The thyroid is a small gland located at the front of the neck, just below the larynx. Appropriate thyroid function is essential for normal metabolism, muscle and digestive function, brain development, and bone maintenance. Hypothyroidism refers to any state in which thyroid hormone production is inadequate. It results in fatigue, constipation, weight gain, dry skin, and hypothermia.

To remember back, it was 1986 when I traveled to Ethiopia. There, I saw many women who had swelling in their necks. Later, I realized it was goiter, enlargement of the thyroid gland. I assumed it was probably due to the lack of iodine from seaweed as Ethiopia doesn’t have a sea. Since then, I have been intrigued by thyroid problems. It has not been that long since I realized many people are suffering from thyroid problems insidiously.

1) What is Insidious Hypothyroidism?

Typically the onset of hypothyroidism is insidious. Insidious means to proceed gradually and subtly, but with very harmful effects. Patients will often experience several subtle and non-specific symptoms, which can vary depending on the severity and duration of the deficiency. Thus, patients often misinterpret it as a symptom of other illnesses, especially in postpartum women and the elderly. Consequently, it results in a delayed diagnosis. Nowadays, insidious hypothyroidism is a pandemic.

In the last 30 years, studies have found that the body temperature has decreased to less than or equal to 36°Celsius (96.8°Fahrenheit). It has been lowering, especially in females. Lower body temperature is the result of many kinds of diseases.

Read at: eLife 2020;9:e49555 DOI: 10.7554/eLife.49555

Moreover, people have fatigue, sluggishness, depression, constipation, increased sensitivity to cold, slow pulse rate, poor concentration, forgetfulness, memory lapses, dry skin, hair loss, coarse hair, brittle nails, a puffy face, unexplained weight gain, joint pain and stiffness, muscle weakness, enlargement of the tongue, excessive or prolonged menstrual bleeding, erectile dysfunction, and so on. Some of these symptoms are appearing at the same time. These modern malaise symptoms are often the effect of decreased thyroid function.

There are three thyroid hormones; T3 (Triiodothyronine), T4 (Tetraiodothyronine or Thyroxine), and rT3. T3 is more active than T4. rT3 is the reverse or mirror image isomer of T3, and

its function is almost nil compared with that of T3. Hence, we consider T3 as the principal thyroid hormone.

However, in standard blood analysis, rT3 and T3 are considered similar and cannot distinguish. Consequently, the check reports analyze T3 + rT3 as a total T3. Let us assume patient blood consists of 10% of T3 and 90% of rT3. Despite this, the test result will show the T3 is in the normal range. But if the rT3 is 90%, thyroid function is considered very weak. In some cases, TSH also seems to be in a normal range. All these fallacies lead the doctor to suppose that your thyroid function is fine.

Generally, doctors test TSH (Thyroid-Stimulating Hormone), T3, and T4 in a blood test for the thyroid. In most cases, three of them fall within the normal range. People can suffer from Hashimoto’s disease (chronic thyroiditis) or Graves’ disease (hyperthyroidism) despite having normal T3, T4, and TSH levels. We can detect these diseases after conducting tests for TgAb (anti-thyroglobulin antibody) and TPOAb (anti-thyroid peroxidase antibody).

Even if there are pathological lesions in the thyroid gland, the thyroid hormone levels seem to be maintained, masking the underlying problems. The general thyroid test lacks the test of these two antibodies, other than at the thyroid specialist clinics. So, if you have any doubts, I recommend you always consult the specialists and have these antibodies test done.

I call such medical conditions Hidden Hypothyroidism. Usually, females with a family history of thyroid problems are most likely to get it, but, can occur in males as well.

Once, a male patient with psoriasis visited me. He was using a disposable hot patch in mid-summer. As a precaution, I recommended he do an echo and a thyroid function test by a thyroid specialist. The test result showed his TSH was slightly higher. It verified that he had a mild symptom of Hashimoto’s disease, for which doctors do not prescribe medications.

Psoriasis and Hashimoto’s disease are not directly related to each other. He had been under the observation of dermatologists for 10 years. However, his dermatologist didn’t notice his symptoms of Hashimoto’s disease. Hypothyroidism is possible to be missed just like this.

Hypothyroidism is relatively more common in women and, thus it is easily overlooked in men. Hence, there are more cases of Overlooked Hypothyroidism in men. In men, laryngeal prominence (the so-called Adam’s apple) is more significant than women. Thus, thyroid enlargement might be mistaken for Adam’s apple.

If T3 and T4 levels were normal in the above case, specialists would have called it Subclinical Hypothyroidism. Since TSH is very sensitive, the anomaly comes first to this hormone. This condition is especially prevalent and is estimated to be 4% to 10% of the general population. Also, the prevalence rate will exceed 20% for the elderly.

Regarding the necessity of therapy for Subclinical Hypothyroidism, there are guidelines on the basis of which doctors decide the treatment. In most cases, patients are under observation before providing any medication. But in the case of pregnant women or those trying to conceive, the treatment begins immediately.

We may have even more cases of Hidden, Overlooked, and Subclinical Hypothyroidism than estimated!

If you feel unhappy, blue, or have unexplained melancholia, chances are you might be suffering from thyroid problems. So, please meet a thyroid specialist before visiting psychiatry or taking psychosomatic medicine.

Similarly, even if you have abnormal TgAb and TPOAb values but normal T3 and T4, then it is considered you don’t need any treatments. If you want to do a depth check of your thyroid, your medical insurance probably will not cover it. So, to get rid of the depressive mental symptoms, you may reluctantly go for psychiatric and psychosomatic medicine. Undoubtedly, antidepressants are ineffective because your problems are from the thyroid, not the brain.

Doctors increase the dose of the drugs higher, making the patients intoxicated by the drugs and finally, inviting true psychosis due to unnecessary and high-dose prescriptions. I have seen this tragic case quite often.

2) Many factors attribute to Insidious Hypothyroidism.

In the United States, salt contains fortified iodine. It is a known fact that excessive salt intake leads to high blood pressure, due to which health-conscious people tend to limit salt intake. This, on the other hand, can cause iodine deficiency.

Likewise, tap water consists of fluorine as a disinfectant. Fluorine, belonging to the same halogen group, interferes with iodine absorption, causing further iodine deficiency. And generally, American people don’t consume seaweeds, which is a good source of iodine. Thus, if you live in the United States and do not eat seafood, you might fall at risk of iodine deficiency.

Vegetarianism is generally beneficial for health. However, if you consume a lot of cruciferous vegetables like cabbage, cauliflower, broccoli, etc., you need to be cautious. As these vegetables contain goitrogens, a phytochemical that interferes with iodine uptake, you can suffer from enlargement of the thyroid gland like goiter.

Read more: (https://www.sciencedirect.com/science/article/pii/B9780123746283000426)

Moreover, indole-3-carbinol is present at relatively high levels in cruciferous vegetables. It is said to have beneficial effects in preventing breast cancer and prostate cancer (and lupus). Some health-conscious people eat these vegetables too much without knowing their adverse effect on the thyroid.

We also consider soy products healthy. While, if soy is not fermented and consumed in large amounts, it might be hazardous to the thyroid. Many mothers feed soy milk to babies who have allergies to cow milk or breastmilk. If you search for soy thyroid in Google, you can find that soy milk is good for your health unless you drink it regularly.

In addition to this, some people take vitamin C supplements excessively. Recently, I saw a young girl nibbling on vitamin C tablets with a crunching sound as if she was eating a cookie. Such a thing is quite dangerous.

From my 38 years of experience as a general physician, I can very well understand the function of Vitamin C. However, studies show that excess intake might lower zinc and manganese levels and inhibits inorganic selenium uptake. Zinc, manganese, and selenium are essential for the thyroid. Thus, food sources of Vitamin C are better than taking supplements carelessly.

Humans and chimpanzees cannot synthesize vitamin c as they lack an enzyme called gluconolactone oxidase. However, other mammals can synthesize vitamin c in their liver by this enzyme. That is why we don’t see a lion eating oranges. Due to this reason, humans have to take dietary sources of vitamin c.

From the evolutionary point of view, humans should not lack the ability to synthesize vitamin c as we need it. The evolved species of humans should have a perfect physiological function. Thus, some scientists regard this as one of the shortcomings of Darwin’s theory of evolution.

We can explain this by the negative influence of excessive vitamin c. Excessive intake of vitamin c interferes with the absorption of vital minerals and hinders thyroid functioning. As a result, the brain cannot develop adequately. This might be the reason to throw away the genes encoding the gluconolactone enzyme.

3) Estrogenic Hypothyroidism

Estrogen Dominance complicates the problem of thyroid disorders. If you are on hormone replacement therapy to alleviate your menopausal syndrome, sometimes estrogen is given slightly more than necessary because of insufficient medical follow-up. This extra estrogen increases the Thyroxine-Binding Globulin (TBG). TBG absorbs flowing freely thyroid hormone in the bloodstream and decreases the functional thyroid hormones in the body. In this case, even if your thyroid function itself is fine, you would suffer from hypothyroidism.

And now our modern world itself has become estrogen dominant due to endocrine disrupters, one of them being dioxin. It is a persistent organic pollutant made as a byproduct of industrial wastes.

Previously, the influence of dioxin was only related to cancer and neonatal malformation. The subsequent studies have now elucidated that dioxin also acts like estrogen. It works in units of picogram (10-12g). You can understand the relationship between this substance and our environment by imagining it as one droplet of the dropper in the 50-meter pool.

However, several other environmental pollutants show estrogenic effects. We all are exposed to excessive estrogen or endocrine disruptors from the time of the fetus.

Obesity also causes estrogen dominance. We live in an obesogenic society, where we have a sedentary lifestyle, excess intake of sugar and fat, and a habit of luxury. Because of this, we have more fat cells and adipose tissues. In the white adipose cells androstenedione is converted to estrogen (androstenedione–> estrone–> estradiol–> estriol). Consequently, both women and men are encountering increased TBG, which may lead to very mild hypothyroidism with an apparent level of T3 and T4.

Nowadays, there is haphazard use of veterinary drugs due to which estrogen enters our body from food sources, especially beef. Moreover, a weak liver function can disrupt estrogen metabolism.

Due to all such reasons, about 1 in 20 people might suffer from unnoticed mild hypothyroidism, despite the normal level of thyroid hormones.

4) Problem of how to interpret blood analysis.

For example, your blood test result for FT4 shows a value of 0.81 ng/ml. Reference value for FT4 is 0.80 to 1.6 ng/ml. In this case, 0.81 is within the reference value, and you have normal thyroid function. However, if the result is 0.79 or falls right below the reference value, it is treated as hypothyroidism.

Where on earth is so much difference between 0.79 and 0.81?
The numbers might fluctuate in the same person according to their physical condition. Physicians overlook these factors during inspections. If your mood is heavy and depressive, doctors recommend you to go for psychosomatic medicine or psychiatry and prescribe an anti-depressant.

Even in your 50’s, 60’s, as far as you are healthy, you can recover from most of the fatigue after a good sleep. However, if you do not, please consider the possibility of hypothyroidism.

Some tips for self-diagnosing hypothyroidism

Thermometer

You can use an ordinary thermometer to measure your body temperature every morning after you wake up. The cut-off temperature should be 36.2°Celsius (97.16°Fahrenheit) in the armpit. If your thermometer shows less than 36 degrees repeatedly, there is a high possibility of hypothyroidism.
(Please pay attention. Use at least two thermometers for measurement as even two thermometers bought from the same place, at the same time, may differ by as much as 0.5 degrees.)

ALP↓+ Cholesterol↑ = Hypothyroidism?

Another easy way to find a decrease in your thyroid function is to check liver function and cholesterol level. The resulting values of ALP and cholesterol level can be a good indicator.

ALP (alkaline phosphatase): When abnormalities of gall bladder/bile duct/ liver system, bone metabolism occur, ALP is disturbed. In many cases, you require medical attention if the value is higher. However, if there is a low value, it is often neglected.

ALP shows lower values only if you are suffering from hypothyroidism or hereditary hypophosphatasia. The latter is a very rare disease that occurs only to about one in 100,000 people. ALP is also low during zinc or magnesium deficiency (alcoholism).

Cholesterol: Hypothyroidism reduces bile acid synthesis from cholesterol in the liver and results in high blood cholesterol.

If you have a decrease in ALP level and a rise in cholesterol level simultaneously, it would be wise to suspect hypothyroidism.

Let us take an example of a specific case:

  • 45 Years old Woman
  • ALP 87U/L (reference value: 104-338)
  • Total Cholesterol 272mg/ dl (reference value: 150-219)
  • HDL Cholesterol 125mg/dl (reference value: 40 to 90)


The main features of this patient are obesity, intense forgetfulness, fatigue, and hair loss. The doctor seemed unconcerned to the thyroid gland and avoided its test. As other biochemical values were good, her doctor recommended taking anti-hyperlipidemic agents based on her test results. However, the symptoms stayed, and she went to another hospital and found out that she was suffering from mild Hashimoto’s disease.

Everyone should check the blood test result of the previous medical examination. And if, “ALP ↓+ Cholesterol ↑” with fatigue, sluggishness, constipation, slow pulse, poor concentration, obesity even after exercising, puffy face, missing eyebrows, stiff hair, dry skin, ED (male), menstruation irregularities (female), you might have a fair probability of hypothyroidism.

Before checking your thyroid level, please do not take statin drugs to lower cholesterol because the side effects of statin drugs include muscle weakness and memory lapses. Then, you and your doctors cannot understand the actual cause of your symptoms.

* When ALP is higher than the normal range, you should check not only the liver and gallbladder but also the bone. ALP has 6 isozymes (ALP1～ALP6). If ALP3 is too high, you can suffer from hyperthyroidism or hyperparathyroidism. Please do visit thyroid and parathyroid specialists.

5) Treatment of Insidious Hypothyroidism

Please take the drug if your doctor advises you to take Levothyroxine（Thyradin) if your thyroid function has already got reduced very much.
Such cases are not insidious. Without medication, your health can be in danger.

If you suffer from any of the following symptoms and your doctor says to you, “You don’t need any treatment now. Let’s see”, please consider taking supplements.

  • Fatigue without any reason
  • Severe constipation
  • Chilling
  • High cholesterol level
  • Slow pulse
  • Poor concentration, forgetfulness,
  • Obesity
  • Coarse and increased gray hair,
  • Irregular menstruation (female) or ED (male)
  • Depression, etc.

Prevention of insidious hypothyroidism

When it comes to preventing hypothyroidism, I recommend the following supplements for the prevention of insidious hyperthyroidism:
Collagen, Vitamin D3, α-GPC, Shell Ginger, Omega 3 Unsaturated Fatty Acid, Selenium, Zinc, Manganese, and Vitamin B.

a) α-GPC (L-Alpha glycerylphosphorylcholine)

α-GPC is one of the choline derivatives mainly contained in the brain and the retina. It can pass through the blood-brain barrier, increase acetylcholine, and encourage the secretion of growth hormones. Growth hormone promotes the conversion of T4 to T3 in the various tissues such as liver, bone, muscle, etc. It is present in breastmilk, which is a very safe food.

Furthermore, studies have confirmed that α-GPC also increases memory and cognitive ability. Hence, it is an important supplement for hypothyroidism.

b) Fermented Leaves of Shell Ginger

Shell Ginger (Alpinia zerumbet) is an essential supplement for the cure of insidious hypothyroidism. It is a plant-derived shell ginger supplement with added Ferulic Acid, Vitamin D3, and Vitamin A. Ferulic Acid prevents the deterioration of thyroid function.

For the detailed explanation: https://en.drmakise.com/shell-ginger-jipang/

c) Vitamin D

Vitamin D is linked to cholesterol because we need cholesterol in our skins cells to make vitamin D from sunlight. Ultraviolet rays convert 7 – dehydrocholesterol from the diet into vitamin D3 on the skin. Further metabolism occurs in the liver and kidney and forms 1,25－dihydroxy vitamin D3.

Nowadays, a lot of people lack vitamin D3. Lack of D3 influences the secretion of TSH from the front lobe of the pituitary gland adversely. Deficient vitamin D level disturbs the immune system and reduces the function of the thyroid gland.

d) Omega 3 Unsaturated Fatty Acid

Omega-3 fatty acid ( α-linolenic acid) metabolizes benign eicosanoids. Flaxseed oil, perilla oil, Sacha inch oil are good sources of α-linolenic acid. Benign eicosanoids are very important to cure inflammation. It is beneficial for Hashimoto’s thyroiditis. (the suffix – it is means inflammation: hepatitis, colitis, pancreatitis)

In contrary to α-linolenic acid, linoleic acid metabolizes into malignant eicosanoids and aggravates inflammation. Vegetable seed oils like safflower oil, sunflower oil, cottonseed oil, and wheat germ oil contain abundant linoleic acids. Hence, please do not take these oils too much. Harp Seal Oil is one the best source of omega-3 fatty acids. Although Fish Oil contains omega-3 fatty acids, please be careful of its quality. This oil can contain toxic heavy metals that can trigger thyroid problems.

e) Selenium, Zinc, and Manganese

Zinc, manganese, and selenium are essential for the thyroid. The supplement for selenium is cheap. But, please be careful not to overtake it. It is the same with zinc and manganese.

Zinc is essential for healthy T3 receptors in your cells. Manganese-dependent superoxide dismutase (MnSOD) is an antioxidant enzyme. It consists of manganese as a vital component. MnSOD converts T4 to T3 in the liver cell members, which is required to reduce oxidant stress.

Selenium synthesizes glutathione peroxidase enzyme, an essential polymer antioxidant. This enzyme protects the cell from oxidative damage by neutralizing free radicals. Selenium also forms selenocysteine, an enzyme required for thyroid hormone activation. It helps to convert T4 into T3.

I usually do not recommend my patients in Japan take these supplements as Japanese cuisine incorporates a good source. But, I am not sure about foreign countries. The mineral content depends upon the soil where the food grows. I have heard that Brazilian nuts contain a lot of selenium. So, if you are living in Brazil, you may not need to take a selenium supplement.

f) Collagen

The follicular epithelial cells of the thyroid gland produce thyroid hormones. Hence, sufficient collagen is essential for the proper functioning of these cells.

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