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Thyroid Health and Polycystic Ovary Syndrome(PCOS): The Missing Link
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Thyroid Health and Polycystic Ovary Syndrome(PCOS): The Missing Link
Do you struggle with symptoms like exhaustion, hair loss, a foggy brain, irregular periods, and weight gain? This sounds like typical PCOS, right? Guess what! These symptoms can also be caused by hypothyroidism.
As if PCOS weren’t frustrating enough, this diagnosis makes you more likely to have hypothyroidism. So how do you know if the exhaustion you feel is because of PCOS or your thyroid? Great question, in this blog we are going to try to help you understand your thyroid and empower you to work with your lifestyle and healthcare team to support it.
Is My Thyroid Working Properly?
Since you are reading this, you may already be wondering if something is wrong with your thyroid. This is an important question that most of us, until now, didn’t know to ask. Here’s a list of symptoms that are common in hypothyroidism. If you can relate to more than 2 or 3 of them, it’s worth asking your doctor for thorough lab work. Actually, I always advocate asking for thorough thyroid labwork (especially in preconception). If your doctor is reluctant to order the labwork – and you have more than 2-3 of the symptoms, I would require they order them or find someone else who is willing to.
Sensitive to cold
Muscle aches and weakness
Brittle hair and nails
Numbness in hands and fingers
Cold hands and feet
Unexplained weight gain
Difficulty losing weight
Irregular menstrual periods
Excessive hair loss
For reasons that science hasn’t figured out yet, PCOS patients often develop hypothyroidism. (1) In fact, in many studies including PCOS patients autoimmune thyroid disorders were present in about 25% of individuals, which is much higher than the typical population. (2) Ladies, that is one out of four of us. That’s A LOT!
Thyroid hormone is important for boosting our metabolism. A slow thyroid means less thyroid hormone. Less thyroid hormone means our metabolism slows down and we feel tired, gain weight, and may even struggle with depression. PCOS is not just a syndrome of hormones (an endocrine disorder) it is also a metabolic condition, so it makes sense that PCOS and thyroid health would go hand and hand.
Hypothyroidism isn’t the only condition of the thyroid, but it is the most common thyroid condition that overlaps with PCOS, so is the focus in this blog post. For the curious mind, other thyroid conditions are called: Grave’s disease, hyperthyroidism, goiters, nodules, postpartum thyroiditis, hashimoto’s thyroiditis. Hashimotos’ thyroiditis is likely the most common type of thyroid condition causing most occurrences of hypothyroidism.
Insulin Resistance and Thyroid Health
If I were to take my best guess, I would say that almost 40-50% of you reading this blog are dealing with thyroid issues. No, I’m not psychic, this guess is actually based on science. In 2015, scientists did a study on the PCOS world and found that over 22% of us had overlapping hypothyroidism.(3) That is a lot of women. This is one of many studies that place the figure somewhere between 20% and 30% of women with PCOS. Now they were looking for overt hypothyroidism via labwork. However, you can have something called subclinical hypothyroidism.
Subclinical Hypothyroidism a Silent but Common Condition in Women with PCOS
Subclinical hypothyroidism is where your actual thyroid hormones are still in normal levels, but a hormone called thyroid stimulating hormone (TSH) is elevated. This is a hormone your brain makes to tell your thyroid how much thyroid hormone to make. It’s kind of like telling you that you have insulin resistance, but it hasn’t advanced to diabetes yet. Where your body is really not able to keep up with the demand for the need of insulin. Your thyroid is still working, but not optimally so it takes a lot of thyroid stimulating hormone to get the normal work done. If not addressed, may move on to diagnosable hypothyroidism. In my practice and work with women with PCOS I see this very frequently and that is why I think almost 1 out of 2 of us have some need for thyroid love.
What Does My Thyroid Do for Me?
preFade fadeIn”>How many of us would say with confidence that we know what our thyroid does for us? A lot of us can’t even locate our thyroid, let alone explain what it does. And sadly, the doctor probably isn’t going to take the time to teach you about your thyroid. I believe that knowledge is power, and if you want an empowering explanation of exactly what your thyroid does, read on!
The thyroid gland is on the front of your neck in between your esophagus and your skin. It is in a butterfly shape. It is a part of the endocrine system. Endocrine just means that it is a part of the hormone signaling system in your body. It is a gland that makes and releases certain hormones. Your thyroid’s main job is to control your metabolism — how your body uses energy. Sometimes, your thyroid doesn’t work properly. These conditions are common and treatable.
Let’s Talk About Thyroid Hormones
Your primary care provider is likely screening your thyroid health annually. They do so with a really inexpensive test called TSH (more on that later). However, this one test only gives us a snapshot of what is going on with your thyroid. To get a more complete picture, you are going to have to advocate for yourself in the doctor’s office.
Because of this, I want to empower you with knowledge of why specific markers are important and how to request that your provider run thorough lab work.
With that said, let’s talk about thyroid labs. The markers we’ll talk about will paint a picture of how healthy your thyroid is and give us some perspective on the other organs that support thyroid hormones. THe nice thing about these tests is that they are simply blood tests, nothing very invasive.
Thyroid Stimulating Hormone (TSH):
Remember this is the one your doctor will likely have already run for you. So go grab your last lab work and let’s look at that level.
This hormone actually comes from the pituitary gland in our brain and tells our thyroid to get to work. Higher levels of TSH mean your thyroid is struggling to create enough thyroid hormone. So your brain has to continue to increase the levels of TSH to get the same job done.
Here’s an illustration: High TSH is like when the battery on your car is dead. When you push the gas pedal, the engine is supposed to rev, which starts the car and gets it moving. But if your battery isn’t working, your car won’t start no matter how hard you press the gas. High TSH may suggest you are dealing with an underactive thyroid, known as “hypothyroidism”.
If you have high TSH, you’re not alone. It’s very common for women with PCOS to have elevated TSH levels. In fact, like I mentioned before, more than 20-30% of the PCOS population have high TSH. (3)
Free T3 and Free T4:
T3 and T4 stand for thyroid hormone. These are two other lab values that are helpful to look at. When the thyroid is told by TSH to start working, it responds by releasing the hormone T4. Your body then sends thyroid hormone T4 out and it reaches the liver where it becomes T3 (the active form of thyroid hormone).
T3 and T4 are hormones that are labeled with the numbers 3 and 4 to indicate how many iodines they are carrying around. T4 is greedy and holds onto 4 iodines. However, that 4th iodine keeps T4 from accomplishing much. In order for T4 to be useful, it has to lose an iodine. When this happens, T4 becomes T3. This loss of iodine allows the hormone to activate and carry out its job speeding up metabolism- and so much more. This is why iodine is such an important nutrient for thyroid health (we’ll talk more about that later).
Reverse T3 (RT3)
There is another type of T3 we look at. It should also be included on a full thyroid panel. RT3 is the evil step twin of T3. It looks almost identical to T3, but it lacks the power to activate metabolism. It has the same number of iodine molecules but put on in a different arrangement. It’s like someone who took their earings and hung them on a string around their neck as a necklace. It just doesn’t really work.
When RT3 is too high, it competes with T3 keeping this hormone from doing its job as effectively. This can be a condition of taking too much medication of thyroid hormone and your body not knowing what to do with the extra T4 so it will turn it into the inactive RT3 instead of T3.
TG and Anti-TPO Thyroid Antibodies:
An antibody is a cell from the immune system. It’s job is to attack and protect. When someone develops an autoimmune disorder it is the body’s own defenses mounted against itself. The greek root “auto” means self. It’s an attack from your immune system on your own body tissues. So these specific antibodies are made to attack and destroy your thyroid.
I do recommend these be screened at different points. At least in a thorough thyroid analysis, prior to pregnancy and in post partum. The names aren’t very catchy, huh? But you may want to write them down because they’re important. They help us distinguish exactly how to treat an underactive thyroid. If you have TG and anti-TPO antibodies floating around in your blood, it’s a sign that your immune system is attacking your thyroid and making it less active. Not good, right? That’s why we want these numbers as close to zero as possible. These labs help you rule out thyroid autoimmune problems like Hashimoto’s(a state of hypothyroidism – or underactive thyroid) or Graves Disease(a state of hyperthyroidism – or overactive thyroid).
If you have high levels of TG and Anti-TPO hormones in your blood, you may have Hashimoto’s thyroiditis. It’s good to know that most hypothyroidism is actually linked to hashimoto’s thyroiditis, yet barely any doctors check these lab values and so the thyroid is treated as if it is sluggish versus being treated as if it is under attack. Seems crazy to me. If my daughter didn’t want to clean her room because she was lazy, I’d motivate her in a different way, than if she didn’t want to clean her room because her leg was broken and so she lacked the ability to get up and clean. Different problems require different care and solutions. This concept holds true for your thyroid.
Interpreting Labs: It’s Not As Scary As You Think
Once you’ve ordered the blood tests, it will be time to interpret them. Here are what I consider to be optimal ranges.
TSH: 1.0-2.5 miU/mL*
Free T4: 15-23 pmol/L
Free T3: 5-7 pmol/L
Reverse T3: 11-18 ng/dL
TPO Antibodies: <2 IU/mL
TG Antibodies: <2 IU/mL
Most doctors will consider that TSH is normal anywhere from 0.5-4.5 miU/mL. However, if your TSH is below 1.0 or above 2.5, it is my opinion that it requires closer attention and thorough testing to see how we can support your thyroid. Having a TSH above 2.5 can significantly increase the risk of miscarriage. It is also highly correlated with insulin resistance. Meaning, if you have a TSH above 2.5, you likely also have insulin resistance.(4)
Thyroid, Insulin Resistance, and PCOS
If you aren’t familiar with the idea of insulin resistance and how it is linked with PCOS check out our other blog post about insulin resistance here. Hypothyroidism is inseparably linked to insulin resistance. Insulin resistance feeds hypothyroidism and hypothyroidism feeds insulin resistance. If you have PCOS it’s a triple whammy. Fixing one doesn’t necessarily mean you’ll fix the other. When insulin resistance improves, you may still need to address thyroid health for symptom improvement.
Hypothyroidism is when your body is making too little of thyroid hormones or struggling to convert the inactive form of thyroid hormone T4 into the active form T3.
But how are they linked? Some studies say that unbalanced estrogen and progesterone ratios in a body which are typical of PCOS may put you at higher risk for hypothyroidism.(3) PCOS messes with your natural hormone rhythms, and when your natural hormone rhythms are off your thyroid can get a little confused. This can cause decreased production of thyroid hormones, leading to hypothyroidism.
Part of the difficulty with polycystic ovarian syndrome and thyroid issues are the overlap of symptoms. Hypothyroidism symptoms that overlap with PCOS symptoms are: irregular menstrual cycles, hair loss, difficulty with weight loss or unexplained weight gain. Determining if these symptoms are related to the PCOS or thyroid problems can be difficult. As both conditions are managed symptoms do improve, weight loss becomes easier, thinning hair and hair grwoth can recover.
Where To Go From Here? Thyroid-loving steps you can take today!
What if your labs don’t fall within these ideal ranges? If you find that your thyroid is underactive there are things you can do to help it function more optimally.
Iodine is likely something you think of when you think thyroid. This is because of public health efforts to decrease the incidence of goiters. As such most salt is “iodized”. If you are like me, you are cooking with things like sea salt or kosher salt which are not iodized.
Incorporating foods that are rich in iodine versus relying on salt has a lot of benefits coming from the synergistic quality of foods and how minerals and vitamins work together. Foods that contain iodine are whole eggs, seafood, seaweed, liver, and dairy. There are times supplementation can be helpful or necessary. I typically recommend taking a minimum of 250 mcg/day.
Your body doesn’t make it’s own selenium. The tissue with the highest concentration of selenium in the body is the thyroid gland. Thus, it’s important that we include selenium-rich foods in our diet. Foods rich in selenium are: high quality brazil nuts, consuming meat and fish, or adding mushrooms to your meals. Selenium has a number of roles related to thyroid hormone metabolism and energy balance. It is not a mineral to skimp on.
Managing Stress levels
There really is not a body tissue that is safe from excessive amounts of stress. However, the thyroid is particularly susceptible to stress. This is especially true if you are in a category of a sluggish thyroid that isn’t quite diagnosable as hypothyroidism yet. This is often called sub-clinical hypothyroidism. Typically the symptoms are there but lab values aren’t far enough out of range yet. Stress management is key here for thyroid health.
There is an interplay between the thyroid, adrenal gland, hypothalamus, pituitary, and ovary. If one of these organs is particularly challenged and the whole body is under a large amount of stress the others can suffer.
There are also many types of stressors the body recognizes. Blood sugar imbalance is actually a stressor on the body. That is a check box most of us can mark off even before we get to all the other normal life stressors: illness, losses, moves, mean bosses, infertility, finances, working multiple jobs, traffic, emails, and even screen time(yes I said screen time).
The idea of “self care” is really taking over as a way to manage stress. It’s a great thing to highlight because time in nature, an epsom salt bath, meditiation/prayer, downtime, massages are all great. However, sometimes we need to look at the stress inputs and not just the stress relief practices. What can we start saying “no thank you to?” What boundaries can we draw? What friendships have turned toxic?
As you start managing stress better and start decreasing the stress inputs your body deals with, your thyroid health will improve.
Sleep is essential for all of us. It is also really important for your thyroid. Loving on your circadian rhythm can help improve thyroid hormone levels. Start by letting sunlight hit your eyes early in the day, throw on some blue light filtering glasses if you can’t help but binge Netflix before bed, and try to keep a fairly normal sleep/wake rhythm no matter the day of the week.
Eating Lots of Fiber
Ready for the broken record and my favorite dietitian soap box? Increasing fiber and varied colors of fruits and vegetables is also important. This is important for so many areas of health.
Do I Need to Cut Out Cruciferous Veggies?
You may have heard that you need to stay away from cruciferous or the brassica family of vegetables. But this is typically not great advice. The logic for this recommendation is that things like broccoli, cabbage, and cauliflower contain compounds called goitrogens that can interfere with thyroid hormone function. However, you would literally need to eat a metric ton of these vegetables (and you’d need to eat them raw) for any of these goitrogenic compounds to accumulate enough to impact your thyroid. These foods have so many other benefits that I would not recommend staying away from them.
When is it the Right Time to Consider Medication?
I often hear: I don’t want to take any medications. I relate to this sentiment. I treat women from a root cause approach with diet and lifestyle interventions. Yet, there are some conditions where you just need more support. The thyroid is usually one of those conditions where it doesn’t make sense most of the time to try and do everything naturally.
If you have hypothyroidism your doctor will likely recommend taking a medication called synthroid or levothyroxine (the generic forms of thyroid supporting medication). Medication can be incredibly helpful. I have met many individuals that feel like they are failing or giving up if they take medication for thyroid. Every situation should be handled individually, but I like to look at thyroid medication as one branch in the tree of thyroid health. Sometimes we must recognize that our body is struggling at a specific point in a specific area and as a result needs specific support. Medicine can take the pressure off while we work on healing and supporting the thyroid. Regardless of what you’ve been told in the past, thyroid medication may not be something you need forever.
There are also non-artificial thyroid hormones like “Nature-Throid”, which are made from powdered pig thyroid glands and may be a good option for you and your doctor to look into. Everyones body response slightly different to thyroid medication so it is important to test your thyroid frequently while you are adjusting to new thyroid meds.
Whether you’re newly diagnosed with PCOS, or a seasoned PCOS veteran, some extra thyroid TLC is something we can all benefit from.
If the doctor tests your thyroid levels and they are not within ideal ranges, they might want to repeat the test approximately 3 months later. If your thyroid levels are still not within range, it might be time to start considering specific interventions to support your thyroid.
When you start a thyroid medication, switch doses, or change medications you will want to check thyroid function every 4-6 weeks until you have found the dose that works for you. After your doctor has determined a stable dose you can decrease testing frequency to every three months to a year depending on how you feel.
Thyroid Health in Fertility and Pregnancy
Pregnancy is a very expensive time in your life when it comes to thyroid hormones, meaning you need a lot of it, as you are growing another human inside your body. Your metabolism needs to be revving on all 4 cylinders. In fact, risk of miscarriage increases greatly when TSH levels are above 2.5. Whether you have been diagnosed with hypothyroidism or another thyroid condition or not, I always recommend TSH be pulled in preconception and then again early on in a pregnancy to ensure levels are optimal. Most often in pregnancy when levels are not, prescription medication is required.
If you are struggling with getting pregnant, it is even more important for you to get thorough thyroid lab work done as I’ve seen very many women struggle to get pregnant when the conversion of T4 to T3 is not functioning like it should. Now this is not necessarily a thyroid issue, it can be a liver issue because the liver does most of the work converting T4 into T3.
If you have had recurrent miscarriages, I also highly recommend having doctors thoroughly screen your thyroid.
If any medical practitioner is unwilling to help you get a thorough lab set for your thyroid, it is your right to find someone who is more comprehensive and curious about your health and your concerns. Sometimes simply stating, “I know my thyroid health can be impacted by my PCOS and my PCOS can be impacted by my thyroid, I’d like to get thorough labs to make sure everything is looking good” should be enough to convince a doctor to order them for you. If not, don’t let the door hit you on the way out and find a more supportive practitioner.
Your Thyroid Health is Central to Your Overall Health and Your Treatment of PCOS
It’s important to remember that PCOS is about far more than just your ovaries. Proper thyroid function is important for getting pregnant and maintaining a pregnancy. But even if you aren’t family planning, every single one of your cells has the ability to respond to thyroid hormone.
Trust me, this powerhouse called your thyroid is 100% worth understanding and caring for with purposeful intentionality. If you want to know more, the hormone academy course has a module dedicated to understanding and managing thyroid health.
Romitti M, Fabris VC, Ziegelmann PK, Maia AL, Spritzer PM. Association between PCOS and autoimmune thyroid disease: a systematic review and meta-analysis. Endocr Connect. 2018 Oct 26;7(11):1158-1167. doi: 10.1530/EC-18-0309. PMID: 30352422; PMCID: PMC6215798.
(was 2)Arduc A, Aycicek Dogan B, Bilmez S, Imga Nasiroglu N, Tuna MM, Isik S, Berker D, Guler S. High prevalence of Hashimoto’s thyroiditis in patients with polycystic ovary syndrome: does the imbalance between estradiol and progesterone play a role? Endocr Res. 2015;40(4):204-10. doi:10.3109/07435800.2015.1015730