How to Recognize and Treat Hashimoto's Disease

Dr. Mike: Hey, Dr. Mike here. Did you know that Hashimoto's thyroiditis is the most common cause of hypothyroidism in the United States? Stick around to learn why and what you can do about it with our guest, Dr. Efrat LaMandre.

Live Foreverish Introduction: You're listening to Live Foreverish, a show dedicated to helping you live just a little longer. Here [are] your hosts, Dr. Mike and Dr. Crystal Gossard.

Dr. Mike: All right. Welcome to Live Foreverish. Dr. Crystal—Hashimoto's thyroiditis. You know, I'm actually really excited to talk about this.

Dr. Crystal: Me, too. I think this was one that we had our social media or SEO team look into. And it's something that people continue to be confused about.

Dr. Mike: It's true. People ask a lot of questions about it. And there's confusion…

When we bring our guests on—and I'm so happy she's back—I want to talk a little bit, too, about [how] I think it's underdiagnosed. Because [there are] symptoms, and it doesn't always match labs. There's that whole thing there, and we're going to get into that with our special guest today.

She's a friend of Live Foreverish: It's Dr. Efrat LaMandre. I love this bio. Oh, there she is.

Don't say hi yet, Dr. E. I'm still on your bio—it's going to take five minutes to get through all this.

Dr. E—[that’s what] everyone calls her—is a bestselling author with over 5 million followers on various platforms. We like Dr. E because she is a Medical Disruptor—disrupting and reshaping healthcare. She advocates against medical gaslighting and empowers patients to recognize that their symptoms are not “in their head,” Dr. Crystal.

She has founded several businesses in the health space, including EG Healthcare for primary care, The KNEW Method for functional medicine, Hawk Scribes for medical scribing, and EG Prep Education for nurse practitioners. Dr. E, your bio wears me out. You are just a warrior in the medical field.

Welcome to the show.

Dr. E: Thank you so much. I'm so sorry. I have to talk to my team about shortening that.

Dr. Crystal: No, no! I think it's great because it's important for people to recognize the true warriors. I like how you said that, Dr. Mike. You are on the front lines.

Many people, especially researchers, are looking at the papers and sometimes there's a disconnect [between] what we see on paper in studies and what you see in front of you—that person that's sitting in front of you and they are saying, “Hey, look, something's wrong. I need you to help me figure this out.”

Dr. E: Yes, 100 percent.

Dr. Crystal: So. Front line!

What Is Hashimoto’s Disease? 00:03:01

Dr. E: Front line!

No, you're right. The thing is, I've been fighting this so long that sometimes I feel I'm not even fighting anymore. I forget.

Dr. Mike: Oh, come on.

Dr. Crystal: No!

Dr. Mike: No. Stay the Dr. E we love…Hashimoto's, we wanted to talk about this. It's a growing trend on social channels.

You hear it a lot. And even when people are diagnosed with it, Dr. E, I don't think they're getting a full explanation of what's really going on by their doctors. To your patients who may have this, how do you describe Hashimoto's?

Dr. E: I'll give a brief overview. And then with your permission, I’d like to dig deep so people can understand it. So, the brief overview is that your body is attacking the thyroid.

A hypothyroid just means your thyroid is not working. Hashimoto's means the reason it's not working is because you have an autoimmune issue. [I’m] not sure if you want me to go deep in right now with how all that works—you tell me.

Dr. Mike: Let's do it. Let's dive. Come on.

Dr. E: Let’s do it. This will serve as a really good understanding of what's going on. Because there's this test and there's TSH, T4 and T3. And people are like, what does all this mean?

So, let me just break it down for you. If you have the ability to actually watch this, I'm going to point to the parts. Your thyroid is right here.

If you feel like a little bump, it's right under that bump. Let's get to know where our thyroid is. And its job is to produce T4.

Your body then converts [T4] to T3. T3 is the stuff that actually makes everything happen. We're going to come back to that. If you have enough T4 in your body, then everything's great.

The way your brain communicates to your thyroid is with TSH—thyroid stimulating hormone—because it stimulates the [thyroid gland]. One day you wake up and there's not enough T4, your brain freaks out and starts to tell the thyroid to wake up.

Thyroid stimulating hormone—TSH, TSH, TSH. You go to your doctor and the TSH is high. If that TSH is high, that means your brain is panicking and your thyroid is not responding.

It's hypothyroid—and that means your T4 is low. The medication that's given is levothyroxine, which is T4. You take T4 in your mouth. Now it's in your body and your brain's like, “Oh great, we have enough T4,” and that TSH normalizes.

And if the TSH normalizes, then we know the right dosage was given to you. If it's still high, we have to give you more. And that's the game of hypothyroid.

Hashimoto's is the reason why all this is happening. Hashimoto's means there is an attack here—it's an autoimmune attack. We could test for it with antibodies.

The conversation we're going to have after this is: Where is this attack coming from? And that is the reason why this is happening. Let me pause there.

Dr. Mike: I love it.

Dr. Crystal: I love that explanation. I think we'll have to pull a clip for that and replay it.

I'm curious when you give us this picture of what's happening and then you're giving us this picture of why. We're finding out why by testing those antibodies.

How Is Hashimoto’s Diagnosed? 00:06:17

Dr. Crystal: How often are you seeing those antibodies being tested? Are we missing the “why” for Hashimoto's disease. Tell me about that. Are we missing those?

Dr. E: You bring up a great point. And the great point is in conventional medicine, the rule is—actually, the rule in the guidelines—you test TSH. If the TSH is normal, no further testing should be done.

Honestly, [these are] the guidelines. You are well within your right as a conventional medicine provider to look at that TSH at 3.5 and say to your patient, “You have no thyroid issue. Have a nice day.” And that patient might say, “But my grandma has that. My aunt has [it]. I really am exhausted.”

And they say, “TSH is fine.” They're not wrong; they're practicing guidelines, but they're not right. To understand that, we have to understand the progression of Hashimoto's—[it] doesn't come on overnight.

Just like diabetes doesn't come on overnight. We [have] all heard this term, pre-diabetes: there's a world before diabetes. There's a world of prediabetes.

And then if I could just watch my sugars, I [wouldn't] get diabetes. That's true for every disease. We have pre-disease all the time.

To understand Hashimoto's, you have a genetic predisposition—kind of stage one. Then you have some sort of activation. During this activation, you will have antibodies.

Your TSH will be normal. You go [to] the doctor; you already have an issue. The antibody is there. TSH can be normal, and the doctor won't test because that's not the guidelines.

So, you have to keep going. The attack has to happen. Keep going, keep going, keep going. Eventually, your thyroid is going to get tired—that TSH will rise.

And then the doctor will say, “Oh, you have a thyroid issue.” And you're like, “Sir, ma'am, I've been telling you for the past 5 years that I'm exhausted.”

Dr. Mike: I love it. As a medical student, we were taught exactly everything you said about TSH.

Dr. E: Right.

Dr. Mike: Then you get out to clinical practice and you realize, “Oh, that may not be complete because these people do have symptoms.” She is tired, she is gaining weight, her skin is all dry. There is something going on. But TSH is normal, here's your antidepressant…

Dr. E: Exactly right! It's in your head.

Dr. Mike: And that's frustrating. I learned pretty quickly in my career that labs are there to confirm things, but they don't take away someone's symptoms and what they're feeling.

Dr. E: Yeah. Labs—and you know me, I still practice conventional medicine; I love conventional medicine—will confirm a disease. They're great and you need them. And then if you need medication, amazing.

But there is a world of pre-disease where we can intervene. Anyone who's listening to this podcast knows we can intervene in this stage, but conventional medicine cannot intervene here. Conventional medicine starts at diagnosis. And anything before that is like, we'll wait and see.

Dr. Crystal: Dr. Mike mentioned some of the signs. Are there any others that you would like to add?

What Are the Common Symptoms of Hashimoto’s? 00:09:44

Dr. Crystal: I mean signs and symptoms.

Dr. E: You're right. I mean fatigue, difficulty losing weight—which a lot of times [people] will say, “Oh, it's my age”—being cold, eyebrow issues, hair issues—like thinning—dry skin, but very commonly, depression. You might really feel depressed.

And then beyond depressive medication—nothing wrong with it, it’s going to help you—one of the first things a good provider should do if you have depressive symptoms, [is] check your thyroid because it could be just that.

Dr. Mike: Yeah. Great point. Let's talk about Hashimoto's more specifically, as you were demonstrating with your hands and everything.

Dr. E: I'm a hand person.

Dr. Mike: I am too. I'm Greek, so I love it. This is normal talk to me.

Dr. E: I'm from the Middle East, and this is what we do.

Dr. Mike: As a matter of fact, I don't think you noticed when I got done introducing you because I move around so much, my mic fell off [and] the battery came out. That's why they took me off the screen. I mean, they have to tape things on me so I don't break something.

Let's talk about the attack itself. Do we know about that attack? We know it's autoimmune. Why is that happening?

And I know that there are these stages that people will often talk about with Hashimoto's—how does that correlate to the attack? So, let's talk about this part of your hand.

What Causes Hashimoto’s and Autoimmune Thyroid Disorders? 00:11:08

Dr. E: Okay. Absolutely. Let's talk about, like, a quick overview of stages.

They're not exactly universal stages. But this is how Hashimoto's happens. First, generally speaking, you have a genetic predisposition: Grandma has it [or] your aunt has it.

That's important to know because anyone who has an autoimmune issue tends to turn on whatever is in our genetic makeup. We say genes load the gun, but then lifestyle pulls the trigger. We're predisposed to it and then something happens in our life.

And we're going to cut to that question mark—what is that thing? Then the attack starts. We have the antibodies…

Your thyroid is declining and your TSH might not be there yet, but you're going to start having symptoms. That’s called subclinical hypothyroidism. You can't really diagnose it or sometimes TSH is a little elevated, but your T3 and T4 are normal.

So, it's mild. Then, we get full-blown Hashimoto's hypothyroidism, [and] we need some medication. If it's not taken care of, you can go into thyroid failure.

But that doesn't really happen because we tend to seek help at some point. The question is, why did all this happen? And that is the question mark for all autoimmunity, not just Hashimoto's: What is happening?

And that has its own progression. But it could be nutrition—sometimes it's as easy as nutrition. That'd be lovely.

So, if somebody has a leaky gut—these are terms I'm sure your audience is familiar with—and then they're eating something, especially gluten. It could be a toxin—they're exposed to mold. It could be Lyme.

Something is assaulting their system that is then triggering that on-off switch on their genetic predisposition. Now that something is different for each person—but [it] tends to be that even if you do have Lyme, mold, or you had an accident, they tend to all also have leaky gut.

That seems to be a common denominator in there, which means that people who have Hashimoto's are extremely sensitive to gluten. And we can talk about that in a second, but those are the causes.

Dr. Mike: Very interesting.

Dr. Crystal: I thought that was nice as well. You're doing such a great job [of] breaking this down and explaining. It can be very complex and overwhelming.

One piece with the stage—and maybe I missed it—[is that] sometimes you find that people have hyperthyroid symptoms first and then see the [hypothyroid symptoms]. Can you talk a little bit about that? Because you know some people may get diagnosed or thinking something…

Dr. Mike: Depends on when they go in to see their doctor.

Dr. Crystal: Right.

Can Diet and Lifestyle Changes Help Manage Hashimoto’s? 00:14:02

Dr. E: That's a really good point.

Because that autoimmune trigger for some, those antibodies—there's different kinds of antibodies—trigger [hyperthyroidism] at first. But they are sides of the same coin because it's still an autoimmune issue. For many people with this, they will first become hyper.

And then they'll get medications to calm that down. But since the cause was never managed, over time they tend to eventually go to hypo. It's on the spectrum of the same disease when we're talking about autoimmune hypothyroidism.

Dr. Crystal: [That] brings us to the next point: food. I want you to give us that deep dive now. Let's go all in.

You mentioned gluten. I know we want to flesh that out as well. But if you can tell us about the food.

Dr. E: First, you know, this is generally for all autoimmunity—gluten specifically for hypothyroid. The goal [of] autoimmunity is to calm the system down. Remember autoimmune means your immune system is on.

It's just attacking the wrong place, but it's on. So, that means it senses an attack. Your mission in life is to reduce the attack: that means removing the Lyme or removing the mold.

But it also means not eating the standard American diet because that is an attack with every mouthful. That doesn't mean forever.

Dr. Crystal: So true!

Dr. E: So true. I want to say that doesn't mean forever, and it doesn't mean you have to be perfect. We have to be real. But it does mean until things calm down, and you can get a sense of what's going on.

You want to calm down. The standard American diet has to go. Anything that bloats you, even if it's healthy, has to go. If you're like, “I love eating salad.”

The salad is healthy, but every time you eat a salad, your belly is a mess. Salad is not it for you. I'm one of those people: do not bring lettuce to me. I cannot have it. It's like hopefully this healthy thing.

I've had plenty of people with autoimmunity who are reacting to quinoa [or] avocado. Just because it's on the healthy list doesn't mean it's healthy for you. This is why I don't like giving people prescriptive lists.

Listen to your body. If you're bloated, once that bloating goes away, that inflammation is going to ignite whatever you have going on. Now, that being said, the one area that I can be prescriptive about is gluten and Hashimoto's.

They are very much connected because the gluten protein looks very similar to a protein in the thyroid. Through a process called molecular mimicry—meaning my body is attacking gluten—it will form that same lock and key component for certain thyroid proteins.

And so, every time I eat my pizza, I'm attacking specifically my thyroid. If you have a thyroid issue—Hashimoto's is a thyroid issue—gluten has got to go.

Dr. Mike: Oh well, there goes pizza.

Dr. Crystal: No!

Dr. Mike: No? Dr. E did not like that.

Dr. Crystal: Let me tell you, no. There are so many other options.

There's cauliflower pizza. That’s huge! We were tasting all the cauliflower crust pizzas.

Dr. Mike: That was good. That was a pretty good option.

Dr. Crystal: And gluten-free options now are so abundant.

Dr. E: They’re so good. But I'll say this to you, Dr. Mike, because I want our audience to know...

Hope for Dietary Flexibility 00:17:30

Dr. E: Sometimes there's so much information and our audience is like, “Oh, my God, I'll never be able to do this. I love pizza.” I would say this: once you calm down your thyroid and your dosage is normalized—or if you're early enough, you can come off of it and things calm down—you can partake in pizza every once in a while.

But you don't want to do it when you're at level 10. I want to give people hope. It's not forever, and it could be in moderation, but let's get things calm first.

Dr. Mike: I think that's great advice because with all the information that's out there online—with all these different “gurus”—they're often so aggressive and definitive about what they say. Never do this. Never eat these three foods. It just bugs me.

And you know, it's just clickbait, they're just doing it to get the attention. They get more likes, and then ads. I don't even know if they believe it. It doesn't matter.

But I hate that. And I think we need more Dr. E’s out there [and] Life Extension people like us. We [have to] bring this down.

Dr. E: We [have] to bring it down. You don't have to do [it] all the time.

It is something that you need to do most of the time. And most of the time, leave some room—if the holidays [or your birthday is] coming. You want to create a world where you can do it again.

Maybe not in a time when you're flared or when you’re first starting out. But we have to give people hope that they're going to enjoy their favorites because otherwise, what's the point? A lot of people [are] like, what's the point?

Dr. Mike: Yeah. Come on. I agree with that, and I love that.

Let's move to nutrients then. We're always food first—you know Dr. Crystal, she's the Doctor of Clinical Nutrition—and I'm glad we did that.

But now let's talk a little bit about nutrient add-ins that might be helpful. And let's focus on that person who truly [is in] that low hypothyroid state. They're not at the beginning with maybe the hyper, right?

Let's focus on where I think most people are diagnosed with Hashimoto's—they're low. What are some of those nutrient add-ins that you like to recommend?

Vitamin D's Role in Autoimmunity 19:48

Dr. E: I would say, first—generally before we get specific to thyroid—is once your belly is calm, you definitely want a good quality probiotic because that's going to help your immune system. About 85 percent of your immune system lives in your belly, so feeding that microbiome is important.

People are always looking for these really sexy supplements, but vitamin D—we need vitamin D.

Dr. Mike: I love it. So simple and cheap.

Dr. E: It's so simple—we need it. It's connected to every autoimmune issue. People with Hashimoto's are often deficient in it. This is one of the things you definitely want to measure: somewhere between 2,000 to 5,000 a day.

You definitely want to measure your vitamin D—you can overdose. I have seen it. This is not one of the things where more is more, but like, that's super basic.

Dr. Mike: I love vitamin D. I always tell people [that] if you think of the immune system, think of it like an orchestra. There [are] so many different parts, and you need that maestro to be in there to key [everything].

That's vitamin D. They all do their thing at the right place. They come in; they leave. That to me [is] vitamin D.

Selenium and Zinc for Thyroid Conversion 21:04

Dr. E: I couldn't agree more. And people are always looking for this crazy stuff. I'm like, “Let's keep it simple.”

[For] thyroid specifically, we're going to want some selenium and some zinc. Selenium really helps calm down the autoimmune response—antibodies tend to calm down. And that could be certainly sourced through supplements, but also—is it Brazil nuts or Brazil nuts? I don’t know.

Dr. Crystal: Brazil nuts.

Dr. Mike: You say Brazil. Yeah.

Dr. E: Those nuts. Have some of those—like one or two a day. [It] doesn't have to be like a whole thing.

But it also helps with that conversion—selenium and zinc. So, that conversion for the audience to know we said that the thyroid makes T4, but T4 doesn't really do much in our body. It has to lose one of its iodine molecules and then become T3.

T3 is the thing that makes everything work. If your body can't convert T4 [to] T3, your TSH could be fine, your T4 might be fine and then your T3 is, like, really low. So, helping that along—that actually cannot happen without selenium and zinc.

This is not like a, “Hey, this would be cute to add.” It literally cannot happen without selenium and zinc. You need to have that.

Dr. Mike: Dr. E, quick question on that. Since you're talking about that conversion, wasn't there some evidence a while ago that T4 [to] T3 conversion could also be inhibited by cortisol and stress? I don't know if that's been laid out better, but I know [there] was some research a few years ago.

Dr. E: Yes. 100 percent. Thanks for bringing it up.

That T4 to T3 conversion will definitely take a hit if you're stressed all the time. And that's important. That's a great point because TSH is fine [and] your T4 is fine. You're like, “What the heck is this? Why am I so exhausted?”

Meanwhile, you're not converting. Your T3 is super low. That's an excellent point.

Dr. Crystal: Yeah. And that's important to know.

I think the conversion piece is an important piece of the puzzle that people are missing. Especially since Synthroid® or levothyroxine is the medication—that's T4. Some people may be on medication and they're not feeling better because their medication is not converting.

Dr. E: Correct.

I always start with levothyroxine when I give that example because the audience tends to know that medication. But when you get a little bit savvier into this, some people do great on levothyroxine. God bless. Amazing.

But most people are going to need a T4-T3 combo—a lot of providers are not comfortable giving it, which is why you may not be receiving it. They're scared of T3, but there's medication. They are [scared].

Dr. Crystal: Oh, they are, Dr. Mike. I do know this.

Dr. Mike: I don’t get it.

Dr. Crystal: I've been trying to get my dad some T3, and it's not happening.

Dr. Mike: It's the act of [forming] the tissues. It’s what the tissues love.

Dr. E: They're terrified; they don't know how to manage it. It's really interesting to see. I would say [to] any provider listening: Armour® Thyroid is [a] really easy way to prescribe for your patients.

Dr. Mike: Yeah. Very simple.

Dr. E: There's a quick conversion chart you can Google—like if they're on Synthroid®, this is how much Armour® I give them. You don't even have to do the math in your head.

I could see where you might need some sophistication if you're giving T3 alone. But Armour® Thyroid is like, “God bless. Let's just do that.”

Dr. Mike: Your patients are going to feel better, and you're going to be the hero. So, do it.

Dr. E: Yeah, 100 percent.

Dr. Crystal: I also do know that there are insurance issues that prescribers are trying to navigate. And so, there are limitations there. But yes, if you can get that combo...

Dr. Mike: Do it!

Dr. Crystal: Make sure you ask for it. We’re trying to empower our listeners on some missing components.

Dr. E: Yes, some missing components.

Dr. Mike: Dr. E, again, just fantastic information. I know you could go on [for] another hour.

Dr. E: Probably.

Dr. Mike: You know, get your hands going. And I don't know. I [have to] stop doing that.

We like to end with: What's the take-home message? And I know that's hard because we just covered so much stuff. But you're in an elevator with somebody—the elevator pitch.

You're going down. You only [have] five floors. It's going fast and this person in there wants to know what you think about Hashimoto's.

How Often Should You Have Your Thyroid Checked? 25:30

Dr. E: About Hashimoto's? I was ready to give you another elevator pitch, but let's talk about Hashimoto’s. I'm going to give you two elevator pitches, one for general [health] and one for Hashimoto’s.

Dr. Mike: Okay, that’s fine. Let's start with Hashimoto's.

Dr. E: [For] Hashimoto’s, you need to advocate for the full panel of testing. If your provider refuses to do it, it's probably a red flag that they're not comfortable managing it—which is okay; everyone has different comfort zones.

Then find someone willing to do that. Because if someone's willing to test that, it means they have an understanding and they can give you what you need.

Dr. Mike: Perfect. Now, the elevator door just opened.

Dr. E: Yes.

Dr. Mike: That person walked out. Now somebody new just came in.

Dr. E: Someone new just came in.

Dr. Mike: You apparently are like a troll on elevators because you’re staying in there.

Dr. E: I just stay on elevators all day.

Dr. Mike: Giving pitches all day long to people. The doors shut, [and] they hit [the] eighth floor [button]. Go! What's your second one?

Dr. E: My second one is [about] choosing a provider overall. It's like dating, even though I haven't dated in a long time—I'm married. It's kind of like dating, right?

If the date doesn't work out, you don't get mad at the person. You're just like, “Oh, it didn't work out.” You keep going until you find the love of your life.

With providers, if they're not the one, don't get mad at them. Don't get frustrated with them. Don't try to say, “You must…Why are you not?” Say thank you so much and move on to the next one. Listen to that voice; don't discount that voice.

But also, don't get agitated. Just keep going until you find the provider that's going to hear you.

Dr. Mike: Dr. Crystal, any last things you wanted to say on all this?

Dr. Crystal: No. She covered what I was thinking. And that was about the labs—it was really about getting that full picture.

Dr. Mike: Yeah, it's so important.

Dr. Crystal: How do you get that? What do you do? I think that's great.

Dr. Mike: Dr. E, how can our listeners learn more about you, what you do, follow you [or] say hi to you?

Where to Find More Information 27:18

Dr. E: It's my name, Dr. Efrat LaMandre, on any platform and the Medical Disruptor podcast. I don't take patients anymore, but I disseminate information. Enjoy it.

Dr. Mike: I just realized I don't say your first name right, do I?

Dr. E: It's Efrat LaMandre.

Dr. Mike: Efrat. See, I say Efrat. I don't know. Sorry, Efrat.

Dr. E: Oh, it's all good. That's why everyone calls me Dr. E because this way they don't have to worry about how to pronounce it.

Dr. Mike: I love it. That makes it easy for me. Dr. E, thank you again for coming on.

We look forward. As we said, you're a friend of Live Foreverish. You'll be back, I'm sure, talking about another topic.

Hey, don't forget you can go to LiveForeverish.com, and there [are] tons more episodes to download, like, share, do all that stuff—and of course, subscribe so you never miss a show. And then our sponsor, Life Extension wants to say thank you.

Head over to LifeExtension.com. When you check out, use the discount code…

Dr. Crystal: “PODCAST.”

Dr. Mike: And you'll get 10 percent off $50 or more, plus free shipping and handling at LifeExtension.com. I'm Dr. Mike.

Dr. Crystal: Dr. Crystal.

Dr. Mike: Thanks for listening.