156 Hyperthyroidism or Hypothyroidism? Reasons for Fluctuating TSH

Hyperthyroidism or Hypothyroidism? Health Mysteries Solved

The Strange Case of Competing Thyroid Symptoms

The Case: 

  • Lucy was experiencing symptoms that went back and forth
  • She would experience heart palpitations, hot flashes, and anxiety and then she’d have periods of fatigue
  • Her doctor suspected hyperthyroidism and tested her for Graves

I knew that there was reason to investigate further because her symptoms weren’t adding up. When it comes to hyperthyroidism, there’s one person I often turn to – Dr. Eric Osansky, a chiropractor and host of the ‘Save My Thyroid’ podcast. 

His interest in hyperthyroidism comes from his personal Graves diagnosis in 2008. He is also the author of 2 thyroid books, ‘Natural Solutions for Hypothyroidism and Graves’ Disease’ and ‘Hashimoto’s Triggers: Eliminate Your Thyroid Symptoms by Finding and Removing Your Triggers

On this show, we talk a lot about hypothyroidism and how Hashimoto’s can be at play. Many don’t think that Hashimoto’s can also be present when someone has an overactive thyroid (Hyperthyroidism and sometimes Graves’ Disease). It all starts by looking at and understanding TSH levels. 

Reviewing the Basics of Thyroid-Stimulating Hormone (TSH)

The thyroid gland is a critical component of our endocrine system, responsible for regulating our metabolism. When it comes to thyroid assessments, most practitioners start by examining the Thyroid-Stimulating Hormone (TSH). Dr. Osansky explained that TSH stands for “Thyroid Stimulation-Communicating Hormone” and is produced by the pituitary gland. This hormone plays a vital role in communicating with the thyroid and serves as a fundamental element of many thyroid evaluations.

When it comes to hypothyroidism, including conditions like Hashimoto’s, you’ll often see elevated TSH levels. This is because the thyroid hormone in the body is on the lower side. It might be just within the lab’s reference range, or it could be overtly low. In response, the pituitary gland sends a clear signal to the thyroid: “We need more thyroid hormone!” This signal takes the form of an increased TSH level, prompting the thyroid gland to produce more thyroid hormone.

Conversely, in the case of hyperthyroidism, it’s the complete opposite. With hyperthyroidism, there’s an excess of thyroid hormone circulating in the bloodstream, mainly bound to proteins. In this scenario, the pituitary gland signals the thyroid to slow down production. As a result, you’ll commonly observe not only low TSH but sometimes an undetectable TSH, especially in conditions like Graves’ disease. This undetectable TSH indicates that the pituitary is working hard to halt the overproduction of thyroid hormone. So, while TSH levels can provide valuable insights, they’re just one piece of the puzzle. We need to dig deeper into the thyroid hormones to get the full picture. 

Comprehensive Thyroid Testing is Always Key

According to Dr. Eric, to reach a proper diagnosis, we must also examine the thyroid hormones, particularly free T3 and free T4. These free hormones offer a more accurate representation of thyroid function. In hyperthyroidism, where the thyroid hormones are typically elevated, examining free T3 and free T4 alone is often sufficient because total hormones will also be elevated. On the other hand, in hypothyroidism, some practitioners prefer to assess not only free hormones but also total hormones to gauge production since a significant portion of thyroid hormone is bound to proteins.

Let’s not forget reverse T3, an inactive form of T3. It’s a bit of a controversial character in the thyroid world. Some suggest that reverse T3 may act as a blocking agent, especially in hyperthyroidism. Elevated reverse T3 levels are common in this condition, further hinting at its role in dampening excessive thyroid hormone activity. 

But the thyroid’s complexity doesn’t end here. We also need to consider antibodies, which play a crucial role in autoimmune thyroid conditions like Hashimoto’s. Plus, keep in mind that it’s not just the thyroid at play; the pituitary gland could be throwing a wrench in the works too. Pituitary issues, such as a pituitary adenoma, can also affect TSH levels and the overall thyroid regulation. So, always remember that a comprehensive view is essential when evaluating thyroid health.

What is Hashi-Toxicosis? 

Hashi-toxicosis is a fascinating term that combines “Hashimoto’s” and “toxicosis.” It essentially refers to Hashimoto’s thyroiditis with intermittent episodes of hyperthyroidism. When someone has Hashimoto’s, the autoimmune attack damages the thyroid gland, causing it to release excessive thyroid hormone into the bloodstream. Consequently, when you get a blood test during such an episode, it can appear as hyperthyroidism. However, it’s different from Graves’ disease, where specific antibodies continuously stimulate the thyroid gland. In Hashi-toxicosis, these episodes of hyperthyroidism are transient, meaning they come and go. The duration varies from person to person, some experiencing these episodes for a few hours, while others may have them for a few days.

These fluctuations can be triggered by various factors. For some, hormonal changes, like those related to the menstrual cycle or stressful events, can lead to these episodes. It’s important to note that the frequency of these flares varies among individuals. Some may experience them frequently, while others only encounter them occasionally. In my own journey, I’ve had a couple of Hashi-toxicosis flares, both linked to high-stress events – one after moving and the other postpartum. These personal experiences have taught me that hormonal changes can significantly influence the frequency of these episodes. For those who face occasional flares, it can be a bewildering experience. 

When I had my first episode, nearly two decades ago, it looked a lot like Lucy’s situation. The doctor ran tests during a flare, and my thyroid hormone levels were off the charts. Not just my TSH, but all my thyroid hormones were elevated, which was rather unusual. The doctor even suggested the possibility of thyroid removal. Thankfully, my knowledge about Hashimoto’s helped me question this recommendation, as I knew there was more to the story than met the eye.

Get Curious About Unusual Thyroid Results

It’s absolutely crucial to explore all the possibilities when dealing with thyroid issues and stop the attack on our thyroid gland. Now, consider a scenario where someone, like Lucy, has a low TSH and elevated hormone levels. If it’s not clear whether this is a transient episode, it’s essential to retest and, most importantly, assess the antibodies. But what if the antibodies turn out to be negative, including TSI? What else could be behind these hyperthyroid symptoms and unusual lab results? 

Dr. Osasnsky introduced the possibility of subacute thyroiditis. This condition often arises from viral infections, such as cytomegalovirus or even, more recently, the effects of COVID. It triggers significant inflammation in the thyroid, resulting in excess thyroid hormone production. Strangely, the presentation mirrors Graves’ disease, yet the antibodies are absent. However, in most cases, within two to four months, this hyper phase shifts to a hypo state, and often, the hypothyroidism is temporary, eventually returning to a normal thyroid balance.

One more thing to consider is medication. For example, if someone is taking a high amount of natural or synthetic thyroid, (whether it’s levothyroxine or desiccated thyroid hormone) it can cause too much thyroid hormone.

Nodules on the Thyroid and What They Mean

In the world of thyroid health, nodules are a hot topic, and I get a lot of questions about them. One common query is, “Can nodules ever cause hypothyroidism?”  Dr. Osansky, explains that nodules typically don’t lead to hypothyroidism directly. In fact, most of the time, they don’t cause either hyperthyroidism or hypothyroidism. 

However, there’s a bit of a gray area. In some cases, people with larger nodules, especially those over two centimeters, might experience changes in their TSH levels. Sometimes you’ll see a depressed TSH with multinodular goiter, but the thyroid hormone levels will appear normal. So it’s not exactly the nodules themselves causing hypothyroidism; it’s more like a subtle alteration in the thyroid function. Of course, it’s essential to consider that the interpretation can vary among healthcare professionals. Thyroid lab ranges can be quite wide, and what’s considered “normal” in conventional medicine may not align with optimal thyroid health. It’s always a good idea to work with a practitioner who understands the nuances of thyroid function.

Nodules are surprisingly common, especially as we get older. About 50% of people over 50 have nodules, and the percentage increases with age. While you can’t always completely prevent nodules, there are some factors to consider. Hormone imbalances, particularly issues with estrogen metabolism, can contribute to nodule development. So addressing this aspect can be essential. 

Tests like the Dutch test can help evaluate estrogen metabolites, and you may need to consult a healthcare provider knowledgeable in thyroid health for this. Insulin resistance can also play a role, and keeping an eye on your hemoglobin A1C and fasting insulin levels can be informative. Iodine is another element that can be both a cause and a potential remedy for nodules. It’s a bit of a gray area, and the research isn’t entirely clear. However, it’s wise to be cautious with iodine supplements, as they can worsen nodules in some cases. 

There are some self-care practices like castor oil packs that some people swear by, although there’s limited scientific evidence. Ultimately, it’s a good idea to monitor nodules with follow-up ultrasounds. If you find that they’re not growing or, even better, shrinking, then you’re on the right track. But always consult with a healthcare provider who understands thyroid health to guide you on the best approach for your specific situation.

Treatment Approaches and Medications for Hyperthyroidism

Managing hyperthyroidism often involves a multi-pronged approach. Dr. Osansky pointed out that treatment can include medications like anti-thyroid drugs, radioactive iodine therapy, or even surgery in more severe cases. The choice of treatment depends on the individual’s unique situation and the underlying cause of their hyperthyroidism. And, a holistic approach is key especially if treating the thyroid (and getting levels back into optimal range) doesn’t cure the symptoms, other factors need to be explored. 

Mystery Solved – Lucy’s Case

In order to get more info on Lucy’s case, we did a few rounds of blood work so that we could

really track what was happening. The tests showed low TSH and high thyroid hormones (generally interpreted as a hyper state). However, tests a few weeks later told a different story ; TSH was high and thyroid hormones were low. This swing left her feeling tired. 

We tested for antibodies and found she was positive for Hashimoto’s but not for Graves’. 

We determined that the high TSH was likely due to a Hashimoto’s flare up – and that these flare ups were frequent which explained why she could go from feeling very high energy to fatigue within days. 

Next Steps 

We needed to calm down her immune upregulation. We initiated an immune calming protocol and started to address her triggers. We discovered that she had a few infections that were adding to her triggers including H Pylori, SIBO, EBV. This was in addition to the other triggers that we all face including issues with her diet, environment, and stress. 

We all have different triggers so it’s important to determine your unique triggers – this is something I work through in my thyroid program.

Happy Ending

After 3 months of immune balancing nutrients and trigger support, Lucy noticed so much more

balance. Her antibodies dropped and her TSH stabilized and she was no longer getting those up and down swings.

Eliminating Health Mysteries

For Lucy, we were able to find that missing piece of the health puzzle and help her regain her health. Could this be the missing clue for you or someone in your life? 


Resources mentioned

Thanks to my guest Dr. Eric Osansky. You can connect with him through his website, Natural Endocrine Solutions, and check out his podcast Save My Thyroid.

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Related Podcast Episodes:

78 [Ask Inna] Your Thyroid and Hashimoto’s Questions Answered

106 Why You Don’t Want to Ignore Symptoms of a Hyperactive Thyroid

85 The Case of the Unnecessary Thyroid Medication

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Hi, I'm Inna!

I am obsessed with getting to the real root of health mysteries. Whether you are suffering from a major health issue like an autoimmune disease or have nagging and frustrating symptoms like fatigue, stomach discomfort, pain, insomnia, brain fog, PMS, skin issues, etc… they have a big impact on how you live your life. You don’t have to suffer. Together we can change that!