The 2 Most Common Thyroid Problems I See (and it’s NOT hypothyroidism!)

The thyroid is an amazing little gland. Every cell in the body has receptors for thyroid hormone, and thyroid hormone regulates your Basal Metabolic Rate, or the metabolism in all of your cells. Thyroid hormone is necessary for heart health, bone health, brain health, gut health, and certainly overall health. If your cells are not getting the correct amount of thyroid hormone, you WILL have problems eventually.

Hypothyroidism is a common diagnosis, but there are other thyroid patterns that I actually see more often in my functional medicine clinic. These are the people (often women) who have all the symptoms such as slow metabolism, low energy, weight gain, brain fog, hair loss, constipation, anxiety, depression, poor sleep….but may have been told their “labs look good.”

This is because conventional lab work typically looks at 2 maybe 3 pieces of the thyroid puzzle, but it’s a 10-piece puzzle! It’s also worth mentioning that autoimmune disease has a big impact on the thyroid, and sometimes the lab numbers actually do look good, but the person is still having symptoms, because the problem isn’t with the thyroid gland, it’s with the autoimmune attack that is creating inflammation and leading to bigger problems. This article talks about 2 patterns that, regardless of Hashimoto’s or not, cause many of the most common thyroid symptoms.

To understand these common thyroid patterns, it’s necessary to have a very basic background of how thyroid hormone production works.

Hypothalamus/Pituitary - these areas of the brain receive signals from the body and send signals to the thyroid gland:

“Hey brain, we need more hormone down here. Tell thyroid.”

“Hey thyroid, they need more thyroid hormone ASAP! Make more!”

TSH (Thyroid Stimulating Hormone) - the signal from the pituitary gland to the thyroid gland saying “Make more hormone!”

Thyroid - The actual gland in the neck producing the hormone.

T4 (Thyroxine) - The thyroid produces almost exclusively T4 (93%), which is the inactive form of thyroid hormone. That hormone needs to be converted into the active form, T3.

T3 (Triiodothyronine) - The active form of thyroid hormone, the one that matters for metabolism and cellular function. T4 needs to be converted to make T3.

True Hypothyroidism

True hypothyroidism is actually the least common of these 3 patterns, but it’s worth describing so you understand why many people are told their thyroid “looks normal”. Hypothyroidism means that the thyroid gland is truly underperforming and is not releasing enough thyroid hormone. When the thyroid is not producing enough T4, the brain is notified, and the pituitary gland sends a signal to the thyroid gland that says “Make more hormone!” This signal is called TSH, or thyroid stimulating hormone, and it’s often the only marker tested by doctors.

True hypothyroidism is diagnosed by a TSH above a certain threshold, typically 4.5 or 5.0 depending on the lab. So, for a person with a TSH of 8.0, their brain is desperately trying to get their thyroid to produce more hormone, but it’s not able to keep up with the demands, and it’s called hypothyroid.

Hypothyroidism is common in our country, but it takes a long time for the body to reach true hypothyroidism, and the following patterns are MUCH MORE COMMON!

Pituitary Pattern - Low T4 and Low TSH

What if the thyroid is not producing enough T4, but it’s not being told to work any harder?

Understanding the thyroid physiology described above is necessary to understand this concept, but a “pituitary pattern” is when thyroid production (T4) is low, but yet TSH is also low, so the “signal” to the thyroid to produce more hormone isn’t happening.

This is somewhat of a hormonal “communication breakdown”. The pituitary also communicates with the adrenal glands to produce DHEA, epinephrine, norepinephrine, and cortisol, and the reproductive glands to produce estrogen, progesterone, and testosterone. If there is a problem in the “pituitary control tower”, there are often hormonal problems in several of these areas.

The causes for a pituitary pattern are unknown, but I see them correlated with chronic stress - both stress of today’s life - kids, job, bills, relationships, traumas - but also toxic environmental stress like mold or heavy metals. The pituitary is very sensitive to all kinds of stress, as it is an integral part of the stress response!

Under-Conversion Pattern - High T4 / Low T3

The thyroid makes thyroxine (T4), but T4 needs to be converted to T3 for it to be “active”. What if the thyroid is doing a fine job of making T4 but it’s not being converted properly to T3?

This is called an under-conversion pattern. Conversion of thyroid hormone is done by an enzyme called 5’-deiodinase, and primarily takes place in the liver and the gut.

If T4 is fine, then TSH will typically be fine, so this often looks like “perfect labs” in a doctor’s office who only checks TSH and T4 (most conventional offices). T3 is crucial, because it’s the one that matters. I like to check T3 and Free T3, which is the free, unbound, available thyroid hormone. T3 is more important to look at for conversion processes.

There are actually 24 different thyroid patterns that I evaluate for in practice, all having to do with different causes. Pituitary pattern and under-conversion are the most common, but still beg the question - why??

Proper thyroid hormone production and metabolism requires a lot of things - vitamins and minerals like B vitamins, selenium, zinc, iodine….but also requires good nutrition, quality sleep, regular exercise, healthy microbiome, proper stress management, good detoxification pathways, etc. Each person is unique and their puzzle will be different than the person before them - this is chess not checkers!