Is a Thyroid Disorder or a Gut Issue Causing Your Symptoms?

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Dr. Ruscio, DC:

Hi everyone, and welcome back to Dr. Ruscio, DC radio. This is Dr. Ruscio, DC. Let’s jump into a case study overview I’d like to walk you through that illustrates this interplay that when we work with a new patient we’re trying to balance, which is really asking the question, where is someone’s symptoms coming from? And we’ll go through a case here where someone had been suggested that the symptoms were coming from their thyroid and they were diagnosed hypothyroid. However, if you look at the symptoms with a discerning eye, you see that these symptoms don’t look very much like thyroid symptoms, which, I’ll help to clarify that a little bit here in a moment, and look more like they’re gut-derived symptoms.

Dr. Ruscio, DC:

And so we’ll walk through: you’re someone with a number of symptoms, how can you tell where they’re coming from? And what is the thought process for: “I was diagnosed with hypothyroid prior, I’m on medication, I’m still not feeling great, what do I do?” How does a clinician, like myself, think through this? How do we discuss this with the patient? And how do we organize our actions so that we can figure out what is causing symptoms with minimal confusion? I think this is one of the things that patients struggle with the most, is feeling like there’s not a good process that’s being worked through. And there’s not a high degree of understanding and clarity in terms of what’s causing their symptoms, or how are we figuring out what’s causing symptoms?

Dr. Ruscio, DC:

So, in this case, we have a roughly 60-year-old female, Beth, with the symptoms of anxiety, some gas, bloating, and fatigue. Now, if we just honed in on these, especially with the fatigue, one might say, “oh, it sounds like thyroid.” But as you look a little bit further, there’s also some hives,there’s also some intolerance to leftover foods, some anxiety, and even some vaginal dryness, disinterest in sex, brain fog. And even further, Hypotension, low blood pressure, and episodes of dizziness when standing.

Dr. Ruscio, DC:

So already, when I’m just looking at these symptoms, I’m thinking obviously histamine intolerance, which stems back to the gut in most cases. But also, that this person could be under-eating and/or eating too low carb, knowing that some patients who are motivated, read a whole bunch about diet and they end up spackling together all these different dietary restrictions and end up undereating either total calories or their carbs. And that can lead to fatigue. It can lead to poor sleep, as the early waking she also reported, and it can lead to low blood pressure and/or dizziness when standing.

Dr. Ruscio, DC:

So already looking at this, I’m saying, okay, I have my problems-list here. I’m definitely going to flag that hypothyroidism may have been incorrectly diagnosed, although we’re not gonna do that dogmatically. We’re gonna build a case for it. Histamine intolerance, which is usually downstream from either overgrowth or dysbiosis in the gut, amongst some other things. But those are a few chief causes. And also electro insufficiency, too low calorie, too low carb, and female hormone imbalances.

Dr. Ruscio, DC:

So let’s go further through the process and start building a case or ruling some things out. So the one thing I want to kind of check-in on here is what was the diagnosis based upon for the hypothyroidism? It was diagnosed via her endocrinologist. This is one area where I want to credit conventional medicine. They do a much better job of calling balls and strikes here, or just diagnosing people correctly or not. That’s one point boding in the favor of the diagnosis being correct. She was started on a low dose, which also bodes in favor of the endocrinologist not being this heretic. I cross-reference this with her current lab work from a few months ago, and her TSH is 4.4, and her free T4 is 1.3.

Dr. Ruscio, DC:

Now what you’ll see when someone’s working with a heretical prescribing is that their TSH will be very low, sometimes flagged low, and their free T4 will be flagged high. Cause a practitioner is saying, “oh, more thyroid hormone, more thyroid hormone, more thyroid hormone.” So, I’m not seeing that here. Right? So all of this is making me think, “hm, okay.” Firstly, endos tend to be more evidence guided here and better at doing this the right way, thankfully, and some of the follow-up inquiries: lower dose reinforced by her lab work—also support that the endo is not just beating on the drum of “thyroid.”

Dr. Ruscio, DC:

When I asked her what else was happening at the time of diagnosis, “do you remember what your labs looked like?” She said, “my TSH was seven, and I think everything else was normal.” Okay. So this would be likely, I mean, we don’t know for sure, but subclinical hypothyroidism where the TSH is elevated and the T4 is normal. And it’s the 7-10 range that that’s when you’re starting to think about hormones being a viable option. Now I used to say 10, and as more evidence is pouring in, it looks like between 7 and 10 is the range where one may want to start thinking about thyroid hormone for those with subclinical hypothyroidism. Now the older you are, the less you care about some of the elevations in TSH cause it tends to creep up over time. At the time of diagnosis, she was about 47. So that’s not 65-75. So again, I’m thinking that the endo here is thinking through this logically.

Dr. Ruscio, DC:

The logical follow-up is, did you feel any better when you started on, in this case, the Synthroid? And her comment was, “yes, it improved my fatigue, and it helped me with weight loss.” She also commented, “I believe that other things were happening and/or it’s hard to say if the Synthroid was fully helpful.” But you know, we’re gonna list this objectively.

Dr. Ruscio, DC:

So right now, we’ve built a case that bodes more in favor of her being subclinical hypothyroid and needing medication for that. And I explained all of this to her, but I also remarked that a decent percentage, it’s around 50%, of subclinical hypothyroid cases will correct themselves with no treatment. And she said, “oh, that’s interesting. And so, does that mean I may not need the medication?” And I said yes. And she said, “well, what about lowering the antibodies? Which I also have positive. My endocrinologist said, ‘there’s nothing you can do to lower the antibodies other than go on medication’”. Which, by the way, is true. Thyroid hormone medication— Synthroid, Levothyroxine, what have you—has been shown to lower antibodies. And of course, the answer there is, well, so far, I’ve been in agreement with everything your endo has said, and I give him or her full credit.

Dr. Ruscio, DC:

This is an area where I’m not gonna fault your endo cause we can’t expect them to know everything about everything. But there are some dietary trials that have shown the ability to lower thyroid antibodies and also some supplement trials, most namely with vitamin D and selenium, that have been shown to be able to lower thyroid antibodies. And also, a couple of interventional trials that have shown the ability to enhance or help those who are subclinical hypothyroid become normal.

Dr. Ruscio, DC:

So zooming way out, okay, let’s reframe where we are. We’ve dug down into thyroid, and here’s what we have so far: your endocrinologist seems like they were pretty rational. You’re on this borderline where hormone for you may have made sense. However, we also know that a subset of these individuals, a decent subset of these individuals, will remit with no treatment, and you’ve been doing a lot of stuff for your health, and we’re gonna do some more intervention for your health. Therefore we’ll make this a mid-level consideration.

Dr. Ruscio, DC:

Let’s focus on, what’s probably the primary driver of your symptoms, at least right now, your gut health—see how your symptoms evolve, consider some other items, along with the gut health, meaning addressing your carbs, if they’re too low, (which, I haven’t dove into that yet, but we’ll come into that in a moment) and getting you on some electrolytes. And then let’s see how that goes. Maybe secondary to that, we’ll use some female hormone support depending on what symptoms are still present.

Dr. Ruscio, DC:

Once we have you at a level where you’re feeling improved, and we’re consistent in that improvement, then we can ask you to check back in with your endo and we can, together, go through the experiment of a withdrawal from the thyroid hormone, and then retesting six to eight weeks later and simply looking to see what happens to your hormones. Does your TSH shoot up to seven or above? Do you end up becoming subclinical and/or full-blown hypothyroid? And then we can figure out how we go from there. But we can’t successfully do that until we’ve cleared out some of the symptomatic noise. We want to have you feeling better consistently, and we have that new baseline to then run the thyroid experiment from.

Dr. Ruscio, DC:

Okay, so that’s piece one. So now we come to the issue of: is she too low carb? So as I look into her dietary history, you see she’s done low FODMAP, low histamine. She’s tried autoimmune paleo; didn’t really seem any better than low FODMAP or low histamine. In fact, low FODMAP and low histamine were the most helpful. And she’s currently doing this low FODMAP, low histamine, paleo-type-combination diet. And as I probe further, are you eating much in the way of starchy carbs and certain fruits? She says, no, I’m pretty low carb. How do you feel on things like rice and potatoes? Oh, I feel good on them, but I feel like they’re not healthy for you. Okay.

Dr. Ruscio, DC:

So right there, those few pieces of evidence are fairly striking points that support that she’s too low carb. That perfectly maps onto her symptoms. So as she’s saying all this, I’m typing away, making notes, and making sure this is something we’re gonna address early on. Especially if she notices that starchy carbs feel good to her, she’s probably just avoiding them because of, you know, insert-thyroid-guru here. Who’s saying that, “don’t eat lectins cause it’ll flare autoimmunity. Don’t eat any type of grains because it’ll flare autoimmunity.” And this is, unfortunately, mis-messaging that hurts people. I want to give some of the educators the benefit of the doubt, but it’s really gotten to a point now where we see this so often—this is my second case like this this week—that I’m just gonna start calling it out candidly.

Dr. Ruscio, DC:

Okay. So we’ve qualified her thyroid is something we’re gonna come to kind of third in the general order of things. And we’ve also qualified that she is almost for certain eating too low carb, and that’s likely causing some electrolyte insufficiency. And those are fairly easy fixes, which may quickly help with fatigue, with anxiety, with early waking, and may have a spillover effect, fairly likely to libido, vaginal dryness, mental fog, and obviously with the dizziness when standing quickly. So already just by going through the process of learning about the person, we’re getting a lot of valuable data in terms of what can we do to help you. And notice, please, that I’m not saying to myself or to her, “well you’re fatigued, so we need adrenal testing, you have brain fog, so we need MTHFR testing, you have food reactivity, so we need food allergy testing.” These things would, undoubtedly, hurt this person and make the situation worse. Okay. So already, I’m feeling pretty good about where we are.

Dr. Ruscio, DC:

Now, we also come to the elephant in the room here, or the real crux of the issue, which is her gut health. Now, these symptoms are fairly evident supporting something like SIBO or dysbiosis. I’m not thinking her symptoms are due to poor diet cause she’s got that pretty dialed in. So instead of saying, “well, we’ve gotta do a bunch of testing to quantify this”, we can do some testing, but let’s glance at your treatment history to get some ideas. She’s done Rifaximin and Neomycin; it was very helpful for the bloating. It also helps some of [her] post-meal fatigue. Hmm. That’s a good sign. The antihistamine, Quercetin, has also been helpful. Magnesium helped to regulate [her] bowels.

Dr. Ruscio, DC:

Okay, great. What about probiotics? She’s only tried two. One was like seven years ago and one more recently, histamine free, and she’s not sure if they’re helping. Now, this is common for me to hear. And there’s usually two things: one, oftentimes people are using an insufficient dose and then two, at least as best I’ve been able to say (and we’re hoping to publish something on this with within a year or so, we’re currently collecting data), the triple therapy probiotic, meaning using three probiotic formulas—akin to using the two antibiotics, right, similar to that approach—is fairly likely to help this person.

Dr. Ruscio, DC:

She tried elemental dieting, but it gave her heart palpitations. I also suspect she was drinking it much too fast. No response to Claritin or Zyrtec and no response to digestive enzymes. So, okay. So right here, I’m seeing there’s a signal that antimicrobial therapy can help you. There’s some use of probiotics in the past, but it’s been kind of haphazard. And I doubt that she’s used enough dose or a clinically viable protocol. So that’s definitely a huge piece of low-hanging fruit that we’re going to explore. Are we gonna be dogmatic? And if someone’s not responding to probiotics, say, “stay on them for seven years because it’s an onion peeling effect.” No. But we definitely want to make sure, especially in cases of histamine intolerance with associated dysbiosis and or overgrowth, that we’re using that foundational therapy for her gut. What else? From her prior lab work from a few months ago, she had flagged extremely low ferritin and also low MCV/MCH hemoglobin.

Dr. Ruscio, DC:

And it turns out she is donating blood three times per year. So thankfully, and obviously, her doctor, who had ordered these labs a few months ago, started her on iron. And I followed up encouraging that and saying, yep, we definitely wanna monitor this. Cause when you’re that low, it’s no surprise that you’re having fatigue, but we also want to have you stop—at least until you get back to normal—the three times per year of donating blood. She also reported, historically, she had heavy menstrual cycles. So all of this together really starts painting a picture of why she’s experiencing some of the symptoms that she is.

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Dr. Ruscio, DC:

Okay. I guess that’s really it, right? So what my problems-list looks like is underneath “dietary and lifestyle”: dietary mismatch, too low carb, too restrictive, and limbic imbalances, maybe, you know, there was some history of prior trauma, but she doesn’t present like a typical limbic imbalance individual would. So I’m putting this kind of mid-to-end level. It’s a consideration, but there’s not strong support. Underneath “gastrointestinal”: SIBO, she had a mild case found prior, dysbiosis, candida, potentially gastritis, potentially hypochlorhydria, histamine intolerance, of course, that one is going to flag. And then under “hormonal”: female hormone imbalances, there’s definitely some evidence there, inappropriate use of thyroid hormone potentially, right? It’s not strongly indicated, so we’re not gonna be dogmatic. We’re gonna always make these decisions based upon what the evidence shows us.

Dr. Ruscio, DC:

And incorrect thyroid diagnosis? Potentially. I think the subclinical hypothyroidism was probably correctly diagnosed, but we want to reappraise that. Under “nutritional”: electrolyte insufficient? Definitely, the dizziness and the low blood pressure, especially when occurring in the context of too low carb. And also iron insufficient, which we’ve already established from her blood work. And there’s a couple of other considerations, like sleep disorder breathing, potentially. She had some stenosis in her throat. So, there’s other much more likely causes of things like fatigue and brain fog. But this is gonna be flagged on my list for end-phase, for us to consider doing a simple at-home sleep test, to see if perhaps there’s brain fog that doesn’t fully respond or fatigue that doesn’t fully respond, now we can go here. And mold is on the list as a very end-phase consideration cause she did have a prior ERMI that had mild findings, and there was no other environmental trigger or observation noted from her history and intake process.

Dr. Ruscio, DC:

So I hope all of that kind of makes sense in terms of: right now, I have a map of what to do with this individual for the next three to six months that has a very high probability of resolving her symptoms. And also, that map informs, from most likely down through least-likely, how we can address the underlying cause of her symptoms in the most efficient and cost-effective order. To juxtapose this with a lab-based model, the challenge with ordering a slurry of tests is the tests, typically, they’re not put into a probabilistic order.

Dr. Ruscio, DC:

So what ends up happening is whatever tests look the worst are treated first, and this is 1000% the opposite of the way medicine should be performed. It should be based upon the individual because, as you’ve heard me say before, lab markers are one-fourth of the data needed to make a decision. So sadly, what we often see in patients who have had their care predominantly dictated by labs. And this is really the inverse. The person’s history, plus their symptoms, plus their response to treatment, THAT comprises the vast majority, 80%, of what guides your decision making. The labs accent that.

Dr. Ruscio, DC:

And so, in her case, I already have a very strong idea of what’s going on and how to fix it, based upon listening to her, talking with her, and diligently taking notes and double-checking a few things. Now we could do a SIBO breath test to see what the current status is. We’ll want to do some follow-up blood work, of course, but the testing is not the central piece of the model. So what I think will happen with this individual is, as we get more carbs in her diet, get her on electrolytes, get her on probiotic triple therapy, I’m anticipating she’s gonna see a, at least a 30 to 70% improvement. Especially given the fact that she hasn’t used a lot of therapies prior in almost all of her symptoms. I think the food reactivity will improve, therefore or along with that, rather the hives, the anxiety, the brain fog, the early waking, mostly probably from the carbs and from the electrolytes, the anxiety, of course, the gas and the bloating—also the fatigue after meals and the dizziness from standing quickly.

Dr. Ruscio, DC:

What may lag behind this might be the vaginal dryness and disinterest in sex. It takes a little longer for the body to kind of fully recoup and kind of reboot steroid hormone production. But as we follow up, I’ll make sure to ask about those things. And, you know, we have kind of the second-level interventions of additional gut therapies like elemental dieting, antimicrobials, immunoglobulins to deploy if we need more assistance in her gut-based symptoms and if her gut’s doing great, but her female hormones aren’t budging or only minimally so, then we have herbal support for the female hormones. And once we get a little bit further and she’s on a level of symptomatic plain, we’ll then revisit and try to reappraise, “do you, or do you not need lifelong thyroid hormone replacement?” And if there’s any lingering symptoms we can’t account for, we’ll consider a sleep test and maybe some mold testing. Although I think the mold is extremely unlikely.

Dr. Ruscio, DC:

So anyway, I hope this helps in terms of trying to exemplify how a good, solid, clinical system that asks the right questions (that, by the way, organizes it in such a way where it’s easy for me to see these trends) and then the appropriate follow up with the patient, a conversation to clarify these things, really gives you pretty much the whole picture. Labs, add a touch of clarification and, and sure there are certain exceptional cases where labs are more important than others, but the labs are really complimenting this process. Without this process, the lab work is like trying to navigate somewhere blindfolded.

Dr. Ruscio, DC:

So I thought I’d share this because as we were having our visit, she said, “Yeah, you know that’s exactly why I wanted to come see you because I wasn’t sure about the thyroid. And I keep reading, and everywhere I read, it’s thyroid, thyroid, thyroid, but after listening to and reading some of your work, I felt like the gut was missed, and maybe I didn’t need to be on thyroid hormone forever. But, I also hear so many conflicting things about how to resolve my gut health. And, I think probiotics might be able to help me out. I kind of want to take them more cause I believe in the concept, but that prior SIBO test makes me feel like I shouldn’t use the probiotics.” Right? So there’s all these things that are, unfortunately, getting in her way. And when we can take all of our data into the system and then organize it, look for the trends, look for the patterns. It becomes fairly evident what we need to do to help her feel better. So anyway, again, hopefully, that helps. And if you guys have any feedback, please pass it along, and I will talk to everyone next time.

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