 Well, today, I want to talk about some evolutionary perspectives on thyroid disease. This is a pretty cool topic, very, I'm very interested in it. Most of my patients, I work at an endocrinology practice, and most of my patients, really biased population, have a thyroid concern. And in this presentation, we're going to go through thyroid disease, what is it? We're going to talk about thyroid and inflammation, and then thyroid and oxidation. And I'm going to riff a little bit on a previous presentation from AHS 12, and hopefully we can get some like, oohs and ahs, you know, during this presentation, because it's kind of cool, all these evolutionary connections that we can make, and how inflammation and oxidation affect us. So why focus on thyroid disease? Why should we care about our little gland that, you know, sits right here in the shape of a butterfly? Well, 95% of people who present to their doctor's office with fatigue get no answers. They're like, I don't know, man, your, all your labs look fine, I don't know what's going on with you, maybe some antidepressants, and it's not fair, because there are so many things that could be happening physiologically that could be provoking this fatigue. And it just so happens that thyroid health could be one of those things. So what are some symptoms of thyroid disease? You can have less stamina, less, you know, fatigue, hoarseness, this cluster right here could be one thing that could indicate that you have a thyroid problem. There are 11 of those symptoms that are a little bit more honed down or clustered. But if you look at this table, they are not very sensitive, meaning that even though you might have this, one of these symptoms, that doesn't necessarily mean that you have a thyroid problem. So it is really, it can be really difficult to diagnose a thyroid problem without serology. And it gets even more difficult because what tests do you order? And there's a lot of controversy, there's a lot of, you know, what's going on in the thyroid, do you have antibodies, are your TSH levels optimized, are they within the range? And these are questions and problems that present at my practice almost daily. So one of the things that I do want to bring out is our ability to be a little bit more discerning with the way we go ahead and diagnose out of thyroid disease. So imagine you are in a desert and you're walking around the desert and then, ah, you know, something bites you on your ankle. And then you look down and you see two perforations and you're like, you know what, I think that was a snake. And then you go, you go to your doctor and your doctor, you know, opens the window and you know, I didn't see any snakes, I couldn't possibly have, you know, a snake bite, you crazy. Here's someone to the presence. Well, so if you don't have antibodies to your thyroid, that does not mean you do not have thyroid, an autoimmune thyroid disease, and it gets really tricky because the gold standard for the diagnosis of Hashimoto's thyroiditis or an autoimmune hypothyroid disease is to take out the thyroid, go ahead and slice it and do cytological analysis and ensure that none of the cells within the thyroid have been compromised. So even if you have a savvier practitioner that is looking at antibodies, you could miss it because those antibodies fluctuate a lot. Secondly, having the, let's say you have those tests drawn and you do have antibodies, but those antibodies don't pass the threshold that some lab figure was, you know, dictated to be, then your doctor might say, guess what, you don't have autoimmune antibodies or autoimmune disease because your antibodies are at 30, not at 31. As if like, your thyroid is going to be looking at his watch and it's like, you know, I don't have, I don't have to stop producing more thyroid hormone because I'm still at 30, just wait until we hit 31 and then I'll crash. So it doesn't work like that. Even if you have a little bit of antibodies that are not crossing the threshold, you could be having an autoimmune attack on your thyroid. And what's the problem with that? Well, when you have an autoimmune condition in your thyroid where you have antibodies attacking that tissue and reducing the amount of thyroid hormone that that tissue is producing, you begin to sense it in your, in your brain and then your pituitary starts releasing thyroid tropin or TSH and TSH acts as a growth factor to the thyroid. So this is very interesting because your thyroid doesn't really know how to respond to that signal from your brain telling it, hey, dude, make more thyroid hormone. And what it does, it starts growing. So it increases and that's how we get, you know, like a goiter or increased blood flow to the thyroid or, you know, those inflammatory markers that we can see on ultrasound. So what we see is that you have a production of thyroid antibodies that attacks your thyroid, that creates an immune reaction that increases TPO in thyroid globulin antibodies, which destroy the thyroid hormone, thyroid hormone's ability to penetrate the cell. As a side note, thyroid is a nuclear signaling, you know, it goes inside the cell, it goes into the nucleus and starts producing different peptides and amino acids and things like that, which, you know, that attack on your thyroid reduces its ability to produce thyroid hormone, which induces hypothyroidism, which increases production of TSH, which that TSH makes your thyroid work harder so that thyroid starts growing and now you have more surface area for those thyroid antibodies to attack. So you have this vicious cycle of an autoimmune response that is not broken until you fix the hormonal signaling so your pituitary stops producing TSH. So what happens in, you know, let's talk about some mismatches. What could be causing this autoimmune condition? Well, if you guys are in this room, you're probably familiar with the, with an epidemic of absence where our immune system is just ADD and doesn't know what to do with itself because we're not in contact with Earth, we're not in contact with everything is so clean that our immune system is just revving up trying to attack anything. Environmental toxins, brominated compounds can attack, you know, can make your thyroid a little bit slower. Infectious disease, you know, having an infection with Epstein-Barr virus, you know, predisposes you to the creation of thyroid antibodies. Iodine supplementation, super controversial, but we see populations where if you decrease iodine, now notice, decrease iodine and you measure output of iodine in urine, those antibodies reduce and that condition actually reverses. Very interesting, you know, and we're going to be talking more about that in the future. So what happens when you control the thyroid output? What happens when you get a little supplementation or you maybe modulate the immune system with really cool things like herbs or low dose naltrexone or maybe an autoimmune protocol? Well what happens is that your TSH kind of goes down because you don't have the need for that thyroid hormone, which that thyroid starts to shrink and now you don't have as much surface area. So you decrease the antibody production and now you have optimal thyroid levels which optimize the TSH levels, which fixes that loop and it's really cool to work at a practice where we use this evidence and we have seen thyroids that have nodules reverse just by using appropriate thyroid dosing, you know, not magic, you know, working on lifestyle, having decreased stress, drinking clean water, an appropriate ancestral diet and a little bit of thyroid supplementation and that's it. All of a sudden you don't have nodules and you reverse damage to your gland, which is pretty cool. And the most beautiful thing about this whole thing is that modern medicine is kind of catching up to this because now we know and it's pretty well documented, if you go to databases like up to date, you can see that the recommendations for someone that is pregnant for their TSH levels are vastly different than a regular human being. So the usual range for an adult would be 0.45 to 4.5 on your TSH. That gets compressed whenever you have a pregnancy and the reason is that you're trying to create a new baby, you're trying to create a new human and now you need more thyroid hormone in order for that baby to grow and be able and viable. One of the top causes of infertility in the United States is hypothyroidism and we see that in her practice. If you get a woman to a good TSH level, you look at her the wrong way and she'll get pregnant. But what happens with the rest of your body when you have good thyroid levels? Well having good thyroid levels even with just the addition of level to rocks and just T4 modulates the immune response in your whole body. It reduces, improves oxidative stress and this is because this thyroid is modulating and controlling so many physiological pathways within your body and this is really cool. So that said, everyone get on some thyroid hormone. The problem is that any time we believe that we have something and we have discovered this little thing, this is going to be like the fountain of youth or this is going to help us fix everything, put someone on level to rocks and that's it. We kind of mess up and if we don't look at the evolutionary perspectives and what's actually happening within the body, we can get into a lot of trouble. There are some evidence based diagnosis like autoimmune thyroid disease, thyroid hormone resistance, which is a really cool phenomenon that happens whenever you take too much thyroid medication and those receptors kind of stop accepting the thyroid hormone and it also can be genetically happening when you don't have the correct phenotype to create those receptors and then HPA acts as dysfunction when you have stress and when you are not taking care of yourself, whenever you are not using a correct circadian rhythm, your body tries to modulate what's going on to maybe decrease inflammation or to increase production of proteins and that can cause your thyroid to become a little bit lousy and then your TSH begins to rise and then there's other alternative diagnosis like youth thyroid syndrome, reverse D3 syndrome and the Wilson's temperature syndrome, you know, not convinced about those things. So a little clap back to CMJ in 2012 where he presented an amazing lecture on the mismatch between oxidative stress and what is really causing diabetes and how if you have an excess of energy that is readily available and unlimited supply for your mitochondria and you begin to make that ATP, you also as a by-product create a lot of reactive oxygen species and then your body is like, wait a minute, if I continue inhaling this reactive oxygen species I'm just going to burst into flames. So it becomes resistant to insulin to prevent the creation of ROSs. So what's our strategy? We give something that is going to be more insulin sensitive which is going to bypass that evolutionary mechanism. So that was like an hour lecture that Chris Masterjohn did in like five minutes or three minutes. So what about with the thyroid? Remember the thyroid is also anabolic, you know, and it's creating things and it requires things for it to happen. So what happens if we just give people a lot of T3 or a lot of T4? Well bad things happen. You start having anxiety, you can start having lesions in your heart, you can start having osteopenia and this is because your body is trying to process this and it doesn't know what to do and it starts creating all of these things and it begins to break down because of overuse, it's stressful. So more thyroid hormone does not equal health. And remember that, you know, that little mitochondria that is trying to not process too many ROSs? It's like a car inside a garage. And if you're saturating that garage with that exhaust, those ROSs, that person driving the car is going to die. So then our body starts coming up with evolutionary mechanisms to prevent this. And we have very tight regulation on how we utilize thyroid hormone. And in some cases, we are going against these evolutionary mechanisms to try to correct a problem that in the beginning maybe it was a very sophisticated way of our body to deal with inflammation, with stress, with circadian rhythm mismatch, with an infection, with a toxic environment. So in the end, trying to decrease the amount of reverse T3 is not a good strategy. And I'm going to show you why. So what is reverse T3? Reverse T3 is called the inactivated form of T3, and your body is confused, and it doesn't know what to do with the T3, and it becomes reverse T3. And then all of a sudden you have this euthyroid syndrome, or now you're getting T3, cytomel, three times a day, and your hair starts to fall and your bones start to break. And it's sad how many people we see at our practice with going through this. As you can see, T4 can be converted into reverse T3, or T3, T3 being more active than T4, and in reverse T3 is the inactive, or it doesn't have as much activity. Well, T3, reverse T3 can convert into T2, and there's a lot of research now going into what does T2 do, and it's been speculated that it aids with weight loss, and most importantly, it aids in apoptosis. So by blocking reverse T3, you are blocking a cancer, an endogenous cancer fighting mechanism for your body. And it makes sense. You're just running your body in that really high, really hot environment where you are bypassing evolutionary mechanisms that are very elegant. Our body wants to maintain that euthyroid level, and that is why TSH is the most important blood marker for assessing thyroid health. And believe it or not, that is a controversial statement. So what happens with, you know, how can I be so sure about this reverse T3? Well, reverse T3 was discovered when this inactive form of thyroid was elevated in ICU patients, horizontal patients, patients that were not moving. And when this reverse T3 levels were really high, after the critical illness part of their disease process was over, then that reverse T3 began to climb back. This indicated that this reverse T3 mechanism is protected at a catabolic state. So if you are in an anabolic state, you might need more T3, more T4, your TSH might climb. But if you are in a catabolic state, your reverse T3 might bail you out to prevent further damage. And that's why it's so important to look at the root cause of your elevated TSH. The TSH is just a thermometer. It just senses the level of T3 and T4 in your body. Your body bails out or absorbs thyroid hormone depending on its needs. So we use, you know, the role of thyroid is it can cause oxidation, or it can cause catabolism, it can cause anabolism. And because of that, having a person that has a little bit of fatigue that gets resolved with a little bit of thyroid hormone does not mean that having a person with a lot of fatigue would get better with a lot of thyroid hormone. Remember, always look at the underlying cause. So in the old paradigm, you know, we would see this linear association with TSH and thyroid levels where that yellow indicates a reference range for thyroid and this incline in your TSH levels and how to manage it. In reality, that line does not look like that. It is a very steep line where if your TSH is super high, it does not necessarily mean that you need super high levels of thyroid. And at the same time, if your TSH is super suppressed, it does not mean that you have excessive amounts of thyroid hormone. Why? Because your body has evolved to be able to bail out, you know, through urine, through your kidneys, through reverse T3, it's able to modulate those thyroid hormones. For example, if you are tired, if you haven't slept, the TSH is going to want a little bit more energy to create those proteins that you're missing. If you're in a catabolic stress, if you're doing intermittent fasting, if you're going to be in really, really low carb, your body might need a little bit of thyroid hormone to kind of balance itself out. But in short, we are not as smart as we believe. We have many, many, many millions of years of adaptation and mechanisms to help us modulate these hormones. And maybe you don't need a little bit of thyroid hormone, maybe you need to look at lifestyle and habits and diet in order to modulate your HPA access. Do we have any questions? Thank you. I just have a question about the iodine supplementation, which I realize you said is controversial. Very controversial. Am I understanding correctly that the idea is iodine supplementation would be stimulating the thyroid to grow and thereby go into that cycle? And that's why you see goiters develop when you have a lot of iodine or when you don't have any iodine. So it's like this Goldilocks supplement where a little bit goes a long way. Interestingly enough, there's a mechanism to where your thyroid stops functioning after a certain amount of iodine. And that's why potassium iodine pills are used to protect you from thyroid cancer. And you only need around 300 micrograms of iodine per day. And for someone with Hashimoto's that is on thyroid replacement therapy, there's about 180 micrograms within the thyroid medicine. So you only need 120 milligrams from your diet, which is very easy to get. So that's why every person with hypothyroid that is on thyroid replacement therapy at our practice goes on a low iodine diet and we check that there's low excretion of iodine in the urine to assure compliance. Thank you. You're welcome. Hi. So I'm kind of interested in this question of your body modulating your thyroid to be protective in various situations. And in regards to if you go in your hypothyroid, your TSH is up, and your physician or even in your practice says, okay, well, we're going to use nature thyroid, for instance, to supplement your thyroid hormone so that you can feel better, so that TSH comes down, aren't you then trying to kind of outsmart the body and force it to do something that is then in that situation not protective? So the problem, yes, we are, but at some point there is enough destruction of thyroid tissue that your body is never going to stop producing TSH, thyroid tropon. So then that tissue is going to continue to be irritated, and your thyroid is going to grow and it's going to, and that's what leads to thyroid cancer. So one of the reasons we suppress TSH is to prevent the development of thyroid cancer. Does that make sense? Yeah. So are you postulating that in many cases or in most cases there's such thyroid damage that the body cannot reverse that damage or reclaim the thyroid capability, even though it does have the ability with TSH to increase it, to decrease it? And that's like an allosteric regulator, so that's your brain. Your brain just notices that you don't have enough thyroid hormone. But your capacity of your thyroid to create new thyroid hormone might be very diminished, so you might need this exogenous thyroid hormone to kind of lower your TSH. Interestingly, if you do correct supplementation of nitratroid or WP thyroid or a combination of T3 and T4, where you land in that sweet spot of 0.5 and 1, that's when we see that there's enough signaling from your pituitary to where it's happy. And then at the same time, your thyroid kind of gets a little bit suppressed, which is a good thing because it can go to bed and it reverses this autoimmune attack. And that's when the glands begins to shrink and that's when we see reversal of nodules. And more likely than not, after a couple of months we start paring back on the thyroid medication because all of a sudden you get a TSH that you were right at the spot between 0.5 and 1.5 and now you come back and you're suppressed and you're like, oh crap, I guess your thyroid is starting to work again. Or maybe you lost some weight and you don't need as much thyroid hormone. And little by little we get you to a place where it's the perfect balance for your size, age, and gender. This is the amount of thyroid that you should be getting and whether your thyroid is producing it or not, we can get that TSH between the 0.5 and 1. Thank you. You're welcome. Thank you Guillermo for a wonderful talk. This is somewhat related, maybe a kind of personal question because I'm really interested to hear your response. But I know thyroid hormone replacement, T4, T3 is somewhat of a controversial topic but also related to that is use of other hormone replacements or bioidentical hormone replacement and wanted to hear your thoughts on maybe how you're applying those tools or not applying them in your clinic in a safe way because I've certainly found a lot of trouble trying to work with folks who either come in on both thyroid hormone replacement and female hormone bioidentical replacement or testosterone and having issues trying to regulate all those systems given sort of the complexity that you pointed out. So I would love if you could share a little bit about what you're doing in your clinic, how to approach that in a safe way. We do see that. Your body, if it needs to be anabolic, or it wants to grow, it might want to get a little bit of testosterone out of your adrenals if you're a woman, your testicles if you're a guy, but it doesn't, it's not producing it. So the HPA axis gets all confused and now it's starting to create a lot of TSH. It's funny, you know, it's like your pituitary is not like an Amazon fulfillment center where if you need TSH it goes and grabs just the TSH and just like sends it. It's a gland and it squeezes things and things come out, you know, at the same time. So you might get a little bit of signaling for your cortisol and you might get a little signaling for your sex hormones and you might get a little signaling at the same time for your thyroid. And that's why we need to kind of balance that whole HPA axis. It is really hard and I don't think I, you know, I probably have one patient where I don't work on the whole HPA axis when I'm working with the thyroid, but I cannot think of an example where someone with HPA axis dysfunction that presents with a little bit of hypothyroidism. It's not working under sleep or they're not taking something to make the liver a little bit more efficient that detoxified in estrogen. So now you're hitting the sex hormones. So yeah, you know, it's not isolated to the thyroid. It's the whole system that you have to kind of look at and see what your deficiencies are in trying to balance things out to improve the output of the thyroid. So yeah, so in that regard, are you finding that adding in additional hormonal support in conjunction is beneficial or actually is, you know, potentially removing in the same way that you see thyroid hormone resistance, removing other exogenous hormones is beneficial during this sort of period, I would say of, you know, a little more suppression and healing if there are nodules. It's all context, you know, a lot of my female patients are in progesterone, you know, and that's something that can be very low risk, very life changing. Does every one of my patients need to have some hormone replacement? No. Am I against responsible? Just like I'm in favor of responsible thyroid replacement therapy, I am in favor of responsible hormone replacement therapy. But yeah, it is very beneficial. It can be completely life changing, you know, to be able to have, you know, sexual intercourse and then they will not be able to. And then you do a little bit of a cream of something, and all of a sudden, you know, now you can have a fulfilling life. So yeah, it can be very, very inefficient. I'm not against that. Thank you. Just had a quick question. I might have missed it, but what would you say the optimal TSH levels would be? 0.5 to 1.5. And that's the sweet spot where you are still getting some signaling, you know, we're not, you're not, your body is not in an oh shit mode. I need to stop producing thyroid because I'm burning. And so you're still getting a little bit of, you know, signal to the thyroid. And at the same time, you're not getting so much signal that your thyroid, you know, is growing. So that's a really cool, you know, even keel place where you're still stimulating the thyroid. You're not completely suppressed, but you're not stimulating so much that nodules begin to grow. And in fact, we see reversal of thyroiditis. Hi, quick question again, kind of going back a little bit to what I was saying. I was really struck by what you're saying about the ancestral component of why the body would modulate thyroid in certain situations and how this is sort of a coping mechanism, a very sophisticated coping mechanism. Have you had any success in your practice with trying to unpack the root cause of the hypothyroidism on a patient-by-patient basis? And then trying to adjust the root cause without first introducing thyroid hormone just to kind of get them over the hump, but rather to kind of see, well, what factor is in this particular case that the body is making this adjustment? Can we take that factor away so that the body will then recalibrate? Because if it's so sophisticated that it creates this, it might be sophisticated enough to uncreate it. So first, do no harm, you know. If I believe, you know, so my normal check for thyroid includes a thyroid ultrasound. And if I see any thyroiditis, if I see any growth of blood vessels, if I see an inflammation, if I see any reasoning for deterioration of thyroid tissue, I'm going to suppress the TSH to preserve the thyroid. If a patient comes back and they have a suspicious nodule that needs to be biopsied and they have cancer, I am going to suggest surgery. And this is because first, do no harm. Now, if your levels are like a 2.5 and you have a lot of stress in your life and maybe you're eating a lot of iodine because you read somewhere that kelp was good for you, kelp might be good for you. Then I might be hesitant about starting someone in thyroid medication or not. You know, one of the best predictors for how well a person is going to do in my experience is how they value their health, OK? And there is a lot of people that value, you know, for some reason value, oh, I don't want to take any prescription medication and they come in hauling 40 supplements. Measure your life or your health by the life that you're living, by the love you're giving your loved ones, by how you are impacting your community, not by how many pills you take. So if being the best person you can be and maybe you can fly three time zones and attend a community like this and be a little bit stressed out and maybe miss a meal and whatever, but you're taking that little pill that is helping you maintain those TSH levels steady, so be it. You know, don't have any, don't hate yourself because you live in a very dirty environment with a lot of toxins, with a lot of stress and you need a little bit of supplementation of thyroid. Don't, you know, beat yourself up for that. A little bit of thyroid supplementation could be the difference between being able to go to a restaurant or being confined to cooking every meal at your house. You know, a little bit of thyroid medication might be the difference between, you know, having success, you know, with like an AIP protocol or just eating rice and boiled chicken. So a little bit of thyroid medication shouldn't be the indicator of how healthy you are. How you feel, what you're doing for your community, what you're doing for your loved ones. You know, if you have high cholesterol and you can't control it and you need a little bit of Lipitor, cool. You know, just try to work on the other stuff and try to clear it and maybe you'll get off of it, but it can be so life-changing. It can be so life-changing and let's use technology to help us and not to hinder us. You know, who's heard, you know, we're the only mammal that drinks another mammal's milk. You know, I wish I could drink milk, you know, because I break out whenever I drink milk, but because I don't have the genetics to, you know, process it. You know, we're the only mammal that wears pants. So should we not wear pants? So let's use technology for our advantage and not for hindrance. So I hope I answered your question, sort of, yeah. But yeah, no, we can work on underlying costs while we're doing a little bit of therapy, you know, and then maybe you can get off of it. And if you don't, cool, you know, as long as you feel great. Any other questions out there? Is that it? Great job, Guillermo. Thank you. Thank you. Thank you.