's thistle, and schisandra, just beautiful herbs that we can use again and again for such great results. 

I wanted to ask about testing though. So, how is subclinical hyperthyroidism actually assessed and what tests are done in a standard blood panel? Let's get the definitions of what we're seeing.

Miranda: Let's get this out, okay. So, when we do a thyroid test, right, and they we'll refer to it as a full thyroid test, and it's literally usually just TSH. Okay. And if we're really lucky, we might get T4 tested as well. And even though they say, "We've done a full thyroid test," it's like, "No, you haven't." 

So, remember that TSH comes from the pituitary gland in your brain, so, by testing TSH, we're actually testing your brain's communication with your thyroid. We're not even testing the thyroid hormones, right? So, it's just missing a lot of details.

So, TSH, the other thing is that a lot of the labs are still using very old reference ranges, you know, where TSH should be sitting anywhere between 0.5, some say 0.5 to 5, some say 0.5 to 4, but they're still old reference ranges. And the most current reference ranges changed in 2003 and it's 0.5 to 3. 

Emma: Right. 

Miranda: But most labs don't even have that as a reference range. I've seen one recently, that was some test coming from Sydney, that had that reference range. So, then, within that, ideally, that's the range. The optimal place I would like to see TSH is somewhere between 0.5 to 1.5, you know? So 1 is pretty spot-on. But I'm pretty okay if it's anywhere between 0.5 to 1.5. But once it starts, you know, if somebody comes to me and says, "Oh, my thyroid's fine and the TSH is coming back at 4.5," every alarm bell is ringing in my head. It's like, "That is just not okay."

Emma: So, if that patient comes in to you and then had their TSH checked, what then do you need to refer them for? And these are private blood tests, so, patients will be required to pay for them, but what tests would you then send a patient on for?

Miranda: T4, T3, reverse T3, the T3 to reverse T3 ratio, the thyroid peroxidase antibody, the thyroglobulin antibody. And then, even if I'm suspecting Graves' disease, then we want to know what your TSH receptor antibodies are doing or even your thyroid stimulating immunoglobulin. They're a little bit more unusual, I'm more looking at the TSH, T4, T3, reverse T3, the T3 to reverse T3 ratio, TPO, and thyroglobulin antibody.

Emma: Okay, great. Okay, perfect. Because I noticed, on the Australian Thyroid Association website, they state that a TSH of around 1.0, a T4 at the high end of normal, and a T3 exactly in the middle of the range gives best results. I mean do you agree with that or not?

Miranda: Yeah, I love TSH sitting, as I said, between 0.5 and 1.5. So, 1, in my opinion, is absolutely ideal. T4 I definitely want at the higher end of the range. Now, again some, labs are sort of talking 9 to 25, other labs are talking 9 to 19. So, this is where it gets a little bit muddied but that's where we go, "Okay, a higher end of the range." So, 19, 20, 21, if the range is in the 20s. 

T3, I like that sitting at 4.8. So yeah, pretty much smack bang in the middle, 4.8-4.9 up to 5. Once it starts getting too high, we can go into that hyperthyroid state. But again, it's really important to be measuring it against the reverse T3 as well. 

So, that reverse T3, again, the range is usually somewhere between 250 to 500, somewhere like that. I like reverse T3 to be below 300. But again, I still want to look at that T3 to reverse T3 ratio. So, if anyone doesn't know, the way that you can work that out, basically you divide your T3 by your reverse T3 and then multiply it by 100. And that will give you your ratio, and that ratio should be between 1.2 and 2.2.

Emma: Okay, great. Because I...

Miranda: Sorry to cut you off. Ideally, with that ratio though, again, I want it to be at around 2. So, even though the range is 1.2 to 2.2, I like that T3 to reverse T3 ratio to be 2.

Emma: Okay, amazing. So, let me synopsis that for the listeners. So, in an ideal thyroid picture, you would see a TSH of around 1.0, a T4 around 19, a T3 of 4.8, a reverse T3 below 300, and then a T3 to reverse T3 ratio of 2.

Miranda: Yes.

Emma: Great.

Miranda: Exactly.

Emma: Is there a too low number for reverse T3, conversely?

Miranda: Ah, absolutely. There is, but there's not a lot of research that says what it's doing. So, if I see reverse T3 drop below 250, for example, and I have seen that, then again, I'm sitting there thinking, "Okay, where does reverse T3 come from? It comes from the conversion of T4 to reverse T3 in the liver. What is going on, again, with the conversion?" 

Because remember, normally, we should be converting about 20% of our T4 to that reverse T3. Why is that not happening? Is the T4 dropping too low? I mean reverse T3 is better low than high, absolutely, but we still don't want it too low because it indicates that something else is still going on.

Emma: Yes, yes. It's so micro, isn't it, that's the first word that comes to my mind, you know, it's the opposite of macro. It's so micro.

Miranda: It is so micro and yet has such catastrophic effects from a symptom sort of picture.

Emma: Yeah, absolutely. And I mean when you see someone with subclinical hypothyroidism, what does that look like?

Miranda: Yeah. So, what it looks like is, subclinical hypothyroidism is where the patient is presenting with all of those typical symptoms of sluggish thyroid hypothyroidism. And that's including things like the inability to lose weight or the unexplained weight gain, cold sensitivity, the hair falling out, fertility issues, whatever the specific set of hypothyroid symptoms are, and yet, it hasn't reached the clinical level yet. And what I mean by that is it hasn't reached the biochemical testing, the testing is not reflecting that there is a problem yet.

Emma: So, in other words, those ideal numbers that we mentioned just a few minutes ago, could they be the numbers on the piece of pathology that the patient’s sharing with you?

Miranda: No, generally, they're not. Generally, they're not in the ideal ranges. Generally, you would see a TSH starting to nudge a little bit too high. You'd see the T4 sitting around 13 or 14, still in range but at that lower end. As soon as I see T4 starting to go below 14...we should not be seeing T4 below 14. 

For T4, one of the most important nutrients, as we talked about, is iodine. And once we see T4 starting to drop below 14, I'm starting to think, "Is this person getting enough iodine?" Like that is starting to stimulate that thought process, in my mind. So, we would see TSH starting to push up, T4 starting to push down, T3 might still be okay, hovering around, you know, 4, 4.2, 4.3, but it's not in that ideal...so, everything, the thyroid hormones are starting to go a little bit low, the TSH is starting to go a little bit high, the reverse T3 probably hasn't been tested.

Emma: Yeah, most likely not. Yeah.

Miranda: And the patient is starting to feel the symptoms, they're really starting to feel it. And yet, their thyroid results are not blown out of the water yet.

Emma: Okay, where do you see the role of basal body temperature charting for thyroid? Like how accurate is it, where do you use it?

Miranda: Okay. So, I do use it in a lot of my fertility patients, although those do their head in sometimes, when they have to test at the same time every day. I want to see the basal body temperature first thing in the morning, before they've moved, I want to see it 36.3 and above. Once it starts to drop below...and this is actually some information from the beautiful naturopath Francesca Naish, she's in Sydney and she's been around forever, this is a lot of the work she was doing.

And I really want to see temperature above 36.3. A couple dropping below is okay, particularly if that's in the follicular phase, but if they're consistently below 36.3, that's really setting off some alarm bells about whether the patient is ovulating and it does drive towards fertility issues.

Emma: So, could this be, for a patient that doesn't have the means to do all the extensive thyroid testing, could this be a means for us to get some information and possibly start some low-dose iodine and see whether that makes a difference?

Miranda: Yes, that's exactly what I would do. So, because the extensive thyroid testing, you're looking at $220 and above. And on top of supplements and appointments and all of that, it just can become quite unreachable for some people. So, to test their basal temperature, get a good quality thermometer. It doesn't have to be a $200-300 thermometer, just a $40-50 thermometer. Get them to test every morning at the same time before they get up. And if it's consistently below 36.3, it would be ideal if there was a GP who could then just test their TSH and their T4, which we can pretty much still get. Those two are pretty standard and should be covered by Medicare without the patient needing to pay more for those. And if we've got a temperature below 36.3 consistently and a T4 that's nudging down at around 14 or below, or 14-15 or below, then I would start thinking about, "All right, let's put some low-dose iodine in there," because there's a clinical reason to do that.

Emma: Yeah, I just think it's so important to make our clinical practices as accessible as possible for patients. And I think that that's a really good clinical pearl for practitioners to keep in mind for the patients that cannot do those extensive tests. I think that's super helpful, thank you.

Miranda: It's an absolute pleasure. Yeah. And it does work, once we start to see T4 coming up, you do see the temperature start to come up.

Emma: Yeah, and the patient will come back and say, "Oh, I don't have brain fog in the morning like I used to."

Miranda: Exactly.

Emma: Yeah, classic, classic.

Miranda: Yeah, or, "I've lost those couple of kilos that I was just wanting to drop. No big deal but just wanted to get those extra kilos off." Yeah, it's great.

Emma: It is, it's delightful. 

I wanted to discuss with you, I wanted to pick your brain on what I think is an infamous gluten and thyroid situation. So, many many practitioners will automatically tell all thyroid patients to avoid gluten, but I wanted to look at what does the research say? And in my reading, I came across a 2019 pilot study, so, it was just a pilot study, and it involved women with Hashimoto's. And half were instructed to eliminate gluten for 6 months while the other half were told to include it. And at the end of the study period, the women who avoided gluten had lower levels of thyroid antibodies and, interestingly, higher vitamin-D levels. And I'm wondering if gluten avoidance is only beneficial in women with an autoimmune component to their thyroid, but I'd love to hear your thoughts.

Miranda: Okay. So, in my opinion, there are several reasons to remove gluten, okay, and most importantly, when there is an autoimmune component. If there's not an autoimmune component, then I think that needs to be a clinical decision based on the patient in front of you. 

However, I don't love gluten, and there's three really main reasons. So, the first one is the molecular mimicry, or the cross reactivity. So, if you have Hashimoto's or an autoimmune thyroid condition, your immune system is making antibodies that are already attacking your thyroid. Okay? If we then put gluten into the picture, gluten contains a protein called gliadin. And gliadin is not a particularly favourable protein for our system. We don't deal with it very well, it's quite a large protein, and our digestive system doesn't deal with it very well. And so, our body views gliadin as a foreign substance and it starts to attack the gliadin. But where it's really interesting is that gliadin is very very similar structurally to transglutaminase, which is an enzyme that's found abundantly in the thyroid gland.

So, what your immune system is recognising is that the gluten, the gliadin, is really similar to your thyroid gland. So, if you already have thyroid antibodies attacking the thyroid, then those antibodies go, "Oh, okay, there's something else we have to attack that looks exactly like transglutaminase in the thyroid gland," and it's the gliadin. So, the antibodies go up even higher in the presence of gluten because the gluten looks like the thyroid gland. Yeah? 

So, our immune system really ramps up its attack on that thyroid tissue. So, then the thyroid tissue is under attack, the gliadin is under attack. And if you take that gluten and gliadin out for 6 months, then the antibodies will drop. And and people can notice a difference within days. But for some people it does take that 6-month period...or I like my patients to remove it for 6 months. Okay? So, that's the molecular mimicry.

And then the second reason is gluten itself is very inflammatory to the guts. As I said, gluten and gliadin are really big proteins, we generally don't break them down very well, and those large molecules cause inflammation to the gut and a separation of the tight junctions in the cells that line the gut wall. And when the gliadin approaches the walls of the gut, the gut becomes more porous, allows the big molecules of gliadin to enter, so, we wind up with leaky gut. And again, in response to that, the human body immediately goes to work in raising an immune response. And if you already have those elevated thyroid antibodies, then you're setting off an even greater immune response.

Emma: Hmm, makes sense. Yeah.

Miranda: Yeah, that was a bit of research that was done in 2017. 

And then the other sort of third thing is most wheat and gluten in Australia is sprayed with glyphosate somewhere in its production. Right? And that could be during the growth of the wheat and gluten or after it's been harvested. And the glyphosate is used to prevent mould but it's an absolute gut irritant and weakens the digestive system as well. And, as a chemical, it can cause thyroid dysfunction itself. Right? So, it can be a trigger for thyroid dysfunction. You may not have antibodies previously and then, suddenly, the glyphosate that's on the gluten or the wheat is actually the trigger that sets off the entire immune response.

Emma: Yeah. It's all so fascinating, isn't it? So, removing gluten for those people with autoimmune-driven thyroid issues. So, three reasons, molecular mimicry between the gliadin and the transglutaminase enzyme and that subsequent elevation of thyroid antibodies. Then you've got that gluten, it's inflammatory to the gut and drives intestinal permeability. And then the third was wheat, essentially, has chemical contamination. 

Now, this is a good segue because I read this landmark study involving over 1,500 people, it was in 2011 but it showed an inverse relationship between environmental phthalates and thyroid hormones. And essentially, as urinary phthalate concentrations increased, serum levels of certain thyroid hormones decreased.

And the lead researcher said something really interesting that really struck me, he said, "This seems like a subtle difference but, if you think about the entire population being exposed at this level, you'd see many more thyroid-related effects in people." And, a 2020 paper, so, very recent, showed that levels of autoimmune thyroid conditions increase the closer people live to areas contaminated with pesticides. Now, this area of environmental impact in thyroid is huge but I just wanted to know how do you counsel patients on this very overwhelming topic?

Miranda: It's completely overwhelming because ideally, we'd love them to move to another area where there isn't any pesticides or phthalates. And as impractical as it is for some patients to be able to do a complete thyroid test, it's also completely impractical for them to up and move their lives. So, it's very much about reducing the exposure where we can. So, the removal of phthalates and the removal of pesticides from food sources. Or it's not just food sources either, but where they can control it.

So, phthalates, as an example, we find high levels of phthalates in cosmetics, and personal-care products, and perfumes, nail polish, hairspray, soap, shampoo, skin moisturisers, we put something like 168 different chemicals on our face just when we get ready in the morning if we're not using phthalate or chemical-free products. And that gets into your skin and it affects your biochemistry, your nutritional biochemistry, and hormonal biochemistry. So, it really is about removing those phthalates and those pesticides, eating organically, biodynamically, from a farmers market as much as you can and just doing everything you can to reduce those phthalates and pesticides in so far as humanly possible.

Emma: Yeah. And they are quite ubiquitous and I often say to patients, "Look, the first thing I want you to do is, every time you finish something in the house, replace it." 

Miranda: Replace it, yes.

Emma: So, it's okay, you finish that spray-and-wipe thing, now you're going to move across to one that's more suitable for you so that... I mean it will take 6 months or so but, over time, the burden, the chemical burden is decreased. And also ensuring they have good detoxification capacity is important as well. Right? Yeah.

Miranda: Absolutely. Yes. So, making sure their body can actually read those, if there's still some exposure, making sure their body can actually get rid of those toxins effectively and efficiently. And again, that, of course, comes back to five organs of detoxification, and liver is a big one involved in that.

Emma: It's huge, isn't it? Yes, yeah. Absolutely.

Miranda: The other thing just with that as well, Emma, is filtered water. I think people forget about water and even if we look at the periodic table, right, where the fluoride, the iodide, and bromide are on the periodic table, they are all halogens. Right? 

Fluoride we find in non-filtered water. The bromide is in crappy toxic bread. And then the iodide is in our salt. Now, those three things all compete with each other. So, if you're having non-filtered water, you've got high levels of fluoride that then displaces your iodide and affects your thyroid hormone manufacture as well.

Emma: Yeah. Look, I'm always saying to patients, "If you don't have a filter, you are the filter." And I think it's that simple, right, it is that simple. 

Just before we close out though, I would just love one little recommendation on building a successful clinical practice. Because you are incredibly successful in our industry but I'd just love one little key takeaway for our listeners.

Miranda: You do you and stay in your lane, I reckon.

Emma: Yeah, I love it.

Miranda: Yeah, just do what you love and how you love doing it and sitting within your own expertise or your own area of interest. And when I was studying, one of my lecturers said, "Miranda, can you come and stand up in front of the class and draw the hormonal cycle?" and I did not want to deal with women's bits, I just...I wanted to do digestion, yeah, and I didn't want to do women's bits. And then I stood up in front of the class and had to draw the hormonal cycle off the top of my head. And I could. I just knew it, I just got it. 

So, for me, it was like, "Oh, okay. I'll do me, I'll do what I feel like I'm good at and what has touched me personally and what I love, the areas that I really love," like work for me is fun, I love what I do, absolutely love it, I think that's really important.

Emma: Yeah, I would agree. I love what I do too, but it's abundantly clear that you love what you do. And thank you so much for all that you bring to our industry, it's just so invaluable.

Miranda: Oh, thank you, Emma. And same goes back to you, you've got an incredible practice and bring incredible knowledge to our industry.

Emma: Amazing.

Miranda: It's fabulous.

Emma: Miranda, thank you so much for taking us through this minefield that is the thyroid. And we know that thyroid issues can be so complex, and being able to really deep dive into it and discuss it is so insightful and instructive. And I think practitioners will have a lot of helpful clinical pearls on herbs and nutrients and diet factors that they can use to start treating thyroid conditions. So, thank you again for being with us today.

Miranda: Absolute pleasure. Absolute pleasure.

Emma: Amazing. Thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website, fxmedicine.com.au. I'm Emma Sutherland, and thanks for joining us. We'll see you next time.


About Dr. Miranda Myles

As a Naturopath and Acupuncturist, Miranda is passionate and dedicated to the world of fertility, IVF support, gynaecology, women’s and men’s hormonal health, children’s health and emotional/mental health. 

Her private practice was established in 2002 and uniquely combines an integrated approach to health through multiple disciplines. As a business owner, director and entrepreneur, Miranda developed one of Melbourne’s leading natural health and fertility treatment clinics for women, men and children.

She has also developed my own hand-blended, organic, therapeutic herbal tea range “Teasing”.


DISCLAIMER: 

The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.

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Emma Sutherland
Emma Sutherland is a successful mum, author and clinical naturopath. Her mission in life is to inspire women to get their Mojo back and to help families raise vibrantly healthy children. Emma is a fully qualified Naturopath, having completed four years of training in Herbal Medicine, Nutrition and Homoeopathy as well as a Bachelor of Health Science. She has over 17 years of experience in treating women and children at every life stage. Her busy clinic provides her with many clinical insights as well as keeping her finger on the pulse of patient led trends. Her friendly personality results in a unique ability for people to feel comfortable and listened to. Emma’s daughter, Sophia, is her greatest teacher and constantly pushes her to do better and be better. Emma is passionate about always learning and discovering new concepts and strategies that she can apply to her clinical practice. And let’s not forget her number one value in life is fun!