Today’s post was written by Kent Holtorf, M.D., medical director of the National Academy of Hypothyroidism
Autoimmune conditions are frequently the source of much confusion and misdiagnosis. Because the immune system has such a vast reach and is influenced by many factors it can be difficult to properly diagnose a specific malfunction or disorder. One such condition that can be particularly tricky to pin down is Hashimoto’s thyroiditis. Those with a thyroid condition may already be familiar with Hashimoto’s as it is the leading cause of hypothyroidism, but also causes temporary symptoms associated with hyperthyroidism.
Standard medical belief argues that to diagnose Hashimoto’s one need look no further than the patient’s thyroid antibody levels. Although this can be a good metric and point directly to Hashimoto’s if elevated levels are found, not all Hashimoto’s patients present increased antibody count. To better understand why this is, it is important to learn about the condition itself, immune function, and some of the ways that antibody levels fluctuate under the influence of Hashimoto’s.
Hashimoto’s Know How
Even though Hashimoto’s has direct impact on the thyroid it is classified as an autoimmune disorder. This is because the damage to the thyroid is caused by a malfunctioning immune response.
The immune system is the body’s first line of defense against foreign substances and attackers such as toxins, viruses, and disease. This is done through the production and mobilization of antibodies. Antibodies are produced to destroy or combat certain cell tissues, which in many cases is healthy. Dead or decaying tissue that needs to be removed is done so with the aid of antibodies. However, if the immune system incorrectly identifies a threat, it may direct the body’s own defenses to attack itself.
In the case of Hashimoto’s, the immune system perceives the thyroid to be a threat, resulting in greater production and allocation of white blood cells or lymphocytes to the thyroid gland. At increased number, these normally helpful defenders can overstep their intended purpose and begin attacking the thyroid itself. It is during this phase of response that most (80-90%) Hashimoto’s patients begin presenting elevated levels of thyroid antibodies. In addition to antibody elevation, those with Hashimoto’s generally present other symptoms that should prompt consideration of this condition even if thyroid antibodies have not increased
Symptoms of Hashimoto’s
Those in the early stages of Hashimoto’s may not experience symptoms. However, as damage continues, one may begin to suffer from significant shifts in thyroid function. This fluctuation is due to hormones released as portions of the thyroid are destroyed. This temporary increase in thyroid hormone can leave one feeling anxious, experiencing increased perspiration, quickly losing weight, and being shaky or jittery. The described scenario is known as Hashitoxicosis. Eventually the thyroid becomes so damaged that it is unable to effectively produce thyroid hormone, causing one to be permanently hypothyroid. This results in symptoms such as fatigue, weight gain, brain fog, memory issues, and hair loss.
In addition to the various symptoms already mentioned above, the following problems are identifying traits of Hashimoto’s thyroiditis.
- Panic attacks
- Loss of voice
- Changes in weight
- Diarrhea or constipation
- Inability to tolerate heat or cold
- Muscle/joint aches and pains
- Unusual weakness and fatigue
- Swelling of the feet, hands and face
- Difficulty swallowing
- Irregular periods
- Throat constriction
Because symptoms are so varied, Hashimoto’s is frequently misdiagnosed as depression, PMS, fibromyalgia, anxiety disorder, bipolar disorder, and/or chronic fatigue syndrome. Part of this misdiagnosis is an overreliance on antibody levels in blood tests.
Testing for Antibodies
Usually, a proper evaluation of one’s thyroid should at the very least include TSH, T4, T3, and Reverse T3. Because Hashimoto’s is an autoimmune condition, many physicians rely primarily on thyroid antibodies to evaluate its presence. If both thyroid peroxidase antibody (TPO Ab) and thyroglobulin antibody (TgAb) levels are elevated, it is a sure sign that one has Hashimoto’s.
There is no doubt that TPO and Tg are important, as many researchers believe that increased TPO Ab and TgAb levels occur prior to hypothyroidism and may help identify the presence of autoimmune thyroid disorders. However, about 5% of Hashimoto’s patients do not have any measureable antibodies, which may cause doctors to overlook their patient’s condition if they are relying solely on antibody testing.
Where are the Antibodies Hiding?
Even if a person has Hashimoto’s they may not present elevated levels of thyroid antibodies. In some cases, they may even have reduced levels while the disorder carries on destroying their thyroid. The following factors are some of the reasons a person with Hashimoto’s may not have an increased antibody count.
Early Stage Hashimoto’s:
Those in the early stages of Hashimoto’s are less likely to have elevated antibody levels. According to a study utilizing ultrasound and FNA biopsy data created by the Thyroid Multidisciplinary Clinic at the University of Wisconsin, increased antibody levels indicating Hashimoto’s are only seen after inflammation and damage has been done to the thyroid. This means that as Hashimoto’s develops it is increasingly easy to diagnose. However, if antibodies are the sole metric, it is likely that damage has already been done to the thyroid before an accurate diagnosis can be made.
In a weakened state, the immune system may not be able to produce enough antibodies to indicate the presence of Hashimoto’s. If one’s immune system has been fighting off the condition for an extended period, it may become fatigued and incapable of producing thyroid antibodies. In this situation, B-cell and white blood cell counts are reduced to a level where they cannot create more antibodies. It isn’t until the patient’s immune function improves that the antibody-related signs of Hashimoto’s are visible.
Balance is critical for healthy immune function. The immune system can essentially be split into two categories, TH-1 and TH-2. These two sides react to threats in different ways. TH-1 is the first responder and attacks invaders right away. TH-2 waits and produces antibodies to counteract the problem. A properly functioning immune system has a balance of these two elements. Those with Hashimoto’s frequently experience an imbalance in this area resulting in elevated TH-1 which suppresses TH-2 thereby inhibiting antibody production. The result is damage to the thyroid with little to no antibody representation.
Reading the Signals
Even though TPO and Tg antibody levels has become the standard of testing for Hashimoto’s, there may be many overlooked and untreated cases. Because Hashimoto’s can occur without elevated thyroid antibodies it is critical to pursue comprehensive testing. If symptoms of Hashimoto’s are present and one’s doctor refuses to examine more than just antibody levels, it may be time to get a second opinion.
Kent Holtorf, MD is an American physician, entrepreneur, and a board examiner of the American Board of Anti-Aging Medicine (ABAAM). Dr. Holtorf is the founder and medical director of the non-profit, multidisciplinary medical society, The National Academy of Hypothyroidism (NAH) [link: https://www.nahypothyroidism.
Join the discussion 2 Comments
One thing about this article I don’t see, is if antibody counts are low, and someone’s doctor wants to overlook it, what is the answer to diagnosing Hashimoto’s?
You’re emphasizing that antibodies aren’t always the answer. So what is?
I have heard that Hashi’s can be diagnosed via biopsy.
Is that the next step?
Hashi can indeed be diagnosed with a biopsy or even an ultrasound but at that point what doctors are looking for is destruction of some percentage of the thyroid. It’s better to catch Hashi before that point. Some practitioners will diagnose based on symptoms alone or testing for thyroid levels over time, antibodies AND acknowledging symptoms as well. A multi-pronged approach is often best.