Nataliia Sanzo RDN, LDN: 0:00

Hello friends, welcome back to Hashimoto's Nutrition Rx podcast. Today's episode is one I know so many of you have been waiting for, because we're digging into those big questions I hear from my community all the time. Do I really need thyroid medication if I have Hashimoto's? What if my antibodies are high but my TSH and T4 look normal? How do I pick the right thyroid medication for me? Thyroid armor, combination therapy? What's the best option? And is it really necessary to go gluten-free or dairy-free if you have Hashimoto's?

Nataliia Sanzo RDN, LDN: 0:38

If any of those questions have been swirling around in your head, this episode is for you, because I'm joined by Alessia Reynolds, a board-certified endocrinologist who takes a truly holistic approach to thyroid care. She is here to break down what conventional medicine often gets wrong about Hashimoto's, why normal labs don't always mean that you feel fine, and how real endocrinologists actually treat the condition beyond just writing a prescription. So by the end of this episode, you'll walk away with clarity, a better understanding of your own labs and more confidence to advocate for your own care. So let's get into it, dr Railnuts, welcome. Thank you so much, natalia. Yeah, we're so excited to have you, and I told you before we went live that I love having endocrinologists on podcasts because you guys are very important, the most important part of Hashimoto's treatment Although a lot of doctors may not attend to Hashimoto's as much as we patient one but when I found you, I told you.

Nataliia Sanzo RDN, LDN: 1:52

When I found you on Instagram, I'm like this is the endocrinologist everyone should contact, know about, follow. So thank you so much for dedicating the whole hour to us. I cannot wait to dive into the specific questions that my community is asking every single day, hundreds of messages. Now, before we get started, can we talk about your personal story? What inspired you to specialize endocrinologist and why are you so passionate about thyroid and metabolic health?

Dr. Alessia Roehnelt, MD: 2:27

So that's a great question.

Dr. Alessia Roehnelt, MD: 2:29

Endocrinology has always been something I've been interested in because it is a specialty that really looks at all of the things that are important for overall health, for metabolism, for longevity.

Dr. Alessia Roehnelt, MD: 2:43

In endocrinology we deal with hormone balances, we deal with thyroid, we deal with blood sugar, weight gain, weight loss all of the things that really, at the end of the day, go into someone feeling well and thriving versus someone really not feeling their best. And what I particularly liked about endocrinology is that balance of hormones one going up, one going down how they interact with each other and how you can tweak them a little bit to really optimize how someone feels. So I love that idea behind endocrinology and, like you, I actually have Hashimoto's myself and so I also can look at this from a patient perspective and what people are going through and what people might feel. When patients come in and they say I'm cold all the time, sometimes I'll be like here, feel my hand Same, so I can really empathize with some of the symptoms that my patients have and I think that helps when I'm trying to treat them.

Nataliia Sanzo RDN, LDN: 3:42

And thank you so much for sharing this personal piece of information about yourself. I didn't realize that you also had Hashimoto's, which now you were already on pedestal for me and now you're just. You took the medal. So sweet, thank you.

Nataliia Sanzo RDN, LDN: 3:57

Now. So thank you for sharing your background story. Now, for people who don't know who you are, I would like to officially introduce you with your official bio, not just a personal story. Now, for people who don't know who you are, I would like to officially introduce you with your official bio, not just a personal story. So Dr Alicia Reynolds is a board-certified endocrinologist with over a decade of expertise treating patients with thyroid disorders, hormone imbalances and metabolic conditions. She completed her residency in internal medicine and was selected chief resident and completed endocrinology fellowship at Mountain Sinai in New York City. I knew I was going to butcher that one, okay.

Dr. Alessia Roehnelt, MD: 4:36

Mount Sinai.

Nataliia Sanzo RDN, LDN: 4:39

Dr Ronald combines conventional endocrinology with holistic, lifestyle-based approaches to help patients feel better, not just have normal labs. She's the host of the Wellness Protocol podcast, where she covers topics like Hashimoto's, insulin resistance, glp-1 medications oh, we need to have you back on the podcast for this topic and hormonal health. She also creates educational content for her followers on Instagram at endo health doc, empowering people to better understand their bodies and advocate for their health. Did I miss anything? I think that's it Now in your practice. How common is Hashimoto's and do you think it's been underdiagnosed or misdiagnosed in women today?

Dr. Alessia Roehnelt, MD: 5:30

So Hashimoto's is very common in my practice. It's a very common autoimmune disease in general and it's the most common cause of having hypothyroidism or an underactive thyroid or an underactive thyroid. So normally when I see patients, if they've been diagnosed with an abnormal thyroid function, hypothyroidism, nine out of 10 times it's going to be due to Hashimoto's. So this is very common.

Dr. Alessia Roehnelt, MD: 5:54

We are certainly seeing a rise in autoimmune diseases and the diagnosis of autoimmune diseases, and so Hashimoto's just seems to be becoming more and more prevalent In terms of is it overdiagnosed, underdiagnosed? I think it's always been there, but we're now recognizing it a little bit more. I think that patients are now really advocating for themselves and they will proactively come to doctors asking for certain things to be tested. I think that patients are more educated now and so they might say listen, I have a family history of this and I read that it can run in families, so should I be checked for Hashimoto's? So I think we're finding it more because we're looking for it more, but it has always been there. It's just we're detecting it a little bit, maybe earlier, but we're being more proactive about it nowadays.

Nataliia Sanzo RDN, LDN: 6:47

I completely agree with that, because a lot of people say, especially on social media, it's that fear mongering, oh, hashimoto's on the rise, everybody's getting Hashimoto's and, just like you said, it was always there, it's just now.

Nataliia Sanzo RDN, LDN: 7:01

We have better diagnostic tools, we're more in tune with our bodies and people are coming to the doctor saying please check more than my TSH. So the awareness is there, and now we have thyroid day and thyroid months, so there are more and more people talking about it. And that lines up with what I see in my practice too. So many of women come to me after like years of being told that they're fine because their TSH was normal, only to find out that without just testing TSH, when they check their thyroid antibodies, they're elevated. So I always remind my clients that even with normal labs, your body is whispering something about your Hashimoto's, so it's on high alert and, like you said, we're just being diagnosed sooner. Now, for listeners who are new to this diagnosis, can you explain what Hashimoto's thyroiditis is in simple terms and how is it different from a general hypothyroidism?

Dr. Alessia Roehnelt, MD: 8:04

Sure, let's start with hypothyroidism. So the thyroid is a gland located at the base of the neck and it makes thyroid hormone. Thyroid hormone is basically responsible for the pace of your body, so it plays into how fast your heart is beating. It plays into how fast your bowels are moving. It plays into how fast your skin and your hair are shedding. So if a thyroid is functioning normally and making the normal amount of hormone, the pace of the body will be okay. But if it's going too fast, if it's making too much hormone, the pace of the body is accelerated. So now you may have symptoms of your heart going really fast and a racing heart rate. You might have symptoms of diarrhea or increased bowel movements because your bowels are moving too fast. Alternatively, if you have an underactive thyroid, hypothyroidism, everything is just moving too slow. So you might be fatigued. You might feel like you are just walking through mud to get through the day. You might feel like you are just walking through mud to get through the day. You might feel like you're gaining weight because your metabolism is slowing down. You might be constipated because your bowels are moving slowly. So if you have an abnormal amount of thyroid hormone, one way or the other, it really affects the pace of your body.

Dr. Alessia Roehnelt, MD: 9:22

It is much more common to have the form of the underactive thyroid. The overactive is much less common. So most people if they have a thyroid condition, it's going to be an underactive thyroid or hypothyroidism, and the most common cause of it is Hashimoto's. Hashimoto's is basically the name of the person who discovered these antibodies basically the name of the person who discovered these antibodies. Antibodies are molecules that your blood makes normally to fight infections and bacteria and foreign things, but in autoimmune disease it's fighting your body. So these antibodies are, to put it simply, fighting your thyroid and potentially making it not work as well, and this is the most common cause of developing an underactive thyroid.

Nataliia Sanzo RDN, LDN: 10:11

I love how you've broken down this complex answer into simple terms, and one thing I always explain to my clients is that Hashimoto's is autoimmune disease first and then thyroid second. So even if your thyroid function looks normal, your immune system may already be inflamed and attacking the thyroid tissues silently right, just like you said, and that can affect how you feel long before labs catch up, like with me, I know my symptoms started probably a decade before I received an official diagnosis, and that's usually I see in my clients. I see that to be true as well. Five to 10 years, maybe even longer. Now you mentioned TPO antibodies. Can you explain or go into details the difference between TPO and TG antibodies? What do these antibodies actually tell us about autoimmune activity and do they always correlate with how we feel so.

Dr. Alessia Roehnelt, MD: 11:15

These antibodies are actually both used to determine if someone has an autoimmune thyroid condition, aka Hashimoto's. The most common, the classic one, is the TPO antibody thyroid peroxidase antibody. That is the one that classically has been associated with having Hashimoto's. The other antibody, fibroglobulin antibody, is a little bit less well-known, but when that antibody is positive, again we also consider the patient to have an autoimmune form of a thyroid disorder. And it doesn't matter as much which antibody you have or which one is positive. The idea is that you have this autoimmune disease, your body is fighting something, your body is reacting to something. Your body might potentially be inflamed, something. Your body might potentially be inflamed. So these antibodies being elevated don't necessarily tell us anything about the function of your thyroid, because these antibodies are what are called reactive antibodies. So let me take a step back. We talked before about how there's overactive thyroid and underactive thyroid. In overactive thyroid, hyperthyroidism, those antibodies totally different. They're called Graves antibodies. They literally bind to the thyroid and kind of stimulate it to make more hormone.

Dr. Alessia Roehnelt, MD: 12:35

In Hashimoto's the antibodies are not directly affecting the thyroid. They are a reflection of inflammation going on in the body. So they will go up if you sneeze. They will go up. If you ate something that's pro-inflammatory for you, they will go up. If you have a broken leg, they will go up when inflammation is happening in your body. They don't necessarily go up and directly cause an issue with the thyroid, so they are reactive antibodies and showing us that inflammation is present. So when they're high, even if someone's thyroid is functioning normally and making the right amount of hormone and their levels are good, they still have inflammation.

Dr. Alessia Roehnelt, MD: 13:22

And when you have inflammation you usually have symptoms. The symptoms are usually very vague, so it's being tired, forgetful headaches, joint pain, feeling achy, and these are all symptoms that are so difficult to really put a diagnosis on because they overlap with so many things. They also overlap with life. Somebody comes in and they say they're tired. Yeah, me too. So it's sometimes hard to figure out if somebody is having a symptom because of what's going on with their body and that there's really a problem. Or is this just stressful life? And you have young kids? Of course you're tired. So checking those antibodies and just seeing if they're elevated or not can just give us a little bit of a window into how much inflammation might be going on in someone's body.

Nataliia Sanzo RDN, LDN: 14:08

I always describe antibodies as like a fire alarm for your immune system, just because if you have antibodies doesn't always mean you feel terrible, but if they are climbing, it usually means that your immune system is more activated. It usually means that your immune system is more activated and it's a sign to look deeper into stress, gut infection, inflammation. So actually I do have a free guide on my website five ways to lower TPO antibodies, but I created it not for people to fixate on lowering the antibody levels but to address, like I said, gut health, inflammation, stress and all that stuff. Lifestyle approaches. But what happens on social media? That everybody talks about TPO antibodies, how to lower them, and it is an indication of oxidative stress, which is true. But people think that the higher your TPO antibodies, the more aggressive your Hashimoto's is, which is not true. Right, we know that the cells are being destroyed by T cells, not your TPO antibodies. They're just TPO antibodies just marking your cells for your immune system to do something with them.

Nataliia Sanzo RDN, LDN: 15:21

So I have patients that have TPO antibodies well above 500, and they feel fine after we address their gut health maybe chronic gut infection, whatever is going on in their life and they feel fine. They don't have chronic constipation. They are doing well. They're in remission in their own terms, because remission looks differently for everybody. I also have patients with TPO antibodies below 100, which is considered what remission right In functional medicine terms, although we really don't know what that means. So I have patients with TPO antibodies below 100 with every possible Hashimoto's related symptom under the sun. So for me, yes, we like to test it, we like to have basically a pulse on the TPO antibodies. But I always say I would never recommend somebody to, let's say, do an AIP diet to decrease your TPO antibodies from 500 to 100. If you don't feel better, if you don't see decrease on any other symptoms, what did we do? So what? We decrease your TPO antibodies, right, like. Address the symptoms, know your TPO antibodies levels, but don't concentrate, don't micromanage.

Dr. Alessia Roehnelt, MD: 16:38

I totally agree. I have a lot of patients that really like to monitor their levels. They like to see their progress. But the problem is again anything can cause them to go up. So maybe they've done this fantastic job tweaking their diet, eating clean. They feel so much better. But they got a cold just before they went for their blood work and now their antibodies are high and now they're upset because they're like oh, I was trying so hard and I do emphasize to them like they go up and down quickly.

Dr. Alessia Roehnelt, MD: 17:06

We can't put too much focus on them. The idea is, your immune system is reactive, so let's keep it as happy as we can. I agree.

Nataliia Sanzo RDN, LDN: 17:13

And actually, if somebody who's watching or listening wants to check if this is true, if your TPO antibodies are jumping up and down, get the blood work done on day one and then two days. Get the blood work done at the same time. Chances are your TPO antibodies may jump 50 points, which is a lot. But again, this is just your body reacting to. Did you sleep okay last night? Did your kids had you up all night, or your husbands were stressing you out? Whatever it is, the bottom line is know your numbers, but don't micromanage, don't concentrate on them too much. Now, is it possible to have Hashimoto's and not be hypothyroid? Should someone with high antibodies but normal TSH still be concerned or take actions?

Dr. Alessia Roehnelt, MD: 18:04

So you absolutely could go your entire life having Hashimoto's and never need medication. That is not uncommon. There are plenty of people that make it all the way, end of life, never needed any kind of supplementation, because it doesn't always cause an issue with the thyroid. But I do think it's important for people to know this about themselves, to know that they have an autoimmune disease, because it helps them number one, maybe understand their body a little bit better, maybe realize that okay, if I go out and I eat this large amount of gluten and I feel really bloated, I know that it was the gluten. I know that it was related to something that I ate that night before. I know that I'm sensitive when it's raining outside. I know that I'm not going to feel as great. So they can predict what situations they might feel best in, they can figure out which things to avoid and they can also be on a little bit of high alert for other autoimmune diseases.

Dr. Alessia Roehnelt, MD: 19:02

So autoimmune diseases like to run together in one person as well as in family members. So, for instance, I see a lot of patients where they're in those years of just having kids and if they have Hashimoto's, I let them know. Your kids are at higher risk of autoimmune disease. So maybe once you start introducing solid foods, be careful, because your child could be at higher risk potentially of something like a food allergy. Or maybe, if you notice the baby has dry skin, bring them to the doctor. They might have something like eczema. So I think it's good to always think that way, that maybe a problem that I'm experiencing or a loved one is experiencing is autoimmune related.

Nataliia Sanzo RDN, LDN: 19:42

So I'm glad you brought up the fact that not everyone develops hypothyroidism even though they have Hashimoto's, because I've came across a few social media profiles not to be named here that claim that I reversed my Hashimoto's, I got off thyroid medication, and let me teach you how you can do that too. And I think it is such a dangerous advice because it's a small subset of people who have Hashimoto's were on thyroid medication and miraculously either reverse, stop their Hashimoto's progression or never got on medication. But I don't think it can be one thing. I don't think it's just dietary approach or lifestyle approach or supplements. We still don't really know how it happens. Why somebody doesn't develop Hashimoto's is not because they have the secret or the key to this autoimmune disease, so I think it has to be so personalized.

Dr. Alessia Roehnelt, MD: 20:43

Yeah, absolutely we also. We know that there are certain times of life when Hashimoto's might present itself and cause a thyroid issue. Those are generally the big peaks in hormonal changes. So the first one is puberty, the second is pregnancy and the third is menopause. I usually tell my patients, if they've gotten through menopause and they have not needed thyroid hormone, they probably never will in their life, and they're just one of those people that their thyroid functions well despite the antibody levels.

Dr. Alessia Roehnelt, MD: 21:12

I have had a few select patients get off thyroid medication with lifestyle modifications, and those are generally the people that make a lot of changes, maybe before they went into it with a lot of pro-inflammatory things in their life. They removed a lot of toxins, from laundry detergents to what kind of clothes they're buying cotton versus polyester to. Are they wearing plastics, all that kind of stuff, taking out foods that were clearly causing gut inflammation, and they were people that when all of their hormones were working better, when their metabolism was good, when their gut microbiome was probably as optimized as possible, their thyroid did not need that extra help. Their thyroid was able to figure everything out because all the stress on the body was low. But during times of stress, during hormonal fluctuations, the thyroid really needs to kick it up a notch and make more hormone, and some people just aren't able to do that, and that's when they need medication.

Nataliia Sanzo RDN, LDN: 22:16

And I would say I also had in the last eight years of only working with people with Hashimoto's hypothyroidism only like 1% of people were able to get off thyroid medication. But I think it's because they started earlier. We caught them on the earliest stage of Hashimoto's, which is now it's like there's some people say it's four stages of Hashimoto's, some people say it's five stages. So somewhere in between. We caught them earlier, on the earlier stage, while their thyroid gland was still optimal and functioning, maybe at 80% capacity. But for most people we get diagnosis at the fourth stage, at the last stage of Hashimoto's, when our thyroid gland is completely destroyed.

Nataliia Sanzo RDN, LDN: 23:02

And some people they try to get off their thyroid medication on their own and they report on social medias that I stopped thyroid medication. I feel so much better, without realizing that your thyroid gland still stores some hormones. And when your body is depleted of thyroid hormone, your thyroid gland releases that stored thyroid hormone and you feel better. But inevitably your bodily functions will go down, your metabolism will slow down, you'll start feeling extremely fatigued. So I think working with the multidisciplinary team is the answer. If somebody's trying to get off thyroid medication, I would never tell somebody oh, just try to do it on your own. If it doesn't work, I think you can do more damage than not.

Dr. Alessia Roehnelt, MD: 23:56

Absolutely yeah. So normally if I'm trying this on my patients where they're on the lowest dose of whatever medication they're on and it's a conversation about listen, we can try this, but we got to check your levels in six weeks. If you're not feeling well, you need to let me know, and usually, again, it's only when you're on the absolute lowest dose that it's a relatively safe experiment.

Nataliia Sanzo RDN, LDN: 24:18

I agree, because when somebody comes to me with taking 120 milligrams of whatever levothyroxine or equivalent of NP, thyroid or armor, chances are your thyroid gland is no longer producing any kind of thyroid hormones. Sure, you can back off the medication, but I think you're still going to need that, and we know the liver is the only organ that regenerates itself, right? So people claiming that thyroid gland will eventually start making thyroid hormone? Truly, I look at the studies every single day at trying to find resources that do tell that your thyroid gland cells regenerate, but I can't find anything that's truly says oh, the thyroid gland will regenerate. Do you have any experience?

Dr. Alessia Roehnelt, MD: 25:05

with it. No, I wouldn't say that it regenerates. So the thyroid gland and the hormone that it's making is weight-based. So, for instance, if somebody has their thyroid removed because they had surgery for something, we put them on a dose of medicine that's based on their weight. So when you have somebody that's overweight or obese, the thyroid is working a lot harder to try to make enough hormone for that body. And that's when it's okay.

Dr. Alessia Roehnelt, MD: 25:31

It's just beyond the limit of what the thyroid can do. It just can't make more. Or similarly, when women get pregnant, their estrogen levels rise. Estrogen increases this type of protein that kind of binds up thyroid hormone. So your body can't see it as much. So now your thyroid needs to make a little more. And again, that's another time when it's okay. The thyroid maybe can't get there. But if things are working really well in the body, you have someone that is a really healthy body weight, they eat well, they're fueling their body with nutritious foods not processed foods, packaged foods, things like that the hormones are in a good place. That's the person that really you could. Potentially their thyroid might be in good enough shape to say okay, I can take it from here. Everything else is calm, you're not putting too much stress on me right now, so it's really the body needs to be optimized in order for that to happen.

Nataliia Sanzo RDN, LDN: 26:23

Now to know where if your thyroid gland is healthy or not. Do you recommend people do ultrasound or check or have a baseline?

Dr. Alessia Roehnelt, MD: 26:34

Do you. I don't recommend just a baseline ultrasound because so in Hashimoto's the thyroid texture does oftentimes change. Initially, when you don't have Hashimoto's or when you're very early on in it, the thyroid looks nice and smooth on ultrasound. We call it homogeneous. It's all the same texture as the Hashimoto's is there for longer let's say like maybe 10 years or so of positive antibodies or somebody with just a lot of inflammation going on other autoimmune diseases. We start to see the texture of the thyroid change. It becomes almost like Swiss cheese. It looks like there's holes in it. Almost there aren't actually holes. That's just what it looks like on an ultrasound and it just looks very choppy.

Dr. Alessia Roehnelt, MD: 27:18

But I have seen I do ultrasounds myself in the office, I do ultrasounds and biopsies and I have seen the most shriveled up, choppy looking fibroids make an absolutely normal amount of hormone and the person doesn't even need medicine. So the structure, the size it generally does not correlate with how much medication you need, how much hormone you need. It certainly does not correspond with how someone feels. So I usually only order or perform an ultrasound on a patient if I feel like their thyroid feels enlarged, if I need to get a better idea of what their thyroid looks for one reason or another, if I'm worried that they might have thyroid nodules, if there's a family history of thyroid nodules. But I generally don't order it as just like a screening test.

Nataliia Sanzo RDN, LDN: 28:04

And that's good to know, and I'm not a medical doctor. But if somebody asks like, should I do an ultrasound, I always recommend that, just as a personal example, only if you have nodules, if there's an enlargement, something, if you feel like it's harder to swallow.

Dr. Alessia Roehnelt, MD: 28:23

So only that.

Nataliia Sanzo RDN, LDN: 28:24

I agree.

Dr. Alessia Roehnelt, MD: 28:25

Symptoms of something or you feel something, that would certainly warrant an ultrasound, but we generally don't recommend them just for everybody.

Nataliia Sanzo RDN, LDN: 28:31

Now speaking of testings, if someone has positive antibodies but normal TSH, we're at the beginning stage of Hashimoto's. How often should they be monitored and what else do they need to look for?

Dr. Alessia Roehnelt, MD: 28:45

in there. So initially, if I see a patient with Hashimoto's, if they have any type of GI stomach symptom, I always check them for celiac disease as well. It is a very common autoimmune disease to see with Hashimoto's, and so that's one additional test that I think pretty much everyone with Hashimoto's should be screened for. You can also have celiac and be completely asymptomatic. Actually, your body gets used to things and it tries to get you through, and so maybe your only celiac symptom is that you're tired or you've had a low vitamin D at times, but you actually are very inflamed in your GI tract. So I will always recommend people to have a celiac screen, if they haven't already. And that's just blood work initially. If that's positive, then they would see a gastroenterologist and have a further workup and testing done. But initially it's just blood work and then we generally recommend checking the thyroid levels, the thyroid hormone levels, or specifically the TSH, at least once a year.

Dr. Alessia Roehnelt, MD: 29:47

That is in the absence of symptoms. If somebody has symptoms, we check them right away. So let's say they just got diagnosed with positive antibodies and their thyroid level was perfect, but for the last few months they've been more tired, they've been more sluggish. We check the level because we don't know when Hashimoto's could come out and start to cause issues with the thyroid Again. We can maybe predict it hormonal changes, things like that but we don't know for sure. So if there's a change in symptoms I always tell my patients let me know. We can check a level. Otherwise, if somebody feels completely normal, they have no symptoms. This was just something that we found on blood work. We just check them once a year for just in case, just to make sure we're not missing something.

Nataliia Sanzo RDN, LDN: 30:36

And that makes so much sense because I also like to remind my clients that we're not just watching for TSA or TPO antibodies. We're watching patterns, trends, symptoms. So I'm on the same page. I usually recommend, if there's no symptoms, check every 12 months, especially if you have a history, family history, of Hashimoto's. So, depending on symptoms, lifestyle changes, especially if they're actively working on like diet, gut healing and trying to lower their TPO antibodies. Now many of my clients come to me and say oh, my labs are normal, but I don't feel normal. Oh, my labs are normal, but I don't feel normal. Why do so many people, so many of us, still have symptoms, even when our TSH or even T4 levels are normal?

Dr. Alessia Roehnelt, MD: 31:20

So a few things with that question. So the one part of that question is what is normal? What is a normal TSH? Because we have what the lab says is normal, but that doesn't mean that is normal for that specific person. As an example, in pregnancy we like to keep the TSH on the lower end of normal, generally under 2.5.

Dr. Alessia Roehnelt, MD: 31:42

So if you have someone that is, let's say they're in their 30s, they're thinking about pregnancy, they're a primary care doctor, check to thyroid level, the TSH is 3.0, I would say, hey, listen, if you're thinking about pregnancy, we're a primary care doctor, checked a thyroid level, the TSH is 3.0, I would say, hey, listen, if you're thinking about pregnancy, we should probably do something to bring this down a little bit. Versus, if that was a 50-year-old male who felt totally fine and, of course, is not planning on getting pregnant, I would say, great, your TSH is 3, it's normal. So depends on the patient. Also, alternatively, if you have an elderly patient, a lot of studies have shown that in elderly people over the age of 65, the TSH goal should actually be much higher, meaning they don't need as much thyroid hormone. Remember, thyroid hormone is controlling the pace of your body and as you get older, your organs get older, your heart is older, your GI tract is a little older, so you don't want to be giving an 80-year-old person the thyroid hormone of a 20-year-old. You want to be giving them something that appropriately matches their physiology. So in elderly people their TSH might be technically elevated, but if they feel I won't touch that.

Dr. Alessia Roehnelt, MD: 32:51

We just monitor, monitor symptoms mostly and just keep an eye on the thyroid level. Number one if somebody comes in and says I've been told my TSH is normal, I'm like let me see it, what's the number? Because I want to determine if, for that particular patient, would I consider that a normal range. Second, not all symptoms are going to get better with thyroid medicine. And when we're looking at the TSH and the thyroid hormones, a lot of times we're talking about does this person need medicine or do they need a higher dose or do they need a lower dose? It doesn't necessarily mean their symptoms are going to completely go away if we get this number to a perfect level.

Dr. Alessia Roehnelt, MD: 33:33

So if I see a TSH that's normal, but a patient still has symptoms we talk about, listen, starting a thyroid medication is not going to help you feel better, but what else can we do to help you feel better. Okay, you have these positive antibodies. That means you have autoimmune disease, I tell them. That means you're more sensitive to the environment than other people. So let's see what can we fix at home to try to minimize inflammation. What can we fix about your diet that we can try to minimize inflammation? And we try to work with their entire lifestyle to figure out how to make them feel better, because I know that just giving them medicine is not going to do it.

Nataliia Sanzo RDN, LDN: 34:10

So how does someone, especially at the beginning of Hashimoto's, can figure out do they need medication and what medication? That would be the best start for them.

Dr. Alessia Roehnelt, MD: 34:23

So normally, again, it depends on where you are in life, your gender, your family planning. All of that will play into when you might need thyroid medicine. What thyroid level cutoff are we aiming for? And then, when you're talking about what types of medication, again it's very patient specific. Most people are on regular thyroid hormone called levothyroxine that's the generic that is T4 hormone. Sometimes people are on a brand of that medicine, such as Synthroid, tyrosine, euthyrox different brands of the same kind of idea. But the idea is this medication is the same as the hormone T4 that your thyroid is trying to produce. So when we give you that medicine, we're giving back what your thyroid needs and theoretically you should feel better. Giving back what your thyroid needs and theoretically you should feel better. Now your body then converts that T4 medication into T3 hormone and your cells need T3 hormone as well. And there is this theory that some people are slow converters of the medication T4 into T3. And there are certain patients where, depending on their symptoms, depending on their blood work results, depending on just how they're feeling, we might consider adding an extra T3 component to help some of their symptoms, and that is the classic way of managing Hashimoto's or hypothyroidism.

Dr. Alessia Roehnelt, MD: 35:48

There is also the idea of using pig-derived thyroid, so that would be brands like Armor or NP Thyroid. These are pig thyroid glands that have basically been created into a pill, a capsule, for you to take. The idea here is that it's a combination of both T4 and T3. And many people like the idea of this because they think of it as a more natural form, because it's coming from nature in a sense, even though, like it's made in a laboratory, it's coming from nature, and some people are just much more comfortable with that idea. The downside, though, to using those kinds of medicines are that pig thyroids are different than human thyroids, so, human thyroids, we make about like 12 times as much T4 as we do T3. And pigs make about three to one.

Dr. Alessia Roehnelt, MD: 36:41

So that means that when you take pig thyroid, your body is seeing much more T3 than it's used to, and actually much less T4. That means some people might actually feel more tired when they're on medicines like this, but also have more side effects, such as a fast heart rate, because T3 can really affect the heart. They might actually be at higher risk of osteoporosis, because too much T3 can potentially cause bone loss or osteoporosis, and they're not really well studied in pregnancy or in treatment of thyroid cancer. So there are some patients where we say listen, this is just not a great idea for you. And for other patients we say you know what, you're healthy, you're in a good place, let's give this a try and see if you feel better on this one. But it's very personalized when it comes to deciding which medication and it really just is a conversation between the patient and the doctor to see what might be best.

Nataliia Sanzo RDN, LDN: 37:39

And I'm so glad you brought it up, because I get these questions all the time and even though I'm just a clinical dietician I don't prescribe medication Because I have Hashimoto's people reach out to me saying what medication are you taking? Is this good? I'm like it's good for me. That's why I don't usually like to share what medication I'm taking or what dose, even because it's based on my lifestyle, my personal choice of pig death, the gated thyroid hormone, my energy level, the desired energy level I want, and even my body weight, right. So it's irrelevant what my dosage is right, because it's all depends. So I usually don't share that.

Nataliia Sanzo RDN, LDN: 38:19

But I am going to say that I used to be on levothyroxine for about five years and the last two years of that first five year span I felt horrible. We kept increasing medication and then I would get a heart palpitation but no improvement in energy. My skin was breaking out. It was horrible and I made a choice to try NP thyroid and I've been taking it for the last five years and it made a huge difference to me. I love it. It's my life just changed upside down from not changing anything in my lifestyle or diet. To me that was a life-saving medication and to make sure that I'm on the proper dose. Now I'm so glad you said that the lab, the blood work, it's so again personalized and what's normal for one person may not be normal for another person. So when somebody comes to me with their blood work and I'm like, oh, how's your thyroid gland? And they're like, oh, everything was normal, and I always say, let me see how normal it was Right, but what was it oh?

Nataliia Sanzo RDN, LDN: 39:29

it was like a 4.8. Yeah, yeah, maybe let's look into that. And I always work with my patients, doctors, and I always refer people to endocrinologists or gastroenterologists, whatever they need. But I always stay in communication with the MDs because I'm like, hey, maybe we should drop the TSH down just to see how patient feels.

Nataliia Sanzo RDN, LDN: 39:54

Now you mentioned T3. It's an active thyroid hormone. I like to keep my T3 at the higher level, but that's my personal choice. As soon as it drops below normal, I feel it, and because I can get the blood work done just down the hallway here in my office. As soon as I feel like my body's changing or the energy levels are changing, I get my T3 checked. And sure it is, it's in the normal range, but for me it's too low. I just know it.

Nataliia Sanzo RDN, LDN: 40:26

So I'm sharing all of this just to tell listeners or people who are watching to find your normal, yes, we follow these guidelines because we have to have some standard of care and some kind of protocol, right, because then we're going to be all over the place. Then our treatment's going to look like Instagram, right Influencer thing. So personalized care is very important and finding your normal is even more important. Now you mentioned that, of course, we were talking about Hashimoto's, and what triggers your Hashimoto's symptoms? What are some of the lesser known environmental or lifestyle triggers that you've seen worsen Hashimoto's in your clients?

Dr. Alessia Roehnelt, MD: 41:15

I would say during the COVID pandemic we really saw how much viruses and infections and things like that bring autoimmune diseases to the surface. I think in my years of practice I've never seen as much Graves' disease, overactive thyroid or new cases of Hashimoto's than I did in those few years of the pandemic. It was like clockwork. Someone would get COVID and then six weeks to three months later start to feel awful. We check their levels. Their thyroid function is all out of whack. So I am a big believer that viruses are probably a big culprit because, if you think about it, when your body is fighting that virus your immune system is very active and sometimes things go a little haywire. And so I do think that viruses are one of the biggest reasons that we see Hashimoto's and other autoimmune diseases.

Dr. Alessia Roehnelt, MD: 42:10

I also think it has a lot to do with the foods that we're eating. I think that we are much more sensitive to foods than people think and we sometimes just say, oh yeah, my stomach hurts, I ate a little bit too much of this. Or oh, I went to that weird Chinese restaurant and ate too much of that sauce and we downplay it. But any type of GI symptoms really speak to what's going on with your whole body. The gut microbiome is just huge here, and when we're fueling it with the bad kind of food and we are fueling the bad bacteria instead of the good bacteria, we are really just changing the balance in everything, specifically our immune system. There are a lot of immune cells in that gut microbiome and so if we're not nourishing that microbiome and we're poisoning it, the result could potentially be an abnormal immune system.

Nataliia Sanzo RDN, LDN: 43:03

Absolutely. In my practice I see mold, chronic viruses just like COVID, and gut infections, especially H pylori, and even over-exercising that's what all of those hidden stressors on the immune system. It either triggers Hashimoto's or exacerbates all the symptoms. So I always say if we want to put out the autoimmune fire, we need to look what's pouring the gasoline on it. And for me you mentioned food. Of course Some people think theories. You know that the food triggers autoimmunity, especially Hashimoto's gluten, dairy soy.

Nataliia Sanzo RDN, LDN: 43:44

For me, we always look for root cause what caused your Hashimoto's? And it's a great thing to know what caused your Hashimoto's. But if the Hashimoto's is already triggered, we can't reverse it, so you're stuck with it. So even if you found out that your Hashimoto's was triggered by hormonal imbalance during pregnancy, what does it give you the years spent on finding the root cause and stressing about it? What does it give you when you find that out? That says it's always it's about balance. Yes, let's look for a root cause. Now, if your root cause of Hashimoto's is iodine deficiency, absolutely we need to find the root cause. Correct iodine deficiency slow down the progression of your Hashimoto's.

Nataliia Sanzo RDN, LDN: 44:30

But it's such a complex thing and for me personally I'm the first generation in my family, on both my father and my mother's side, with Hashimoto's, and I'm the first generation living in the United States. I'm from Ukraine, so I moved here when I was 20 years old and I'm convinced that 10 years at this point, 18 years of eating food, american foods, breathing this air, drinking this water, triggered this autoimmune disease. Like I said, I'm the only one, the first one. So no genetic predisposition, right? No, I wasn't exposed to radiation, I didn't work in the plant. So what's the third? They say there's a three-legged stool that you should have.

Nataliia Sanzo RDN, LDN: 45:20

What's the third? They say there's a three-legged stool that you should have the legs. It's the environmental triggers food and genetic predisposition. I don't have two of those. I only have left food triggers. So I truly believe, even after becoming registered dietitian, I'm like food is the first line of defense if we're trying to heal the body. Dietician, I'm like food is the first line of defense if we're trying to heal the body, but at the same time, it can be a trigger of so many autoimmune diseases. Now, since we're talking about food and stuff, what is your take on a gluten and dairy-free diet? Do everyone with sashimotos need to follow it? Especially, is it all gluten-free, all daily free. What's your take on it?

Dr. Alessia Roehnelt, MD: 46:04

So my take is that it is definitely not for everybody.

Dr. Alessia Roehnelt, MD: 46:09

You do not have to go gluten-free or dairy-free if you have Hashimoto's or both, but it's something to maybe test out once in your life. I generally do encourage my patients to maybe do a little bit of an elimination diet with both of those food groups separately in order to determine if they're sensitive or not. As I said before, you know your body really compensates for things. So you may be sensitive to gluten, but you've been having it day in and day out all of these years and your body has just learned to struggle but deal with it. So I normally say okay, even if you don't feel like you're sensitive to it, try it. And I tell them to remove that food group, one at a time, from their diet for a good six weeks, because it really takes at least six weeks for that inflammation to come down and for the gut to start healing. So I tell them take that food out for six weeks, very strict, no cheat days, and after that six weeks think about how you feel, if anything has gotten better, like you're sleeping better, your skin is softer. You normally get five headaches a week and now you only got one a week for the last few weeks. If things are getting better, it probably means you are sensitive to it. Then I tell them. Now you have to weigh the risk and benefit.

Dr. Alessia Roehnelt, MD: 47:26

So a gluten-free diet is not easy. So if I have someone that had a huge improvement, like I had a patient I saw today she has not been able to put her wedding band on in years because her joints were so swollen. She gave up gluten last month and finally for the first time, despite this crazy heat in July, she is able to put that ring on. So for her, removing gluten was huge and it just represented like how much swelling she had, joint pain and everything just from that food. But if for another person all they get is maybe a little bit of softer skin, it might not be worth it.

Dr. Alessia Roehnelt, MD: 48:01

So then I say, if you don't feel like you had a significant response, add it back in and then try taking out the other one dairy and sometimes we have them go down a few other food groups if they really feel very symptomatic of something that we're not able to fix with thyroid medicine. But I usually encourage my patients to at least just try it and test out if they're sensitive. And the feedback I get is most times people are not sensitive. Most times they actually didn't notice a change. It was a big deal for them to keep that out of their diet and so they decided they were going to eat it again. But there are those few patients where it is life-changing for them to cut out gluten and they certainly continue with it.

Nataliia Sanzo RDN, LDN: 48:49

I would say majority of my clients don't follow a gluten-free diet. If somebody comes to me on a gluten and dairy-free diet I definitely support them and make the diet more balanced, healthier, eliminate nutrient deficiencies. But I also, as a dietician, my ultimate goal for everyone, including myself, is a normal diet. Less elimination is possible. Remove the stress, because sometimes planning a restrictive diet like this is more stressful and more harmful for Hashimoto's from the stress perspective than actual the antibodies that possibly circulating, that are similar to your thyroid gland and all that stuff. So it's so personalized and, like I said, most of my clients don't see a difference on the gluten-free diet when we do have a trial to see if maybe they're reacting to it and there's no test that can tell us the true sensitivity. There's no test. There's no true food sensitivity test. It's all gimmicks and stuff. The gold standard to find your food sensitivities is to eliminate that specific food or food group for at least six weeks and then slowly reintroduce just that one group at the time and watch for symptoms. And that's what I still do it with my clients daily.

Nataliia Sanzo RDN, LDN: 50:04

When I was diagnosed I went. I got scared right. That was 10 years ago. We didn't have this Hashimoto's platform that so many people have access to now and they have access to me and you and all this information is free and they get to ask questions. I didn't have that 10 years ago. So of course I went rogue. I went gluten-free, dairy-free, soy-free and all that stuff for a year, but then I started slowly reintroducing all that stuff back and I didn't have any symptoms. Now I don't know if it's because I healed my gut and I felt better or because I just eliminated for no reasons. So that's why I always test it out with my clients.

Nataliia Sanzo RDN, LDN: 50:45

And another fun fact is that when I brought normal diet back I brought gluten back and dairy my TPO antibodies actually went down like from 200 to 100. And now they're hovering at 80 plus minus. Again, I'm tracking it. I test it every six months just to see what's going on. But after I made this huge diet change, my TPO antibodies went down. I actually lost a little bit of weight unintentionally, and I think it's because the stress of planning and just purchasing certain foods and just there's so much going on with that because that disappeared. I just breathed in, relaxed and started enjoying life. So that's again my personal experience and if somebody asks, I do share that. I just I don't just tell my client listen to my experience and you'll do the same. No, it doesn't work. It doesn't work. We're still clinical people and we have to treat people where they are. But it's just interesting how diet doesn't work for everyone and if somebody comes to me, wanted to do an AIP diet, absolutely Just.

Nataliia Sanzo RDN, LDN: 51:59

Let's make it healthier and let's make it short-term, because it's never meant to be followed for a long time. So this is such a hot topic right Now. What are the top three things someone with Hashimoto's can do today, regardless of either their own medication or not?

Dr. Alessia Roehnelt, MD: 52:19

To do to feel better? Yeah, oh, okay. So one thing I would do is the main thing is trying to figure out things you might be doing that are promoting inflammation, because at the end of the day, this is an autoimmune disease that might affect your thyroid, but it's not necessarily a thyroid disease. So we want to think about the immune system first. What is triggering that?

Dr. Alessia Roehnelt, MD: 52:47

One thing I would encourage patients to look at is, first and foremost, their diet. Are they having too many processed foods? Are they having too much sugar, which is very pro-inflammatory? Perhaps they do eat a lot of gluten and they might want to try a gluten-free diet. Perhaps they do eat a lot of gluten and they might want to try a gluten-free diet. Perhaps they do have a lot of dairy and they want to go that route. But looking at your diet and trying to figure out, maybe one at a time, what is one thing I can cut down on to see if it makes me feel better. So first, I would absolutely approach diet. Second, sleep.

Dr. Alessia Roehnelt, MD: 53:17

Sleep is so absolutely critical to allow the body to heal and restore your energy for the next day and restore function to.

Dr. Alessia Roehnelt, MD: 53:28

That's going to wait until the morning, making sure that the kids are in bed when they need to be Everybody. The whole house should be dark by nine o'clock, in my opinion, in most homes Everybody needs to prioritize sleep For growing children, for any adult, sleep is critical and exercise. If the body is not moving, you are slowly decomposing your muscles. You need to be proactively building up. If you are too sedentary, those muscles will continue to deteriorate, atrophy. Your metabolism will slow down, certain hormones in the body will start to be disrupted. Loss of muscle can lead to insulin resistance and that can lead to prediabetes and diabetes, weight gain, of course. So making sure that you are also prioritizing activity, because if you are just getting weaker and weaker by the day, your body will not be able to make that thyroid hormone that you need and really be optimized. You need to fuel your body with nutritious food, adequate sleep and movement in order to really optimize all the hormones and everything.

Nataliia Sanzo RDN, LDN: 54:50

I love how you summarized it and I hope people are taking notes, because that's the foundation of healthy lifestyle for anyone. It doesn't matter if regardless if you have Hashimoto's or not. Now, what are some misconceptions that drive you crazy when it comes to conventional medicine?

Dr. Alessia Roehnelt, MD: 55:10

I would say the main one is focusing too much on the blood work. I have patients come in and they say I don't feel well and I want the whole thyroid panel or maybe their doctor ordered a whole thyroid panel for them and we put so much focus on all of these different hormones that we are able to check and maybe not enough focus on the actual symptoms. Because if you sit down with a very good clinician, they should be able to go through your symptoms and figure out what you might be missing. Maybe not even with blood work. I can tell if somebody has a certain complaint about something or symptom of something I already know.

Dr. Alessia Roehnelt, MD: 55:53

You know what that sounds like. They probably have low T3 and I need to give them some T3 back. You don't necessarily always have to see it on a blood test. So I think there's too much emphasis on checking all of these markers and how do we react to one of the numbers being off? I think it is much more important to react to the patient in front of you and the symptoms they're experiencing.

Nataliia Sanzo RDN, LDN: 56:16

I completely agree. I think we're at this point everybody are so hypersensitive about everything and we tend to micromanage everything every symptoms, every blood work. Even if your LDL cholesterol goes two points over the normal, people freak out, and I think it's actually more. The stress from it drives Hashimoto's even more. So I always hey, let's stop micromanaging. What's one thing you can do today, or the you're not really doing, that may be fueling your Hashimoto's, and I doubt that. It's two points higher LDL cholesterol, absolutely. So let's calm down, let's do less blood work and let's treat the symptom, not the numbers. Dr Ronald, I know we're running out of time, so I want to thank you for your time today and for sharing your expertise on treating Hashimoto's beyond medication.

Dr. Alessia Roehnelt, MD: 57:15

Thank you so much for having me. This was such a great time.

Nataliia Sanzo RDN, LDN: 57:18

Yes, and we would love to have you for other podcasts, because I know you said you talk about insulin resistance and GLP-1 and all that stuff, so I think your input would be invaluable here.

Nataliia Sanzo RDN, LDN: 57:30

Oh, I'd love to come back anytime. Yeah, now, guys, I really hope this episode helped clear up some of the confusing or frustrating parts of managing Hashimoto's, especially if you've ever been told that your labs are normal but you still just don't feel like yourself. And if there is one thing I want you to take away from today is this that your labs don't define your health experience, whether it's understanding your antibodies, choosing the right thyroid medication or figuring out if gluten-free diet really makes sense for you. There are options beyond just hey, let's wait and see and figure it out. So if this episode resonated with you, please share it with someone else who navigates Hashimoto's, or leave a review on either podcast, or you can say hi here on Instagram, you know, because it really helps get these conversations into the hands of more women who really needs them. So thank you so much for listening and I will see you next time on Hashimoto's Nutrition Rx. Thank you, bye, bye.