Did you know that thyroid conditions are routinely misdiagnosed as fibromyalgia? Before we were labeled with fibromyalgia, I’m sure most of our doctors ran a TSH test to check our thyroid function since hypothyroidism is one of the many conditions that are supposed to be ruled out before diagnosing fibromyalgia.
That’s because the TSH test, the test most commonly used by doctors to diagnose thyroid issues, is a poor indicator of overall thyroid health. It takes a much more comprehensive approach to testing and clinical expertise to properly diagnose thyroid disorders.
I recently interviewed Dr. Brady about the connection between fibromyalgia and thyroid dysfunction and how to get properly evaluated and treated if you have a thyroid disorder. I hope you enjoy our interview.
National Pain Report: What is the connection between fibromyalgia and thyroid disorders?
Dr. David Brady: They are both mainly occurring … in women who are middle age or approaching middle age, although they certainly can occur in women who are younger and males as well, but they’re both predominantly female disorders.
They’re both big points of diagnostic confusion. Underperforming thyroid, even if it’s not overt hypothyroidism, is one of the top three masqueraders of fibromyalgia. There are a lot of women who have symptoms that are really caused by underperforming thyroid that, when they go to a physician, they get erroneously diagnosed as having fibromyalgia, and unfortunately [are] often put on a fibromyalgia medication, which has no hope of helping them and a high degree chance of causing side effects and problems, and their underlying true condition is never getting addressed.
That being said, it’s not uncommon at all that I find patients, mainly women once again, that do truly have a central pain processing disorder and would meet the criteria for having fibromyalgia that also concomitantly have underperforming thyroid, so they go hand-in-hand a lot, but there’s not necessarily a causal relationship between the two.
What are the most common symptoms of thyroid dysfunction?
Tired all the time, cold all the time, constipation, dry skin, dry hair, hair falling out more than normal, difficulty concentrating, and you can also start to develop muscle aches or myalgia.
Even joint pain can be caused by hypothyroidism. When hypothyroidism gets severe enough, you can get something called mixed edema where you start getting very swollen and puffy looking, but that rarely happens.
How common is it for thyroid disorders to be misdiagnosed as fibromyalgia?
It’s unbelievably common! There are lots of conditions that get erroneously labeled as fibromyalgia mainly because they are occurring in a woman, and there’s sort of a golden cluster of symptoms, like pain or achiness around the body, feeling tired or fatigued, anxiety and/or depression, poor sleep or insomnia, constipation and vague bowel problems [and] brain fog. All of those things occur if you’re having thyroid [dysfunction].
Unfortunately when you look at how thyroid disorders are assessed within very conventional orthodox medicine models, you have to be significantly hypothyroid to pop onto the radar if they’re only doing a TSH test or maybe a TSH and total T4 test. You have to have a type of underperforming thyroid where it’s actually the thyroid not producing enough hormone to begin with.
[But] many thyroid conditions occur outside of the thyroid. By that I mean the thyroid may be putting out a reasonable amount of hormone to satisfy the lab test, but then [the body is] not doing the right things with the hormone.
It gets a little complicated, but in thyroid disorders, the vast majority of thyroid [hormone] that [is] produced is something called thyroxin or T4. It gets converted to a more active hormone known as T3 or triiodothyronine. There are many things that are going on in our environment right now that are causing a sabotaging effect on thyroid hormone conversion … and if anything gets in the way along the process, the ultimate end scenario is the same: You don’t have enough thyroid hormone, your biochemistry slows down, and you feel like you got hit by a train.
If you’re only looking at the front end of it [by just testing TSH], and you’re not looking at the whole picture, it’s very easy to miss it. The way they look at thyroid disorders in the conventional medical paradigm right now, I equate it to picking up the book, “War and Peace,” reading the first couple of chapters, and then trying to write a book report. You’re just not getting the full picture, and that’s what goes on if you don’t take a much more granular, detailed look at thyroid physiology using more lab testing and data points than they normally do.
Most doctors are only testing TSH levels. Why is TSH not a good measure of thyroid function?
You have to go to a very low total production of T4 to stimulate an increase in TSH, and that’s what they’re looking for when they are doing a TSH test. They are looking for elevations of TSH to be indicative of a hypothyroid state.
When you’re using laboratory ranges … you have to be different statistically than 95 percent of the population to come up either high or low on most blood tests. What that means for hypothyroidism is you’re only dealing with one end of the bell curve tail, so you have to be in the lowest 2.5 percent of the population to come up low on a TSH test, and facts are that many people feel the effects of underperforming thyroid long, long before they would meet that criteria.
If the thyroid is producing a reasonable amount of T4, the test never goes abnormal … but if you don’t convert the T4 you make to T3 adequately, your lab test may look fine, but from a functional standpoint you’re hypothyroid, or you at least [have an] underperforming, suboptimal thyroid, so you have to look at other tests. You have to look at not only the T4 hormone, but the T3 hormone, and you have to look at both of those hormones in both their total state and their free state.
It’s something that really needs to be assessed, and when you’re not going to that level of assessment, it’s easy to grasp at straws of other things. One of the first things a doctor is going to grasp at is “Oh, this must be another one of those fibromyalgia cases.”
What are the thyroid tests that patients should request?
When I’m doing a full thyroid assessment initially on a patient, I order a TSH. I order a total T4, a free T4, a total T3, a free T3, and then particularly if there’s any family history of Hashimoto’s, Grave’s or any kind of autoimmune thyroid condition, we order what are called TPO antibody and thyroglobulin antibody [tests].
Your thyroid levels can come back normal, but you can still have dysfunction, correct?
Yes, because once again you’re looking at standard, normal ranges based on the 95th percentile. We want you to be at least in the mid part of the normal range.
There’s a difference between normal and optimal thyroid function.
Exactly. I don’t even look at it as normal. The lab ranges are looking at is it common, not is it normal. If you think about it, these [laboratory ranges] are based on data from the population, so if the population en masse starts getting sick all in the same way, the labs’ normal ranges follow the sickness because they’re based on that population statistically, but just because something is common doesn’t mean it’s a normal state of affairs.
I’ve read that the most popular thyroid medications, like Synthroid, are not always the most effective treatment. What’s your approach to treating thyroid issues?
Synthroid is synthetic T4. That can be very effective in patients whose core problem is they aren’t making enough T4 hormone. In those patients, generally, they show up on the orthodox testing. They usually have an elevated TSH and low T4, and they get put on Synthroid, and often they do fine.
But if you’re one of those many other folks who your problem is more in converting T4 to T3, [then] you won’t convert the synthetic T4 any better than you convert your own. You end up taking Synthroid, and you don’t feel better, so they increase the dose. You still don’t feel better, so they increase the dose [again]. They get to the maximum dose they’re comfortable giving you, and you still don’t feel better, and they just leave you there, and you are the way you are.
When we test more comprehensively, if we find out the problem is mostly or at least partially due to [poor] conversion of T4 to T3, the first thing we’re doing is looking at why might you be having a problem with conversion, why might those enzymes be downregulated. We’re making sure that if you’re excessively stressed that you’re dealing with your stress levels to bring your cortisol down. If there’s any kind of toxins at play, whether it’s heavy metals or any other kind of toxic exposure, we try to deal with that. We make sure your nutrition is good, particularly some of the trace minerals that are involved as enzyme catalysts in those pathways, like selenium and zinc.
But often we still have to intervene with some level of thyroid support. When we do that, we tend to use a form of replacement agents that have a combination of the right physiological ratio that your thyroid would put out of T4 and T3, and usually we’re using these in a bioidentical form or some sort of glandular form.
A popular alternative to the synthetic hormones is Armour Thyroid. Armour Thyroid is a porcine-based thyroid, so it’s from pig hormones. It’s a fully processed pharmaceutical that’s standardized. A lot of the stuff that’s said about it is just patently untrue. It’s regulated like any other drug, and it has to meet targets of T4 and T3, so it’s very easy to use, and patients basically get a much more complete treatment. They feel better. They get better results because they’re getting the same kind of hormones introduced from the outside that they would be producing internally in the right ratios of T4 to T3.
There’s another analogous product to Armour Thyroid called Nature-Throid. I tend to use Nature-Throid a lot because it’s the same as Armour Thyroid from a hormone standpoint, [but] it’s cleaner. There’s no corn starch. It doesn’t have some of the binders.
What is your best advice for how to get properly evaluated for thyroid issues?
Find a doctor who’s trained in functional medicine or integrative medicine who really understands looking at thyroid in a very granular way. Particularly if you have a lot of those symptoms we talked about, particularly if you’re a woman and particularly if there’s a history in your family of thyroid conditions.
If you’re a woman … in your 30s or 40s, and you’re starting to feel like “I’m tired all the time, I can’t think straight, I don’t have any energy, I don’t have any exercise tolerance, my muscles ache, I’m constipated, my hair’s getting thinner,” and then ask yourself was your mom on Synthroid, was your aunt on thyroid medicine, is your older sister on thyroid [medication]. If you start answering yes to [those questions], you need to find someone who can really evaluate your thyroid even if your family practitioner or endocrinologist says your thyroid is fine. It might be fine statistically in the laboratory, but it may not be where you need it to be to feel good.