The document discusses an integrative medicine presentation on hypothyroidism and the thyroid. It provides background on the speaker's commercial relationships and credentials. The presentation examines the limitations of conventional thyroid testing and treatment, exploring additional factors like selenium, iron, and cortisol that can impact thyroid function at the tissue level. It advocates for a more comprehensive evaluation and management of hypothyroidism that considers multiple nutritional and lifestyle factors.

1. THYROID On My Mind
Louis Cady, MD
Presented at the 2016 Integrated Medicine for
Mental Health Conference
Reston, VA (USA) – September 29th
, 2016

2. Continuing Medical Education Commercial
Disclosure RequirementI, Louis B. Cady, MD, have the following commercial relationships to
disclose:
•Speaker honoraria received from:
• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX
•Speaker’s bureaus (active) for:
• Arbor, Allergan (Aventis), Lundbeck, NEOS, Shire,
Takeda, Vaya Pharma
•Historical data – speaker’s bureau for Arbor, Bristol-Myers Squibb,
Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil,
Pfizer-Roerig, Sanofi~aventis, Searle, Sepracor, Shionogi,
Sunovion, Wyeth-Ayerst
•Distributor – Pharmanex supplements & Biophotonic scanner

3. Attention class!!
www.slideshare.net/lcadymd
Cady Wellness Institute app – Apple
“app” store or Google Android store
Where (else!) to get “the slides”

4. How to get the MOST out of this presentation:

5. But why haven’t I heard any of
this before?

6. • The body works like a machine.
• Mind = “non-material” & does not follow laws of nature.
• (The body can influence the otherwise rational mind.)
• Cartesian “dualism”
René Descartes
1596-1650

7. What you can do with an integrated approach
in 15 months ((permission granted to use photos & data)):
RX: Armour thyroid, dairy free diet (+IgG test); D3 5000 IU/d;, Testosterone
cypionate 100 mg IM q wk, MVI, Zinc, DHEA 50 mg SR, CoQ10 400mg
(photo shot 15
months after tx)
And fluoxetine was stopped. He no longer needed it.

11. [ http://www.umm.edu/patiented/articles/how_serious_hypothyroidism_000038_6.htm -
accessed August 2015 and 08 20 2016]
• “Thyrotropin (Thyroid-Stimulating Hormone or
TSH). Measuring TSH is the most sensitive
indicator of hypothyroidism.” (hunh?!) –
accessed 9/5/2011
• “…blood tests for measuring levels of
TSH and free thyroxine (T4) are the only
definitive way to diagnose
hypothyroidism” – 10/6/2012

12. http://umm.edu/health/medical/ency/articles/thyr
accessed 8/2/2013

13. 4

14. “the foot soldier” “the evil twin”
Selenium
required!
FEEDBACK
INHIBITION
CORTISOL
80% of T4 converted in
the liver
Iodine
required
(65% of T4)

15. What are the TYPES of
hypothyroidism (from the top down)?
• Tertiary hypothyroidism – deficiency in
hypothalamus – not enough TRH
• Secondary hypothyroidism –pituitary isn’t
kicking out enough TSH “your thyroid labs
are ‘just fine’”
• PRIMARY hypothyroidism – where thyroid
gland can’t make thyroid hormone
– This is the only one that high TSH is good for
diagnosing!!
• Low TSH
• Low TSH
Your doc is
happy!! 
• HIGH TSH
(finally!)

16. “the foot soldier” “the evil twin”
Selenium
required!
CORTISOL
80% of T4
converted in the
Conventional medical practice:
-Only TSH is typically considered.
-You get T4 if you’re lucky.
-Ill-considered: “T7”, Total T4, Total
T3, %T3 uptake
-You DON’T get Free T3 or Rev T3
Conventional medical practice:
-Only TSH is typically considered.
-You get T4 if you’re lucky.
-Ill-considered: “T7”, Total T4, Total
T3, %T3 uptake
-You DON’T get Free T3 or Rev T3

17. Review of all hypothyroid patients in
a private practice in Belgium
between May 1984 and July1997
• 24 hour urine Free T3 correlates better with
clinical status of hypothyroid patients, and
even better than T4 by RIA.
• Conclusions: In this study symptoms of
hypothyroidism correlate best with 24 h
urine free T3 Baisier WV et al. 2000, Vol. 10, No. 2 , Pages 105-113

18. Must have iodine to make T4!
Source: Office of Dietary Supplements, NIH accessed 8/11/2013
http://ods.od.nih.gov/factsheets/Iodine-QuickFacts/

19. Sources/locations of deficiency:
• Chlorinated or fluorinated drinking water
• Not using iodized salt
• Consumption of NaCL in processed foods
• Consumption of soy & “goitrogens” -
cabbage, broccoli, cauliflower and Brussels
sprouts
• Being pregnant
• People living with iodine deficient soils &
eating local foods

20. North America 85%
South America 76%
Asia 76%
Africa 74%
Europe 72%
Australia 55%
% Mineral depletion from the soil during the
past 100 years, by continent
Source: UN Earth Summit Report 1992

21. - Selenium is one of the factors that may affect the
risk of cognitive decline. In selenium deficiency the
brain remains selenium replete the longest
suggesting that Se plays an important role in brain
functions.
- Results from this study: “Low Se status is a risk
factor for cognitive decline even after taking into
account vascular risk factors.”

22. SELENIUM DEFICIENCY in FASEB:
• “Adaptive dysfunction of
selenoproteins from the
perspective of the ‘triage’
theory: why modest
selenium deficiency
may increase risk of
diseases of aging.”
Foundation of American Societies for
Experimental Biology
McCann, J, Ames BM. FASEB J.
2011 Jun;25(6):1793-814.

23. As of August 20, 2016
• “Low selenium status is associated with increased risk of
thyroid disease. Increased selenium intake may reduce the risk
in areas of low selenium intake.”
– Wu Q et al. Low population selenium status is associated with increased prevalence of
thyroid disease. J Clin Endocrinol Metab. 2015 Nov;100 (11):4037-47.
• “We demonstrated …the beneficial effects obtained by
selenomethionine treatment on patients affected by subclinical
hypothyroidism.”
– Nordio M. Combined treatment with myo-inositol and selenium ensures euthryoidism in
subclinical hypothyroidism patients with autoimmune thyroiditis. J Thyroid Res.
2013;2013:424163

24. • 123 citations search on “iron deficiency
hypothyroidism” as of 8/20/2016
• “Iron deficiency impairs thyroid
hormone synthesis by reducing
activity of heme-dependent thyroid
peroxidase.”
– Zimmermann MB, Kohle J.
Thyroid. 2002 Oct;12 (10):867-78
• Subclinical hypothyroidism assoc. with
Fe deficiency.
– Nekrasova TSA, 2013 Kloin Med (Mosk).2013; 91
(9):29-33.
• Fe deficiency assoc with Thyroid
microsomal antibody levels.
– Wang YP et al. J Formos Med Assoc. 2014
Mar;113(3):155-60.
• Fe salts + T4 worked best.
– Ravanbod M et al. Am J Med. 2013 May;126(5):420-
4.
*Integrative tip: check iron, TIBC, and
ferritin.
Consider IRON deficiency

25. “But the doctor told me my thyroid was fine.”
• Can be “wnl” but suboptimal.
• TSH frequently only thing checked.
• Nothing known about Free T4 or Free
T3.
• Free T4 can be converted to Reverse T3 under
stress (cortisol)
• Free T4 can be underconverted to T3 (Se def).
• Can have normal levels (or slightly elevated
levels) of everything and have auto-immune
thyroid disease.

26. • Early 20’s college student
• Weight gain, fatigue, brain fog
• Saw “numerous” MD’s asking for help
• Told “nothing is wrong with your thyroid;
your labs are fine.”
(permission granted to use photos & data)

27. (c) 2013 Louis B. Cady, M.D. - all
rights reserved
A physician’s wife. “Fatigued”
“No sex drive.”

28. “the foot soldier”
Selenium
required!
FEEDBACK
INHIBITION
CORTISOL
80% of T4 converted in the
liver
“the evil twin =
REVERSE T3”

29. Why Reverse T3?
• Hibernating bears can:
–Lower temperature 9 – 11
degrees Farenheit
–Reduce their metabolism by 75%
–Drop heart rate from 55 to 9 bpm
• Rev T3 thought to “hibernate”
humans

30. What causes elevation in Rev T3?
• High Cortisol (emotional stress) or high copper
• Nutritional starvation
• Heavy metal toxicity – mercury, lead,
cadmium*
• Selenium or Zinc deficiency*
• And high dose of thyroxine
(T4) – a “pro-hormone”
–iatrogenic!)
*Integrative tip: hair analysis is an inexpensive and effective screen. Also
RBC-Selenium and RBC Zinc.

31. Increased T4 and Rev T3, with decreased Free T3
associated with hypothyroidism at the TISSUE LEVEL
Van den Beld, AW, et al. Journ Clin Endo Metab. 2005; 90(12):6403-6409
FT3 (pg/dL)
Rev T3 (ng/dL)
>20:1 = optimal
Calculator: http://www.stopthethyroidmadness.com/rt3-ratio/
Notion of “Reverse T3 ratio”

32. ♦ Depressed mood 100%
♦ Reduced energy: 97%3
♦ Fatigue or loss of energy: 94%94%2
♦ Impaired concentration: 84%3
♦ Tiredness: 73%1
♦ Hypersomnia: 10%–16%4
(Insomnia)
Useful Target Symptoms in MajorUseful Target Symptoms in Major
DepressionDepression
1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J Gen Pract
1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath et al. J Affect
Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.

33. A FEW common symptoms of hypothyroidism
(adapted from multiple sources)
• Depression, fatigue
• Concentration problems
• Poor cognitive
performance
• Lack of motivation
• Reduced libido
• Psychosis – “myxedema
madness”
• Exacerbation of bipolar
symptoms 
• Cold intolerance
• Weight gain
• Slowed relaxation
phase of DTR’s
• Brittle hair/fingernails
• Decreasing eyebrows
• HIGH blood pressure
• Constipation

34. 1149 women - mean 69 years of age.
Definition of SCH: THS >4.0mU/L and normal
Free T4 (0.9 0 1.9 ng/dL) (Annals, 2000)
1149 women - mean 69 years of age.
Definition of SCH: THS >4.0mU/L and normal
Free T4 (0.9 0 1.9 ng/dL) (Annals, 2000)
“Subclinical hypothyroidism is a strong
indicator of risk for atherosclerosis and
myocardial infarction in elderly women.”
“Subclinical hypothyroidism is a strong
indicator of risk for atherosclerosis and
myocardial infarction in elderly women.”

35. Multiple study review
“normal FT4 and elevated TSH” Definition of
SCH: THS >4.0mU/L and normal Free T4 (0.9
0 1.9 ng/dL) (Annals, 2000)
Multiple study review
“normal FT4 and elevated TSH” Definition of
SCH: THS >4.0mU/L and normal Free T4 (0.9
0 1.9 ng/dL) (Annals, 2000)
“The treatment of subclinical hypothyroidism is
seldom necessary”
“The treatment of subclinical hypothyroidism is
seldom necessary”
Recommendation: only treat if TSH >10
(??????)
Recommendation: only treat if TSH >10
(??????)

36. “Data supporting associations of subclinical
thyroid disease with symptoms or adverse
clinical outcomes or benefits of treatment are
few.” (JAMA 2004)
“Data supporting associations of subclinical
thyroid disease with symptoms or adverse
clinical outcomes or benefits of treatment are
few.” (JAMA 2004)

37. Subclinical hypothyroidism in
the US– what’s the latest?
As of August 6, 2015• Synthesis: treat only those with TSH >10
– Hennessey JV Espaillat R. Diagnosis and management of
Subclinical Hypothyroidism in Elderly Adults: A Review of
the Literature. J Am Geriatr Soc. 2015 Jul 22. epub ahead of
print
• Synthesis: SCH [TSH >/= 4.5- 19.99] associated with hip and
other fractures.
– Blum MR et al. Subclinical thyroid dysfunction and fracture risk: a meta-
analysis. JAMA. 2015 May 26;3(20):2055-65.
• Synthesis: Treatment of SCH [TSH 4-11] improved risk of
coronary heart dz risks. “Direct evidence on the benefits
and harms of screening remains unavailable.”
– Rugge JB et al. Screening for and treatment of thyroid dysfunction: An
evidence review for the US. Rockville (MD) Agency for Healthcare
Research and Quality (IS);2014 Oct. Report No. 15-05217-EF-1.

38. As of August 21, 2016NEW LITERATURE – AUGUST 2016 – “Association between
serum thyrotopin levels and mortality among euthyroid
adults in the United States. [Inoue K et al. Thyroid. 2016 Aug 18 [Epub
ahead of print]
•Population – NHANES III study . N = 12,584 adults>/= 20
years of age.
•Associations between TSH tertiles (high, medium, and
low) and mortalities (all cause, cardiovascular and
cancer)
•Mean followup = 19.1 years with 3,395 deaths.
•Increase risk of all-cause mortality found in high
normal TSH compared to medium normal TSH group.
( Low normal compared to medium also had higher all
cause mortality).
•“This study indicated that the normal range of TSH
levels may require reevaluation.”

39. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN
COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON THYROID
DYSFUNCTION CASE FINDING. [Hennessy JV. Endoc Pract. 2016 Feb;22(2):262-70
We recommend that thyroid dysfunction should
be frequently considered as a potential etiology
for many of the nonspecific complaints that
physicians face daily. The application and success
of safe and effective interventions are dependent
on an accurate diagnosis. We, therefore,
advocate for an aggressive case-finding
approach, based on identifying those persons
most likely to have thyroid disease that will
benefit from its treatment.

40. This is it in a nutshell…
1. 70% of older patient with TSH > than 4.5 mIU/L were
within their age-specific reference range.
2. From the “Conclusion” statement: “TSH distribution
progressively shifts toward higher
concentrations with age. The prevalence of
SCH may be significantly overestimated unless
an age-specific range for TSH is used.”

41. Mental stretch break:
How would you take care of a classic?

42. Oil gets dirty; transmission fluid
breaks down. It is unnatural to
replace them or intervene. It’s just
part of the aging process.
Oil should be changed every 3-5K
miles. Transmission fluid per
owners manual. If you don’t keep
them clean and fresh, you are
STUPID.
The quality of the gas is irrelevant.
Anything that the motor will burn is
adequate.
We should use optimal quality of
gas. Cheap gas causes “pinging”
which is hard on the engine.
Preventive maintenance? This is
silly! Wait until something breaks,
then have the car towed in so the
mechanic can really tell what is
wrong. Too bad if it costs you a
fortune. (Or your car is ruined and
has to be replaced.)
We should take our car in for
preventive maintenance before
anything breaks. Everything should
be optimized. You can’t replace
your body.
“Conventional practice”

43. Oil gets dirty; transmission fluid
breaks down. It is unnatural to
replace them or intervene. It’s just
part of the aging process.
Oil should be changed every 3-5K
miles. Transmission fluid per
owners manual. If you don’t keep
them clean and fresh, you are
STUPID.
The quality of the gas is irrelevant.
Anything that the motor will burn is
adequate.
We should use optimal quality of
gas. Cheap gas causes “pinging”
which is hard on the engine.
Preventive maintenance? This is
silly! Wait until something breaks,
then have the car towed in so the
mechanic can really tell what is
wrong. Too bad if it costs you a
fortune. (Or your car is ruined and
has to be replaced.)
We should take our car in for
preventive maintenance before
anything breaks. Everything should
be optimized. You can’t replace
your body.
“Conventional practice” “Integrative”

44. How much subclinical hypothyroidism?
• 4 – 8.5% of US population (for TSH> 5.1!!)
– Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T4 and
thyroid autoantibodies in the United States population (1988–1994):
National Health and Nutrition Examination Survey (NHANES III) J Clin
Endocrinol Metab. 2002;87:489–99.
– Canaris GJ, Manowitz NR, Mayor G, et al. The Colorado Thyroid
Disease Prevalence Study. Arch Int Med. 2000;160:526–3
• UK study (2011): 8% of women over 50 and
men over 65 have under-active thyroid and
100,000 could benefit from treatment
– BBC News 2011 - January 24

45. More studies
• 24.2% of an adult female population in
Puerto Rico = hypothyroid
– Vonzales-Rodriguez LA, et al. Thyroid dysfunction in an adult female
population: A population-based study of Latin American Vertebral
Osteoporosis Study (LAVOS) - Puerto Rico site. P R Health Sci J. 2013
Jun; 32(2):57-62.

46. Modern Medicine’s Paradigm: 2 Standard Deviations –
“if you are not sick, then you must be well.”
“NORMAL”
OPTIMAL TSH:
{<2 0r <1 per some experts)
TSH = 0.45 4.12 source:
Percentile (2.5th%
97.5th
% NHANES III

47. Average (normal) or optimal?
• Would you like an normal wife (husband) or
an optimal one?
• Would you like a “normal” marriage or an
exciting and optimal one?
• Would you like a “normal” medical practice
or an incredible, exciting, and (optimal!!)
stimulating one?
• Would you like “normal” thyroid
labs or OPTIMAL ones?

48. Definition of “normal labs”:
“When your lab
values are as
crappy as
everyone else’s.”
- Neal Rouzier, MD
(World Link Medical Seminar II –
Spring 2011)

49. So what are people
doing out there?
What does the literature say?

50. As of 8/21/2016 (6
more than last year)
Yes.
Correlated, yes.
No apparent link.
Yes.
Yes.

51. As of
8/5/2015
“schizophrenia subclinical hypothyroidism – 6 results
8/21/2016
• “These findings render possible the diagnosis
of subclinical hypothyroidism in neuroleptic-
treated schizophrenic patients.”
Martinos A et al. Effects of six weeks’ neuroleptic treatment on the pituitary-=thyroid axis in
schizophrenic patients. Neuropsychobiology. 1986; 16 (2-3):72-7.
• The depressives and schizophrenics showed
subclinical or chemical hypothyroidism while
the manic showed slightly higher values for
T(3), and T(4), when compared to normal
control subjects.
• Boral GC . Thyroid function in different psychiatric disorders. Indian J Psychiatry. 1980 Apr,
22(2):200 – 2

52. CONCLUSIONS: This is the first study to
demonstrate associations between CBCL-DP
[Child Behavior Checklist Dysregulation Profile]
and subclinical hypothyroidism.

53. • “Thyroid abnormalities occur frequently in patients with BD
regardless of treatment.” [Lambert CG et al. Bipolar Disord. 2016 May;18(3):247-
60]
• Patients with SCH had poorer performance than patients
without SCH in measures of verbal memory, attention,
language, and executive functions. [Martino DJ, et al. Subclinical
hypothyroidism and neurocognitive functioning in bipolar disorder. J Psychiatr Res. 2015
Feb;61:166-7]
• “There is no significant association between hypothyroidism
and bipolar disorder.” Menon B. Hypothyroidism and bipolar affective disorder: is
there a connection. Indian J. Psychol Med. 2014 Apr;36(2):125-8
• Hypothyroidism, either overt or more commonly subclinical,
appears to the commonest abnormality found in bipolar
disorder. Chakrabarti S. Thyroid functions and bipolar affective disorder. J Thyroid
Res. 2011;2011; 2011:306367.
44 citations – 8/21/2016

54. Aim: evaluate biological factors assoc. with suicide attempts in
naturalistic sample
439 patients with major depression, bipolar and psychotic
disorders consecutively assessed in the ER of an Italian Hospital
(Jan 2008-Dec 2009)
Suicide attempters were 2.27 times less likely to
have higher Free T3 values than non-attempters (odds
ratio = 0.44; 95% CI; p=0.01) (prolactin level differences failed to
reach significance)

55. Treatment resistant depression is a common challenge.
Best augmenting strategies available:
-Lithium
-Thyroid hormone
-Anti-anxiety medications
-Atypical antipsychotics.

56. Per HDRS – 17, remission in:
15.9% on Li
24.7% on T3
Per QIDS-SR16, remission in:
13.2% on Li
24.7% for T3 *
* Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial, Medscape Psychiatry
LEVEL III RESULTS:

57. 63 patients with “subclinical hypothyroidism”
HAM-D and MADRS scales with serum TSH Free T4, free T3
TPO AB and Tg-AB levels
“This study suggests the importance of a psychiatric
evaluation in patients affected by subclinical
hypothyroidism.”
Prevalence of depressive symptoms in this
population was 63.5%
Hunh?

58. Aim: Evaluate relationship of subclinical hypothyroidism and cognition in the
elderly.
- 337 outpatients; {177 = men; 160 = women}
“Patients with subclinical hypothyroidism had a probability about
2 times greater (RR = 2.028, p<0.05) of developing cognitive
impairment.”
MMSE scores were SIGNIFICANTLY lower in
subclinical hypothyroid patients compared to
euthyroid (p<0.03)

59. An opposing view:
• “Thus, any abnormal thyroid function tests in
psychiatric patients should be viewed with
skepticism. Given the fact that thyroid function
test abnormalities seen in non-thyroidal illness
usually resolve spontaneously, treatment is
generally unnecessary, and may even be
potentially harmful.”
• Dicerman AL, Barnhill JW. Abnormal thyroid function
tests in psychiatric patients: a red herring? Am J
Psychiatry. 2012 Feb;169(2):127-33

60. Dr. Imre Zs-Nagy, MD – one more time!
Archives of Gerontology and Geriatrics, Volume 48, Issue 3, May-June 2009, 271-275
"[The] gerontological elite has instead
sought to obfuscate the facts ... the
reason for this is nothing less than an
abject fear ... to avert their loss of
control, power, prestige, and position
in the multi-billion dollar industry of
gerontological medicine.”
Prof. Dr. Imre Zs.-Nagy, MD - part of the gerontology
movement for four decades; founder and Editor-in-Chief
of the Archives of Gerontology and Geriatrics

61. “Subtle deficits in specific cognitive domains
(primarily working memory and executive
function) likely exist in subclinical
hypothyroidism and thyrotoxicosis, but these
are unlike to cause major problems in most
patients.” (Endocrinol Metab Clin North Am.
2014 Jun)
“Subtle deficits in specific cognitive domains
(primarily working memory and executive
function) likely exist in subclinical
hypothyroidism and thyrotoxicosis, but these
are unlike to cause major problems in most
patients.” (Endocrinol Metab Clin North Am.
2014 Jun)
“Patients with mild thyroid disease and
significant distress related to mood or
cognition most likely (??) have independent
diagnoses that should be evaluated and
treated separately.”
“Patients with mild thyroid disease and
significant distress related to mood or
cognition most likely (??) have independent
diagnoses that should be evaluated and
treated separately.”

62. The Glamorous Grandmother
• 4/8/11 – 80 yo returned to practice. No real
complaints. History of depression. On des-
methylvenlafaxine.
– Daughter “handling her finances”
• 5/2/11 – “doing terrible.”
– TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4
– Fasting BS 120; HgBA1C 6.5%
– Fasting insulin 36 (!!!) {3 – 25}
– Progesterone – 0.2 {0.2 – 1.4 follicular}
– Total testosterone 11
– DHEA-S = 25 MICROgrams/dL (!!)

63. G.G. - interventions 5/2/11 & Follow-up
• Interventions:
– RAISE T4 from 50 to 75 MICROgrams
– DHEA – 25 mg SR q a.m.
– Progesterone 50 mg then 100 mg HS, transdermal.
– Testosterone – 2 mg for one week, then 4 mg
transdermal
– Referred to better MD for intervention with AODM.
• 6/13/2011 – improvement in fatigue. Labs
rechecked.
• 7/11/2011 – “feeling wonderful”
• 2012 – 2014 – N.P. meddled with thyroid Rx;
began declining; returned back to baseline Rx.

64. G.G. – labs before and after
` 4/11/11 interventions 7/11/11 changes
TSH 3.84 Raise T4 from
50 – 75 ug
0.01 (L) none
FT4 1.16 “ 1.24 “
FT3 2.8 “ 3.3 “
Progesterone <0.2 100mg topical
HS
0.9 None
Testosterone 11 4mg topical 15 4 mg LABIAL
DHEA-S 25 25 mg SR n/a continue

65. The glamorous grandmother – post tune-up: DHEA,
thyroid, testosterone, progesterone
9/28/2011 (permission granted to use photos & data) 01/26/2012

66. July 29, 2014 – used with permission
85 years old – living
independently
•Reading books
•Driving car
•Dating nice man from
church
•Thyroid RX:
– T4 – 75 ug
– T3 – 5 ug 2x/d
•Hormones:
– DHEA 50 SR, Biest,
Progesterone,
Testosterone

67. G.G. – interventions & labs
` 4/11/11 Interventions,
current
6/9/2014 Ref range
TSH 3.84 Raise T4 from 50 –
75 MICROgrams,
add 10
MICROgrams T3
0.02 (L) {0.45-4.5}
FT4 1.16 “ 1.07 {0.80-1.76}
FT3 2.8 “ 4.0  {2.3 – 4.2}
Estradiol 0.4 mg E2 SL 20 {27-122}
Progesterone <0.2 10 mg SL HS 1.5 {0.2 – 1.4 =
follicular}
Testosterone 11 2 mg topical (wrists) 235(H) {5-32}
DHEA-S 25 50 mg SR 463 (“H”) {“10 – 90”}
NTX 19!!  {17 – 94 –
premenopausal}

68. Health Status, Mood, and Cognition in Experimentally
Induced Subclinical THYROTOXICOSIS [emphasis Cady]
Samuel MH et al. J Clin Endocrinol Metab May 2008, 3(5):1730-1736
• 33 hypothyroid subjects receiving T4
• Double blind, randomized, cross-over study
of usual dose T4 or higher dose T4
• Mean TSH levels decreased from 2.15 to
0.17 mU/L on “subclinical thyrotoxicosis”
arm (p<0.0001) with NORMAL FREE T4
AND FREE T3 LEVELS.
• So what happened???

69. Health Status, Mood, and Cognition in Experimentally
Induced Subclinical THYROTOXICOSIS [emphasis Cady]
Samuel MH et al. J Clin Endocrinol Metab May 2008, 3(5):1730-1736
• POMS (Profile of Mood States) confusion,
depression, and tension subscales IMPROVED.
• Motor learning was better
• “These findings suggest that thyroid
hormone directly affects brain areas
responsible for affect and motor
function.”
• Question to ponder: were they really
“thyrotoxic”? Or were they OPTIMIZED?

70. Association of thyroid dysfunction with
depression in a teaching hospital
Johan SO et al. J Nepal Health Res Counc. 2013 Jan;11(23):30-4
• 70 patients diagnosed with first episode
depression - selected by random sampling
– 21% found to have thyroid dysfunction of some
type
–11% were found to have
SUBCLINICAL HYPOTHYROIDISM
• Conclusions: “…thyroid dysfunction is
common in depressed patients…”

71. Low mood and response to levothyroxine treatment in Indian
patients with subclinical hypothyroidism
[Visnoi G et al. Asian J Psychiatr. 2014 Apr; 8:89-93]
• 300 patients with SCH vs. sex matched controls
• HAM-D significantly higher for SCH
• Positive correlation between Hamilton scores and
serum TSH
R(2)0.87, p = 0.00
“Levothyroxine treatment
resulted in a significant decrease
in TSH levels and
Hamilton scores.”
April 2014

72. August
2014

73. Demartini B, et al, cont. J Nerv Ment Dis 2014 Aug
• 123 consecutive outpatients with SCH vs control
group w/o thyroid disease
• Psychiatric interview, HAM-D, MADRS
• TSH, Free F4, Free T3
• Scales:
– HAM-D 63.4% vs. 27.6%
– MADRS 64.2% vs. 29.3%
– DX of patients 17 vs. 7
• “The prevalence of depressive symptoms
between these two groups was statistically
significant.”

74. HEART DISEASE risk
• Citation: Subclinical hypothyroidism and the risk
of coronary heart disease: a meta-analysis.
Rodondi N et al. Amer. Jour of Med. July 2006,
119, 541-551. (meta-analysis)
• Medline search from 1966- April 2005
– 14 observational studies met criteria
• Subclinical hypothyroidism (elevated TSH,
normal T4) increased odds ratio of CHD
to 2.38 (CI 1.53-3.69) after adjusting for risk
factors

75. Rhee CM et al. J Clin Endocrinol Metab. 2013 Jun; 98(6):2326-36.
“Subclinical hypothyroidism vs.
euthryoidism was associated with
greater mortality in those with CHF
but not in those without.” [Adj.
hazard ratio = 1.44X, CI = 95%]
“Subclinical hypothyroidism vs.
euthryoidism was associated with
greater mortality in those with CHF
but not in those without.” [Adj.
hazard ratio = 1.44X, CI = 95%]

76. So what does the American Association of
Clinical Endocrinologists (ACEE) say?
• “The upper limit of TSH should remain
at 4.5 mIU/L, rather than 3.0-3.5 as
some other organizations have
suggested.”
• “Routine T4 treatment for patients with
TSH between 4.5 and 10mIU/L is not
warranted.”
– https://www.aace.com/files/position-
statements/subclinical.pdf retrieved August 25,
2014

77. Lab values – one more time…”4.5” is where the American
Assn. of Clin. Endocrinologists wants the highest level of TSH
TSH = 0.45 4.12 source:
Percentile (2.5th%
97.5th
% NHANES III
4.5 is the
upper limit
they want –
this is at c.
the 99th
%

78. The perils of pharmacology
“Too much… of a
good thing… is
WONDERFUL.”
– Mae West

79. A word of caution, and a reflection on the
Glamorous Grandmother
• OPUS (Osteoporosis & Ultrasound Study) - 2,940
POST-menopausal women 6 year prospective study
– 1,278 healthy euthyroid average 68yo women selected
19 yrs post-menopausal who did not take any medication that
might affect their bones.
• The higher one's FT3 and/or FT4, the lower one's
BMD and the greater one's risk of non-vertebral
fracture.
• FT4 <0.88ng/dL had better outcomes than those w/FT4
>1.12ng/dL.
Source: Murphy E, et al. Thyroid function within the upper normal range is associated with reduced bone mineral density and an
increased risk of nonvertebral fractures in healthy euthyroid postmenopausal women. J Clin Endocrinol Metabl. 2010 Jul;95(7):3173-
81. with commentary adapted from Alvin Lin, MD Las Vegas, NV.

80. BUT: does Grandma have to pick between
optimally euthyroid or osteoporotic?
• 57 yo MWF transferred to me - 11/19/2009
– On Prometrium, Androgel (??? Tiny dose), Bi-est,
Estriol pV, and Norditropin (which was
subsequently able to be tapered with DHEA)
– Armour thyroid – 30 mg
• PMH
– TSH of 6.89 in June 2007
– Bone densitometry – within normal limits
• PE – hint of thyromegaly.
– Neuro – normal DTR’s, normal exam

81. Case study – a woman with her TSH
“suppressed” from 1.19 to 0.10 (L)
` 1/4/11 3/1811 5/16/11 11/14/2012
Thyroid Rx 75ug T4 /
15 ug T3
75ug T4 /
10 ug T3
100 ug T4/ 5
ug T3 bid
100 ug T4/ 5 ug T3
bid
TSH {0.34-
4.72}
0.12 1.19 0.06 (L) 0.10 (L)
FT4 {0.6 – 1.8} 0.5 (L) 0.5 (L) 0.9 0.6 (L)
FT3 {2.0 – 4.4} 2.8 3.2 3.7 3.4
Rev T3 Within
normal
limits
Within
normal
limits
Within
normal limits
Within normal limits
NORMAL
???????

82. Case study – a woman with her TSH “suppressed”
“The Rest of the Story”
` 1/4/11 3/18/11 5/16/11 11/14/2012
Estradiol
{12.5-166.3}
0.12 21.2 53.3 15.1
Progesterone 1.9 2.0 2.4 2.0
Testosterone,
total
50 41 118 (H) 60
LH/FSH 53.9/86.4 59.6/94.9
DHEA-S 314.2 363.8 573.1 (draw
after Rx)
481.1 (H)
25-OH Vit D 53.7
NTx-
Telopep
7.5 {6.2-
19.0}
On triple Hormone RX, DHEA, Vit D & MVI
Bone loss of a teen – 20 yo

83. Thyroid treatment riffs:
• “Compounded slow-release T3 has been
suggested for use in combination with T4,
which proponents argue will mitigate many of
the symptoms of functional hypothyroidism and
improve quality of life. This is still controversial
and is rejected by the conventional medical
establishment.” [?????]
– Todd, C H (2010). "Management of thyroid
disorders in primary care: challenges and
controversies". Postgraduate Medical Journal 85
(2010): 655–9.

84. Rx controversies:
• “As of 2012 there are no controlled trials
supporting the preferred use of desiccated
thyroid hormone over synthetic L-thyroxine
in the treatment of hypothyroidism or any
other thyroid disease.”
– American Thyroid Association
– Garber, Jeffrey R., et al. “Clinical practice guidelines for
hypothyroidism in adults: cosponsored by the American
Association of Clinical Endocrinologists and the American Thyroid
Association.” Endocrine Practice 18.6 (2012): 988-1028.

85. 70 patients- ages 18-65 years of age. w/ primary hypothyroidism on stable T4 for 6
months.
70 patients- ages 18-65 years of age. w/ primary hypothyroidism on stable T4 for 6
months.
Randomized to either dessicated thyroid extract (DTE) or T4 for 16 months, then
crossed over for another 16 months.
Randomized to either dessicated thyroid extract (DTE) or T4 for 16 months, then
crossed over for another 16 months.
RESULTS:
- “No differences in symptoms” and neurocognitive measures.
RESULTS:
- “No differences in symptoms” and neurocognitive measures.
BUT:
-DTE patients lost 3 lbs!
-48.6% of patients (n=34) PREFERRED DTE.
-Those patients preferring DTE lost 4 lbs during the DTE treatment and
subjective symptoms were all significantly better while
taking DTE as per general health questionnaire-12 and
thyroid symptom questionnaire.
BUT:
-DTE patients lost 3 lbs!
-48.6% of patients (n=34) PREFERRED DTE.
-Those patients preferring DTE lost 4 lbs during the DTE treatment and
subjective symptoms were all significantly better while
taking DTE as per general health questionnaire-12 and
thyroid symptom questionnaire.

86. “Conclusions”:
- DTE therapy did not result in a significant improvement in quality of life; however,
DTE caused modest weight loss and nearly half (46.8%) of the study patients
expressed preference for DTE over L-T4.
DTE therapy may be relevant for some hypothyroid
patients.” [Can you believe it????]
“Conclusions”:
- DTE therapy did not result in a significant improvement in quality of life; however,
DTE caused modest weight loss and nearly half (46.8%) of the study patients
expressed preference for DTE over L-T4.
DTE therapy may be relevant for some hypothyroid
patients.” [Can you believe it????]

87. Finally….Rambo no go?

88. Kelly, T. An examination of myth: a favorable
cardiovascular risk-benefit analysis of high-dose thyroid
for affective disorders. J Affect Disord. 2015 May
15;177:49-58
CONCLUSION:
The cardiovascular risks of HDT appear
to be low. HDT is at least as safe as or
safer than many psychiatric
medications. It is effective and well
tolerated.
CONCLUSION:
The cardiovascular risks of HDT appear
to be low. HDT is at least as safe as or
safer than many psychiatric
medications. It is effective and well
tolerated.
CONCLUSION:
High circulating levels of thyroid
hormone is not the cause of the sequela
of hyperthyroidism. The reluctance to
using high dose thyroid is unwarranted.
CONCLUSION:
High circulating levels of thyroid
hormone is not the cause of the sequela
of hyperthyroidism. The reluctance to
using high dose thyroid is unwarranted.
Kelly, T et al. Elevated levels of circulating thyroid
hormone do not cause the medical sequelae of
hyperthyroidism.
Prog Neuropsychopharmacol Biol Psychiatry. 2016 Jun
11;71:1-6.

89. So what the
heck am I
supposed to
do with this
stuff?

90. Framework:
• Decide where in the literature you want to be.
• Do you want to practice the way things “used
to be” or do you want to practice evidence
based medicine?
– [or just blindly listen to the specialty societies
who parrot from the past?]
• Do you want your patient to be “normal” or
“optimal”?
• And can you live with yourself and your
decision?

91. Rx:
• Synthroid ® (levothyroxine)
• Cytomel ® (Tri-iodothyronine – “T3”)
– Instant release (cheap!)
– Compounded in SR capsule (easier
dosing)
• Armour® thyroid (brand or
generic) = T4 + T3
• Naturethroid & Westhroid = T4 +
T3 – better tolerated in some

92. Holistic Rx:• Background:
– There are 4 molecules of iodine on T4 (thyroxine =
thyroid hormone) and 3 molecules of iodine on T3,
active thyroid hormone.
– T4 is made up of 63% iodine.
– How can we make them if we don’t have enough
iodine?
• Filter your drinking water.
• Iodine supplementation as needed (testing)
• And consider selenium supplementation

93. Dx:
• TSH
• Free T4
• Free T3
• Reverse T3
• If indicated:
– Anti-thyroid antibodies (anti-
TPO)
– Anti-thyroglobulin antibodies
– Thyrotropin receptor antibodies
(TRAb’s)
• We typically do not do:
– Total T4, Total T3, or thyroid
reuptake
Test! Test! Test!

94. Thyroid “by the numbers.”
1. Review this lecture.
2. Go get good training. (Neal Rouzier, MD)
3. PSYCHIATRISTS! Acknowledge that “T3 augmentation” is in your
literature and it is your RIGHT TO PRACTICE IT. (Consider “HDT”!)
4. Therapists/other practitioners: wake up! Don’t fall into trap of “blaming”
the functionally hypothyroid patient. REFER!
5. Start LOW.
6. Go SLOW.
7. Test test test test test.
– MUST GET BASELINE (which typically hasn’t been done).
– If you are unsure or nervous, TEST.
– MONITOR THE THERAPY.
1. Explain “Goldilocks and the Three Bears” to your patients and start
LOW, giving them some flexibility.

95. “Sit down before fact as a little
child,
- Thomas H. Huxley
be prepared to give up
every preconceived
notion,
follow humbly wherever
… nature leads,
or you shall learn
nothing.”

96. Contact information and slide resour
Louis B. Cady, MD
Cady Wellness Institute
4727 Rosebud Lane – Suite F
Newburgh, IN 47630 USA
Office (812) 429-0772
info@cadywellness.com
Available on Apple “app store” and
Google Android store.
www.slideshare.net/lcadymd