A lot of attention is put on thyroid health - for a good reason. Twenty million Americans have some form of thyroid disease, and up to 60% are unaware of their condition. Women are at higher risk, with one in eight developing a thyroid disorder during her lifetime. While hyperthyroidism is less common than hypothyroidism, diagnosing and treating it is just as important. Hyperthyroidism affects one in 100 Americans over age 12 and can cause serious health complications when left untreated, such as infertility, osteoporosis, and heart failure. (1, 2)

Conventional medicine provides limited treatment options for patients with hyperthyroidism. This article will discuss a functional medicine approach to managing hyperthyroidism and provide a sample treatment protocol that can be utilized in clinical practice.

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What is Hyperthyroidism?

Hyperthyroidism is a condition characterized by an overactive thyroid gland. The thyroid is a butterfly-shaped endocrine gland in the front of the neck responsible for producing thyroid hormones. Thyroid hormones, thyroxine (T4) and triiodothyronine (T3), travel through circulation and bind to receptor sites on every cell in the body to regulate metabolic rate, growth, and development.

In normal conditions, the brain and thyroid work together to closely monitor and maintain a healthy amount of thyroid hormone in circulation. In certain scenarios, however, the thyroid gland produces too much thyroid hormone, causing hyperthyroidism. (3)

Hyperthyroidism Signs & Symptoms

Excess thyroid hormone causes a hypermetabolic state throughout the body, causing systemic symptoms. The most common symptoms of hyperthyroidism include (4):

• Nervousness, anxiety, or irritability
• Heart palpitations, irregular heartbeat, and rapid heartbeat
• Sweating
• Weight loss despite increased appetite
• Fatigue
• Muscle weakness, especially in upper arms and thighs
• Insomnia
• Hair loss and fine, brittle hair
• Diarrhea
• Tremors
• Irregular menstrual cycles and periods
• Dry, thinning skin
• Enlarged and bulging eyes (in Graves' disease)
• Thyroid swelling (goiter)

Without proper treatment, hyperthyroidism can cause the following health complications:

• Heart problems like atrial fibrillation and congestive heart failure
• Hypertension
• Osteoporosis
• Graves' ophthalmopathy, which can lead to vision loss
• Brain damage
• Neonatal hyperthyroidism (in pregnant women)
• Graves' dermopathy: red, swollen skin
• Thyrotoxic crisis ("thyroid storm" ): a sudden and drastic increase in thyroid hormones, causing fever, vomiting, dehydration, and delirium without emergent care (4)

What Causes Hyperthyroidism?

Autoimmunity, inflammation, thyroid nodules, excess iodine consumption, overmedication, and tumors can cause hyperthyroidism. (5)

Graves' Disease

Graves' disease is the most common type of hyperthyroidism, causing four out of five cases in the United States and affecting one in one hundred Americans. This is an autoimmune form of hyperthyroidism caused by thyroid-stimulating immunoglobulin (TSI), also known as thyroid-stimulating antibody (TSAb). TSI binds with thyroid-stimulating hormone (TSH) receptors of thyroid cells, stimulating thyroid hormone synthesis and gland growth. The onset of Graves' disease can be influenced by genetics, pregnancy, iodine excess, infections, emotional stress, and smoking. (6)

Thyroid Nodule

Hyper-functioning thyroid nodules, encompassing toxic adenoma and multinodular goiter, cause about 15% of hyperthyroidism. These can occur when glandular tumors (adenomas) form within the thyroid gland and produce too much T4. Toxic multinodular goiter causes 5% of hyperthyroidism in the United States and typically occurs in patients older than 40. Thyroid nodules are more likely to develop in iodine-deficient areas. (7)

Thyroiditis

Thyroiditis occurs when a trigger causes the thyroid gland to become inflamed and swollen, resulting in thyroid hormone leakage from the gland. Infections, pregnancy and the postpartum period, and medications can induce thyroiditis. Over time, chronic hyperthyroid thyroiditis can convert to hypothyroidism. (7)

Jod-Basedow Syndrome

Iodine is a non-metallic trace element required for thyroid hormone synthesis. However, Jod-Basedow is a rare form of thyrotoxicosis that occurs with iodine administration. Exogenous iodine is typically encountered through iodinated contrast media, supplements, and certain medications (e.g., amiodarone). (8)

Overmedication

The ingestion of excessive amounts of thyroid hormone causes factitial hyperthyroidism. This may occur with incorrect dosing of thyroid replacement hormones for patients with hypothyroidism or accidental ingestion of supplements containing glandular thyroid. Working with a medical professional to monitor your thyroid levels and medication dosing is important to avoid this. (3, 7)

Tumors

Rarely, pituitary tumors secreting excess TSH or human chorionic gonadotrophin (hCG)-releasing tumors can overstimulate TSH receptors on the thyroid gland, causing increased glandular stimulation and excessive thyroid hormone release. (7)

Functional Medicine Labs to Test for Root Cause of Hyperthyroidism

Functional medicine labs help practitioners personalize treatment options for their patients. Below are some of the most common labs ordered for patients suffering from hyperthyroidism.

Thyroid Panel

To assess the health and function of the thyroid gland, order a complete thyroid panel, including TSH, T4 (free and total), T3 (free and total), and thyroid antibodies (anti-TG, anti-TPO, and TSI).

TSH measures how the pituitary gland in the brain communicates with the thyroid gland; a low TSH indicates hyperthyroidism.

Free and total T4 and T3 levels reflect the bound and unbound thyroid hormone levels in circulation. These levels are important in understanding how the body synthesizes, converts, and utilizes thyroid hormones. Elevations of these hormones are reflective of a hyperactive thyroid state.

Thyroid antibodies screen for thyroid autoimmunity. TSI is associated with Graves' disease. While Anti-TPO and anti-TG are more likely to be present in autoimmune hypothyroidism (Hashimoto's thyroiditis), they may be produced in patients with Graves'.

*Note: Biotin supplements may interfere with thyroid tests, causing a falsely low TSH and falsely high T4 and T3. Patients taking biotin supplements should discontinue them two days before assessing thyroid function.

Gut Analysis

Food sensitivities, dysbiosis, intestinal inflammation, and digestive dysfunction can contribute to systemic inflammation and autoimmune diseases. Comprehensive stool analysis, gluten and food sensitivity testing, and leaky gut screening provide an in-depth analysis of gastrointestinal health and function concerning thyroid health and autoimmunity.

5.5% of patients with autoimmune thyroiditis have positive antigliadin antibodies, indicative of celiac disease. The link between autoimmune thyroiditis and gluten intolerance is so well-established that researchers recommend screening all patients with autoimmune thyroid disease for gluten intolerance and vice versa.

Nutritional Assessment

Nutritional demands increase during hypermetabolic states, increasing the risk of nutrient depletion and deficiencies. A micronutrient assay screens for nutritional deficiencies, helping to personalize dietary and supplemental interventions to optimize thyroid function, reduce inflammation, and prevent secondary health complications.

Environmental Toxins

Many environmental toxins, including organochlorine pesticides, bisphenol-A, PCBs, and heavy metals, have been shown to contribute to thyroid dysfunction and autoimmunity (3, 9). Heavy metal and environmental toxin panels help to screen for exposures so that proper strategies to reduce contact and promote detoxification can be recommended to the patient.  

Infections

Viruses and bacteria, like herpes simplex virus (HSV), Epstein-Barr virus (EBV), and Helicobacter pylori, can hyperstimulate the immune system and trigger autoimmunity, leading to thyroid disease (9). The Pathogen-Associated Immune Reactivity Screen (Array 12) by Cryex Laboratories can be used as a generalized screen for infections that increase susceptibility to autoimmune diseases.

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Conventional Treatment for Hyperthyroidism

The primary conventional options for treating hyperthyroidism include antithyroid medications (methimazole and propylthiouracil), radioactive iodine ablation, and surgical thyroid removal (thyroidectomy). Radioactive iodine ablation is the most widely used treatment in the United States. The treatment choice depends on the underlying diagnosis, contraindications to a particular treatment modality, the severity of hyperthyroidism, and the patient's preference. (10)

Propranolol, a beta-blocker, is also routinely prescribed for the symptomatic treatment of irregular/increased heart rate, anxiety, and tremors. Propranolol is the beta-blocker of choice because it has the additional benefit of inhibiting the enzyme that converts the conversion of T4 to T3. (10)

Functional Medicine Treatment Protocol for Hyperthyroidism

A functional medicine protocol utilizes a variety of complementary and integrative natural modalities that rival conventional treatments in their effectiveness, have lower side effect profiles, and address the root cause of thyroid disease.

Therapeutic Diet and Nutrition Considerations for Hyperthyroidism

Perhaps the most important dietary consideration for patients with hyperthyroidism is ensuring they are meeting caloric and nutrient demands. As a result of their increased metabolic rate, nutritional interventions that emphasize nutrient-dense foods with an increased intake of calories and protein will be necessary.

Patients with autoimmune thyroid disease are more likely to suffer from celiac disease or gluten sensitivity than the general population. Patients with celiac disease and non-celiac gluten sensitivity (NCGS), or patients who have opted against testing, should initiate a gluten-free diet.

Dietary goitrogens are substances that prevent cellular utilization of iodine. These compounds are similar in action and structure to antithyroid prescription medications and are found naturally in foods like turnips, cabbage, kale, broccoli, cassava, soybeans, lima beans, and millet.

Caffeine can worsen symptoms of hyperthyroidism, like anxiety, palpitations, tremor, sweating, and anxiety. Avoidance of caffeine (i.e., coffee, black tea, energy drinks) can be beneficial in the symptomatic management of hyperthyroidism.

Supplements Protocol for Hyperthyroidism

Supplements can be added to a treatment protocol, in addition to pharmaceutical and dietary interventions, to normalize thyroid function, reduce thyroid antibody counts, palliate hyperthyroid symptoms, and prevent disease relapse. Below are supplements that would be appropriate to include in a functional medicine protocol.

Thyroid Calming™

This tincture by Herb Pharm combines bugleweed (Lycopus spp.), motherwort (Leonurus cardiaca), cactus grandiflorus (Selenicereus spp.), and lemon balm (Melissa officinalis). Together, these herbs can reduce hyperthyroid symptoms and block/reduce thyroid hormones. Studies have shown motherwort to be cardioprotective, and bugleweed and lemon balm as successful agents in reducing T4 and T3 hormone levels. (11, 12)

Dose: 30 drops three times daily

Duration: at least six weeks

Multivitamin

Because the requirement for many different micronutrients is increased in patients with Graves' disease, a broad-spectrum, high-potency multivitamin is appropriate for general nutritional support to meet nutritional needs.

Dosed per label instructions

Duration: until the patient achieves a euthyroid state

Selenium

Selenium has several documented benefits for patients with Graves' disease, who are more likely to have lower selenium levels. Selenium is an excellent option to include in an integrative treatment plan, as evidence indicates supplementation improves treatment outcomes using conventional hyperthyroid treatments. (13, 14)

A meta-analysis showed that patients with high thyroid antibody levels are more likely to experience hyperthyroid relapse, and selenium has been shown to reduce thyroid antibody counts, eye complications, and inflammatory cytokines associated with Graves' disease.

Dose: 200 mcg daily

Duration: 3-6 months

L-Carnitine

L-carnitine is an amino acid that reduces hyperthyroid symptoms, including weakness, fatigue, shortness of breath, heart palpitations, insomnia, nervousness, tremors, and bone frailty (15).

Scenarios in which L-carnitine would be particularly indicated include treatment of thyroid storm and treatment of hyperthyroidism in patients who are pregnant/breastfeeding or have coexisting liver or hematologic diseases (15, 16).

Dose: 1-2 grams twice daily

Duration: at least 6-8 weeks

Melatonin

Emotional and physical stress is implicated in the onset of Graves' disease and can impact treatment success when left unaddressed (9). Insomnia and sleep disturbance, a common symptom of hyperthyroidism, can exacerbate perceived stress and the body's physiologic stress response pathways (17). Various supplements, along with creating healthy sleep hygiene habits, have been shown to encourage desired sleep outcomes. Melatonin is an easy-to-find over-the-counter supplement that effectively induces sleep, increases total sleep time, and improves sleep quality.

Dose: 1-3 mg 30-60 minutes before bed

Duration: as needed

When to Retest Labs

Many patients will note improvements in their symptoms within two weeks of starting any type of treatment for hyperthyroidism. However, treatment can take up to 6-8 weeks to have full effect. Because of this, retesting thyroid hormones 6-8 weeks after initiating any change to a thyroid protocol is recommended. Once thyroid markers have stabilized, testing frequency can be reduced to once or twice yearly as long as the patient remains stable.

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Summary

Hyperthyroidism is a potentially life-threatening condition characterized by hyperactivity of the thyroid gland. Although conventional medical treatments may be required in acute thyroid storm situations or to normalize thyroid function quickly, they have potentially serious side effects and do not address the underlying cause of thyroid dysfunction. Dietary changes and supplements, sometimes alongside oral medications, can correct pathology and bring the thyroid back into balance.