Treatment Protocol for Subclinical Hypothyroid and Adrenal Fatique Syndromes

Paul Reller, L.Ac.

Subclinical hypothyroid syndromes and adrenal stress syndromes are being recognized as an underdiagnosed and increasingly prevalent problem in the United States and other developed societies due to variety of factors that include environmental chemicals, dietary habits, overuse of prescription medication and work routines that create an accumulation of immune and metabolic stress. It is estimated that as of 2008, 10 to 18% of all women over 60 years of age in Europe and the United States show signs of subclinical hypothyroidism. A history of surgery, chemotherapy or radiation therapy to the head or neck area are also prevalent causes. 5 to 20% of subclinical hypothyroid cases with elevated TSH and positive antibody titers proceed to overt hypothyroidism each year.

In order to prevent a pattern of ill health that is all too prevalent in our aging population, these health issues should be recognized and treated as soon as the signs and symptoms appear. The patient should not wait until clinical endocrine problems, cancer, autoimmune disorders or cardiovascular problems occur. Just as metabolic syndrome, or the prediabetic state, should be treated before the need for insulin replacement occurs or secondary problems occur, these endocrine problems should be treated with a preventative medical perspective utilizing a comprehensive holistic approach.

Subclinical hypothyroid syndrome is diagnosed primarily by signs and symptoms, but laboratory testing and monitoring is still essential to correct differentiation and guidance of therapy. We often see an excess of TSH with normal values of circulating freeT3 and freeT4 (fT3 / fT4) in plasma blood tests. Circulating blood tests of freeT4 and freeT3 are the most accurate in normal testing, with accurate tests of total serum T4 and T3 sometimes problematic. Total serum T4 and T3 may be altered by the levels of thyroid binding proteins, since more than 99% of these hormones are typically bound to carrier proteins. T4 converts to T3 and reverse T3 to achieve hormonal effects. When there are problems with T4 conversion at the receptor sites, an excess of reverse T3 (rT3) may present problems, since rT3 excess blocks active T3 at the receptor sites. This presents a pathology that is not technically a hypothyroid condition, but produces similar symptoms. TSH levels are best assessed by attention to various antibodies as well as the circulating levels of TSH, fT3 and fT4, since autoimmune disorder such as Hashimoto's thyroiditis has become increasingly prevalent in the United States. In addition, diurnal cortisol levels are helpful to assess TSH, as an excess or deficiency of this adrenal hormone may be the cause of abnormal TSH levels.

Today, health management, or HMO, has brought modern medicine to a point where the patient assessment is often limited to a circulating TSH test alone. Since there is little that the pharmaceutical industry has to offer besides synthetic thyroid hormone replacement for the various hypothyroid pathologies, the number crunchers have stepped in and exerted pressure to limit supposed unnecessary testing. Responsible physicians should still pursue a complete diagnostic set of lab values and spend time analyzing the individual case and differential diagnosis. The temptation to simplify and generalize the diagnosis with one or a few lab values is one of the curses of modern medicine. True diagnosis examines all of the pertinent lab parameters from tests and compares this to signs and symptoms to insure intelligent and thorough assessment. Of course, one could start with a simplified approach, and when questions persist, do more testing. Some laboratories today offer low cost saliva, bloodstick, and now even urine blot analysis, and have developed accurate means of freezing the samples for future testing when more data is needed. This provides the physician with simple, low-cost testing, and allows a flexibility in testing that still maintains excellent value and accurate results in a timely fashion, with results immediately posted on a secure personal webpage. Accurate thyroid assessment is vital to a treatment approach that utilizes Complementary Medicine.

Recent advances in testing technology allows us to accurately assess thyroid metabolites in blood stick samples, and this is recommended for assurance of accurate diagnosis and monitoring due to its ease of collection, speed of assessment and relatively low cost. ZRT laboratories in Portland, Oregon offers TSH, freeT3, freeT4, and Thyroid Peroxidase Antibody assessment, and has published papers describing methods to insure accuracy and comparison to plasma levels. Deficiency of SHBG (sex hormone binding globulin) is also seen in hypothyroidism and can be assessed. This laboratory also offers assessment of Testosterone, Estradiol, Progesterone, Cortisol, DHEA-S, VitD 25-OH and other metabolites to help with an overall endocrine assessment when needed. We often see a hyperparathyroid and subclinical hypothyroid presentation today, tied to hypothalamic deficiency, especially in the aging population, and ZRT offers assessment of Somatomedin C (IGF-1) to help assess growth hormone irregularity, along with LH and FSH values. Use of automated testing and a mass spectrometer has greatly increased accuracy. This type of testing does not require drawing blood and can be ordered by a Licensed Acupuncturist in California to help monitor and assess a patient to succeed with a treatment plan that is integrated with the M.D. specialist. This type of assessment outside of the hospital clinic insures that the complementary care plan can adjust to the changing needs of the patient condition. Since the holistic approach may be complicated, this teamwork on the part of the secondary physician is essential to optimum results in the treatment plan. This type of test data can be given to the patient and brought to the M.D. specialist or case management M.D. to add to the data from more standard blood and urine testing. The modern Licensed Acupuncturist and Medical Doctor should not shy from this sensible and thorough approach to diagnosis, and collaborate freely. This approach does nothing to negate the standard approach of either the TCM or modern physician, but objectively integrates perspectives to provide better assessment and care.

The various reasons for the subclinical hypothyroid condition need to be explored if the physician wants to take a thorough and holistic approach to restoring health rather than just managing the situation with synthetic hormone substitution. Like metabolic syndrome and insulin resistance, we now know that there may be a problem with the cellular uptake of circulating freeT3, with hormone receptor function and with intracellular transport. The extent to which problems with liver metabolism, kidney metabolism, deficiencies of the hormone components iodine and threonine, nutritional deficiencies of selenium, iron, copper, chromium, zinc, vitamins B12, B2, B6, A and E, chronic inflammatory conditions, autoimmune disorder, excessive cortisol, adrenal fatique, estrogen dominance, environmental toxins accumulation, fluoride, or effects of medications such as SSRIs, glucocorticoids, beta-blockers, birth control pills, hormone replacement therapy, steroid therapies in asthma control or skin problems, lithium, opiate pain medication or dilantin contribute to functional hypothyyroidism must be assessed. This is a long list of potential contributors to the subclinical hypothyroid condition. Oversimplified reliance on a circulating level of TSH alone is ridiculous, and a holistic analysis is now expected by intelligent patients taking a proactive approach and educating themselves to their condition.

Other signs of subclinical hypthyroidism include weight gain, abdominal bloat, reduced basal body temperature, low ferritin levels, as well as dry brittle nails, thinning hair, especially eyebrows and puffiness of the face. Symptoms commonly seen are constipation, dry skin, easy fatique, intolerance of cold, anxiety and depression, and waking insomnia. We may also see heavier menstrual bleeding premenopausally, increased idiopathic joint or muscle pain, and loss of sexual drive. Basal body temperature should be measured under the axilla upon waking, before activity, and charted. Menstruating women should take the temperature on days 2 to 4 of the cycle. Normal axillary temperature is 97.8 to 98.2, although normal temperature between individuals may vary.

Essential nutrient therapy includes L-tyrosine, which is often deficient, Kombu seaweed or kelp, as a mineral and iodine source, sublingual B12, Vitamin B6 (P5P), Brewer's yeast, Krill oil for essential fatty acids EPA and DHA, selenium 200 to 800mg daily (or methylselenocysteine), and magnesium. Tyrosine attaches to iodine molecules to form active thyroid hormones, and deficiency symptoms may include low blood pressure, cool extremities, and restless leg syndrome. Other supplements may be useful for specific thyroid pathoogies, such as Pantothenic acid and Calcium AEP, which are more useful in peripheral thyroid dysfunction and hypothalamic deficiency.

Supplemental iodine may be useful if there is a deficiency, which does occur in over 80% of the population in parts of the United States. If the deficiency of iodine is too great, iodine supplementation for a small subset of patients with a particular genetic makeup (or allele) will result in temporary symptoms of hyperthyroidism that is reversed when the supplement is stopped. This is more often seen in patients with a history of autoimmune, or Hashimoto's, thyroid disorder who are now hypothyroid. To avoid this problem, conservative use of Iodoral (modern Lugol's solution) is recommended, with first trying a lower dose of the supplement, and starting with a very low dose and gradually increasing to therapeutic levels. Tapering of dosage at the end of a course is also recommended to prevent reactions to sudden changes in iodine and iodide circulating levels. Keep in mind that about 90% of iodine and iodide store in the thyroid and breast tissues, and continuous supplementation in therapy is not necessary or desirable. Monitoring is now much improved, as ZRT laboratories has completed their assessment of accurate testing and evaluation utilizing just a urine dipstick. This lab utilizes the latest technology with mass spectrometry enhanced with gas chromatogramy to fully refine and achieve accurate results. ZRT also utilizes their own extensive research, accumulated with each individual test adding to data, to insure the highest level of accuracy. Iodoral supplementation is found to be an effective and safe part of treatment protocol for most patients with hypothyroid pathology, including Hashimoto's patients with the inevitable transition to a hypothyroid state from the initital hyperthyroid condition. High dosage Iodoral or prolonged supplementation is seldom necessary.

It is recommended to avoid trans fats, aspartame sweeteners, processed whole foods, and to avoid gluten for at least 60 days (avoid commercial bakery products, wheat, barley and oats) when an autoimmune component is suspected in thyroid pathology. Analysis of the TPO levels is important in these cases. There are products that combine a variety of the essential nutrient substances, such as Immunogenics Future Formulations Thyro-Balance, for ease of use, in therapy, but these products may have limitations concerning individualized treatment protocol, or even quality assurance.

Acupuncture and herbal product recommendations are listed at the end of this article. These are suggestions of this particular TCM physician and should be utilized only by trained and licensed acupuncturists and herbalists. A variety of other treatment protocols are used effectively by other physicians and may work just as well. These recommendations also include treatment for the Adrenal Stress or Fatique Syndrome.

Since adrenal fatique may be an important cause or precursor to subclinical hypothyroidism, this should be assessed and treated first if the signs and symptoms are evident. Up to 80% of people wtih Adrenal Fatique may also have low thyroid function. Chronic pain may be a key factor in this syndrome. Pain stimulus of any sort will stimulate the hypothalamus and trigger corticotropin releasing factor (CRF), leading to larger amounts of cortisol in the blood, which in turn will cause suppression of the hypothalamic function via negative feedback control. Studies at UCLA and Taiwan in 2010 proved that deep tissue therapies, or TuiNa in TCM, produced dramatic normalization of cortisol levels, as well as improved Oxytocin balance, and immune cytokine optimization. This type of therapy may be an important addition to the protocol.

Contributors to adrenal fatique syndrome include chronic overuse of corticosteroid medications, especially in the asthmatic patient. Because of the prevalence of this problem, pharmaceutical companies have come up with a new class of asthmatic inhaler, ciclesonide glucocorticoid, called Alvesco. This steroid will reportedly deliver greater than 50% of the inhaled steroid directly to the lung tissue with smaller particles and conversion to the active des-ciclesonide in the bronchial membranes with esterase activity. Increased lipid conjugation, higher protein binding in plasma, and P450 deactivation in the liver were all bioengineered in this drug in response to the serious problems with adrenal insufficiency that occurred with standard corticosteroid use. The physician should work toward decreased use of any corticosteroid medication if possible in patients suspected of adrenal fatique syndrome.

Adrenal Fatique Syndrome, like subclinical hypothyroidism, is also diagnosed primarily by signs and symptoms, although we often see low morning cortisol levels, high evening cortisol levels, low testosterone and high fasting glucose levels. Again, active hormone saliva testing can accurately assess diurnal cortisone levels and testosterone, as well as DHEA-S. In Adrenal Fatique, the cortisol may rise abnormally at night, preventing one from falling asleep easily. This high cortisol level may inhibit 5'deiodinase enzyme that converts T4 to T3, as well as inhibit production of TSH in the pituitary. Standard tests that look only at the TSH and freeT4 levels, and not the freeT3, may be overlooking a functional T3 deficiency. Deficiency of cortisol may inhibit thyroid hormone receptor sites.

Signs of adrenal fatique may also include loss of hair on the lateral calf, dry skin, hypoglycemia with stress, decreased immunity and a craving for salty foods. Symptoms may be very similar to subclinical hypothyroidism, and typically increase with stress. These include easy fatique or diurnal energy patterns, lack of stamina, constipation, difficulty falling asleep, poor memory, increased irritability, depression, apathy and difficulty with mental focus. Differences with hypothyroid symptoms include: fatique in the early morning or mid-afternoon only, more vitality in the evening, and constipation that alternates with loose stools.

I believe that the term 'alternative' medicine has long promoted an unhealthy and mistaken attitude about the science of TCM, which historically has always been a complementary partner with allopathic medicine, and that the modern progressive MD should seek out a knowledgeable Complememtary Medicine physician, such as a Licensed Acupuncturist and herbalist, or a Naturopath, to integrate into the treatment team and provide the best and most economical care for the patient.

It is believed that the number of cases of subclinical hypothyroidism has grown substantially in recent years. Unfortunately, the standard treatment protocol for subclinical hypothyroidism, in most cases, is still the same as that for clinical hypothyroidism and involves synthetic thryroid hormone substitution such as synthroid (levothyroxine sodium). This type of treatment has become controversial, and a meta-analysis by the Cochrane Collaboration has shown no benefit and substantial risk in taking synthetic thyroid medication for subclinical hypothryoidism. The risks include the possibility of stimulating hyperthyroidism as well as cardiovascular risks.

Fortunately, use of bio-identical hormone therapy and comple mentary medicine is finally being used with great success, even among a small percentage of M.D.s, over the objection of the big pharmaceuticals. Studies have proven that use of T3 and dessicated thyroid in the treatment may control the deficiency of thryoid production with fewer risks and side effects. One study showed substantial benefit from T3 use for both mood and cognitive ability, while a study of dessicated thyroid showed benefits across the board in symptom improvement compared to standard synthetic T4 use.

Some studies have shown that treatment of subclinical hypothyroidism with levothyroxine are ineffective. Tijdschr Psychiatr. 2008;50(8):539-43: This search of all relevant studies by 2008 of the treatment of subclinical hypothyroidism with levothyroxine showed no beneficial effect on the accompanying depressive syndrome. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003419. This meta-analysis concluded that levothyroxine therapy in cases of subclinical hypothyroidism did not increase survival or decrease cardiovascular morbidity, nor did it improve symptoms or quality of life compared to either no treatment or placebo.

Herbal products found useful for Adrenal Stress or Fatique include Health Concerns' Adrenosen with adrenal glandular extract, PKA and supportive herbs, as well as products with adaptogenic herbs, including Dr. Kang's Quality of Life, Heron Botanicals Fu Zheng Formula and Health Concerns Astra 8 or 6 Gentlemen. Herbal Products to clear chronic infection or gut imbalances include Health Concerns Astra Isatis, Phellostatin or Artemestatin, and possibly a short course of Clear Heat if needed. Restoration of gut function may include Health Concerns Chzyme and Collagenex, as well as a reliable probiotic primaphadophylus. Health Concerns CordySeng is also useful periodically; study has shown that large dosage of American Ginseng over short periods increased thyroid function in animal studies, but small dosage over a longterm appeared to reduce thyroid function. Cordyceps is an herb that serves both as an immune tonic and adaptogen to stress. The supplements L-Tyrosine, sublingual B12 high dose crushed, Vitamin B6, selenium, magnesium, EpaQ krill oil, pantothenic acid, and OptiZinc, or zinc methionine, are also essential to therapy.

Acupuncture recommendations may focus on the Shaoyang, Yang Wei and Dai Mai meridians, as well as the regulatory points, using SI3, DU20, DU16, GB20, UB10, a point beside and under the spinous process of C4, DU4, K7, K6 and UB62. This will help with regulation of the autonomic nervous system, endocrine and thyroid, and aid with deficiency of the adrenals, utilizing the extraordinary meridians. If the shaoyang pulse indicates emptiness, GB41, 43, 37, xieLV5, SJ5 to P6, H7, buUB10, xie GB20, xieGB25. Direct stimulation of the thyroid gland may be accomplished with ST9 and Ren22, using Lu7 and K6 to enhance the meridian effect. In addition topical herbal creams to increase pregnenelone, progesterone and estriol may be utilized as needed and appropriate, with lab values monitored. Use of a very low dose of topical creams is recommended when starting the therapy, and care must be taken not to overstimulate. In the menstruating female patient, the progesterone stimulating creams are used only in the second half of the cycle, and use of estriol cream is used only when progesterone stimulating cream is also used.

As time goes on and research continues to improve the efficacy of integrated treatment for subclinical hypothyroid and adrenal fatique syndromes, this physician, like many others, continues to utilize improved evidence-based protocols in his practice, and this article may not be fully updated to reflect the advances in treatment protocol over time. Feel free to contact me by phone or in writing to gain more information about clinical practice and results.

Information Resources

  1. Wikipedia gives a clear explanation of hypthyroidism.
  2. Dr. John R. Lee, a pioneer in the use of bio-identical hormones, is well represented with hypothyroid information at
  3. The Holtorf Medical Group, Inc. of Foster City, California, provides excellent resource on the internet with information that is valuable to modern Complementary care.

Of Interest

NOTE:“long-term use of high-dose inhaled corticosteroid therapy has potential to cause systemic side effects – impaired growth in children, decreased bone mineral density, skin thinning and bruising, and cataracts. Hypothalamic-pituitiary-adrenal-axis suppression, measured by serum or urine cortisol decrease correlates with the occurrence of systemic side effects of high-dose inhaled corticosteroids.”

The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.