QUESTIONS?
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FAQs From Physicians
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For common questions asked by patients, please click here. |
Screening and Testing
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Why isn't the TSH lab test a dependable method for detecting thyroid disease?
Current research and a growing number of physician reports suggest that the TSH test is not a sufficient measure of overall thyroid function and can be unreliable in many cases [1-7]. This is because TSH is not an indicator of cellular hypothyroidism, but rather an indicator of how the pituitary gland is reacting to thyroid hormone levels. It does not tell the practitioner the amount of thyroid hormone that is available to the cells. The Free T3 and Free T4 lab tests, however, provide a much better picture of thyroid hormone cellular status [4,6]. Physicians and researchers are now learning more about the hypothalamic-pituitary-thyroid (HPA) axis and tissue regulation of thyroid hormones [4,8-9]. As a result, many practitioners are discovering that the TSH lab test is not reliable for diagnosing thyroid dysfunction in all of their patients. For more detailed information on the accuracy of the TSH test, T4 to T3 conversion issues, and thyroid resistance, please refer to How Accurate is TSH Testing? and Thyroid Hormone Transport by Kent Holtorf, MD, Director of the National Academy of Hypothyroidism.
What other labs are important with thyroid testing?
The following comprehensive thyroid panel should be drawn for any patient exhibiting symptoms related to thyroid disease, including changes in mood (e.g. depression, anxiety). While there are limitations to all testing, running a full thyroid panel will help to better evaluate tissue thyroid status and/or possible thyroid hormone pooling in the bloodstream. Clinical presentation should be given proper weight alongside test results. It should be noted that most patients demonstrate best results when they hit their optimal target level which may differ from the standard normal of test results. Mounting evidence indicates that the TSH reference range is too wide and insensitive to measuring cellular thyroid hormone status in many patients. More information can be found on our About Testing page.
Do you have supporting evidence for the testing of full thyroid labs which include Free T3, Free T4, Reverse T3, TSH, and thyroid antibodies ?
Yes. Please see a comprehensive list of sources in the “Limitations of the TSH Lab Test and the Importance of Other Testing” section on our supporting Research, Articles, and Videos page. A full thyroid panel with these specific tests should be drawn for any patient exhibiting symptoms related to thyroid disease, including changes in mood (e.g. depression, anxiety).
How frequently should thyroid antibodies be run?
Thyroid antibodies (anti-TPO, TgAb, TRAb, and TSI) are markers to help determine if the patient has an autoimmune thyroid disease such as Graves’ disease or Hashimoto’s thyroiditis. Clinical reports have noted that antibodies can be elevated despite a normal, in reference range TSH, thus warranting treatment in symptomatic patients [17-19]. Antibodies should be tested for initial diagnosis and should be tested approximately once per year to assess autoimmune status.
What is Reverse T3 and how is it clinically significant?
Reverse T3 is a marker for either the inhibition of Reverse T3 uptake into the cells and/or a marker of increased T4 to Reverse T3 formation. Reverse T3 can compete at the receptor site with T3 causing cellular hypothyroidism and resulting symptoms [4,10-15]. Elevated Reverse T3 can be triggered by physical stress, adrenal dysfunction, chronic illness and low ferritin, among other factors. A Reverse T3 level of above 250, or a free T3/reverse T3 ratio that is lower than 1.8 (if the free T3 is in ng/dL) or lower than 0.018 (if the free T3 is in pg/mL) is grounds for possible hypothyroidism or hyperthyroidism [4, 20].
Why do patients with normal labs still need prescriptions for high cholesterol and depression symptoms?
Thyroid disease can cause secondary psychiatric symptoms. There has been substantial research linking anxiety and depression to thyroid disease. Proper thyroid treatment can often alleviate symptoms without the need for further medication [30-35]. Increasing number of studies also demonstrate an improvement of depression and anxiety using T3-containing treatment methods [36-40]. Additionally, the presence of normal thyroid labs may not indicate what is truly optimal for the individual patient. Please see our About Testing page on our website for necessary testing and optimal level evaluation. Thyroid dysfunction and ineffective treatment of thyroid dysfunction is also correlated with high cholesterol levels [41-43]. When a patient has high cholesterol, physicians may prescribe statin medications, however, T3 supplementation has also been found to lower cholesterol in thyroid patients [43, 44]. Statins or antidepressants may not be needed once thyroid levels are optimal for the patient.
Why isn't some of this information in the new guidelines of medical organizations?
Current medical guidelines for the treatment of thyroid disease call for the use of TSH-only testing and for levothyroxine (T4-only medication) to be administered to all hypothyroid patients. These guidelines are issued by organizations such as The American Association of Clinical Endocrinologists and The American Thyroid Association [45]. However, a growing number of physician reports and current research suggests that not only is TSH-only testing insufficient for diagnosis and monitoring in all patients, but many patients continue to suffer on the gold-standard therapy of levothyroxine yet thrive with the addition of T3-containing therapies. It is unclear why many mandating organizations are behind in publishing these concepts within the clinical practice guidelines for thyroid disease. Please see our supporting Research, Articles, and Videos page for cited sources.
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Why isn't the TSH lab test a dependable method for detecting thyroid disease?
Current research and a growing number of physician reports suggest that the TSH test is not a sufficient measure of overall thyroid function and can be unreliable in many cases [1-7]. This is because TSH is not an indicator of cellular hypothyroidism, but rather an indicator of how the pituitary gland is reacting to thyroid hormone levels. It does not tell the practitioner the amount of thyroid hormone that is available to the cells. The Free T3 and Free T4 lab tests, however, provide a much better picture of thyroid hormone cellular status [4,6]. Physicians and researchers are now learning more about the hypothalamic-pituitary-thyroid (HPA) axis and tissue regulation of thyroid hormones [4,8-9]. As a result, many practitioners are discovering that the TSH lab test is not reliable for diagnosing thyroid dysfunction in all of their patients. For more detailed information on the accuracy of the TSH test, T4 to T3 conversion issues, and thyroid resistance, please refer to How Accurate is TSH Testing? and Thyroid Hormone Transport by Kent Holtorf, MD, Director of the National Academy of Hypothyroidism.
What other labs are important with thyroid testing?
The following comprehensive thyroid panel should be drawn for any patient exhibiting symptoms related to thyroid disease, including changes in mood (e.g. depression, anxiety). While there are limitations to all testing, running a full thyroid panel will help to better evaluate tissue thyroid status and/or possible thyroid hormone pooling in the bloodstream. Clinical presentation should be given proper weight alongside test results. It should be noted that most patients demonstrate best results when they hit their optimal target level which may differ from the standard normal of test results. Mounting evidence indicates that the TSH reference range is too wide and insensitive to measuring cellular thyroid hormone status in many patients. More information can be found on our About Testing page.
- TSH: A marker for measuring the amount of thyroid-stimulating hormone that is produced by the pituitary gland. TSH activates the thyroid gland to produce thyroid hormones [4, 8-9, 11]. Optimal levels are closer to 1.0 and anything above 2.0 is grounds for possible hypothyroidism [20-24]. Anything below 1.0 is grounds for possible hyperthyroidism.
- Free T3: A marker of the level of unbound T3 thyroid hormone within the cells [1-4, 6, 10-11, 25]. Optimal levels are near the mid-top end of the range. Results at the bottom of the range are grounds for possible hypothyroidism [16, 26-27]. Elevated levels are grounds for possible hyperthyroidism [28].
- Free T4: A marker of the level of unbound T4 thyroid hormone levels within the cells [3-4, 10-13, 25]. Optimal levels are near mid-range or slightly higher. Bottom of the range results are grounds for possible hypothyroidism [26-27]. Elevated levels are grounds for possible hyperthyroidism [29].
- Reverse T3: A marker for either the inhibition of Reverse T3 uptake into the cells and/or a marker of increased T4 to Reverse T3 formation. Reverse T3 can compete at the receptor site with T3 causing cellular hypothyroidism and resulting symptoms [4, 10-15]. Elevated Reverse T3 can be triggered by physical stress, adrenal dysfunction, chronic illness and low ferritin, among other factors. A Reverse T3 level of above 250, or a free T3/reverse T3 ratio that is lower than 1.8 (if the free T3 is in ng/dL) or lower than 0.018 (if the free T3 is in pg/mL) is grounds for possible hypothyroidism or hyperthyroidism [4, 20].
- Thyroid Antibodies (anti-TPO, TgAb, TRAb, and TSI): Markers to help determine if the patient has an autoimmune thyroid disease such as Graves’ disease or Hashimoto’s thyroiditis. Clinical reports have noted that antibodies can be elevated despite a “normal” TSH, thus warranting treatment [17-19]. Patients who present thyroid symptoms and high antibodies may warrant treatment.
Do you have supporting evidence for the testing of full thyroid labs which include Free T3, Free T4, Reverse T3, TSH, and thyroid antibodies ?
Yes. Please see a comprehensive list of sources in the “Limitations of the TSH Lab Test and the Importance of Other Testing” section on our supporting Research, Articles, and Videos page. A full thyroid panel with these specific tests should be drawn for any patient exhibiting symptoms related to thyroid disease, including changes in mood (e.g. depression, anxiety).
How frequently should thyroid antibodies be run?
Thyroid antibodies (anti-TPO, TgAb, TRAb, and TSI) are markers to help determine if the patient has an autoimmune thyroid disease such as Graves’ disease or Hashimoto’s thyroiditis. Clinical reports have noted that antibodies can be elevated despite a normal, in reference range TSH, thus warranting treatment in symptomatic patients [17-19]. Antibodies should be tested for initial diagnosis and should be tested approximately once per year to assess autoimmune status.
What is Reverse T3 and how is it clinically significant?
Reverse T3 is a marker for either the inhibition of Reverse T3 uptake into the cells and/or a marker of increased T4 to Reverse T3 formation. Reverse T3 can compete at the receptor site with T3 causing cellular hypothyroidism and resulting symptoms [4,10-15]. Elevated Reverse T3 can be triggered by physical stress, adrenal dysfunction, chronic illness and low ferritin, among other factors. A Reverse T3 level of above 250, or a free T3/reverse T3 ratio that is lower than 1.8 (if the free T3 is in ng/dL) or lower than 0.018 (if the free T3 is in pg/mL) is grounds for possible hypothyroidism or hyperthyroidism [4, 20].
Why do patients with normal labs still need prescriptions for high cholesterol and depression symptoms?
Thyroid disease can cause secondary psychiatric symptoms. There has been substantial research linking anxiety and depression to thyroid disease. Proper thyroid treatment can often alleviate symptoms without the need for further medication [30-35]. Increasing number of studies also demonstrate an improvement of depression and anxiety using T3-containing treatment methods [36-40]. Additionally, the presence of normal thyroid labs may not indicate what is truly optimal for the individual patient. Please see our About Testing page on our website for necessary testing and optimal level evaluation. Thyroid dysfunction and ineffective treatment of thyroid dysfunction is also correlated with high cholesterol levels [41-43]. When a patient has high cholesterol, physicians may prescribe statin medications, however, T3 supplementation has also been found to lower cholesterol in thyroid patients [43, 44]. Statins or antidepressants may not be needed once thyroid levels are optimal for the patient.
Why isn't some of this information in the new guidelines of medical organizations?
Current medical guidelines for the treatment of thyroid disease call for the use of TSH-only testing and for levothyroxine (T4-only medication) to be administered to all hypothyroid patients. These guidelines are issued by organizations such as The American Association of Clinical Endocrinologists and The American Thyroid Association [45]. However, a growing number of physician reports and current research suggests that not only is TSH-only testing insufficient for diagnosis and monitoring in all patients, but many patients continue to suffer on the gold-standard therapy of levothyroxine yet thrive with the addition of T3-containing therapies. It is unclear why many mandating organizations are behind in publishing these concepts within the clinical practice guidelines for thyroid disease. Please see our supporting Research, Articles, and Videos page for cited sources.
Treatment
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Why is there a need for treatment options for hypothyroidism when levothyroxine monotherapy is the gold-standard?
Mounting research and physician reports indicate that thyroid hormone imbalance can be treated in many ways depending on the cause of the imbalance and its severity. Thyroid treatment options and dosing are as varied as the individual patient. It is common for hypothyroid patients to be prescribed levothyroxine-only (T4-only) therapies sold under various brand names, however, many patients continue to be symptomatic on T4-only [46-51]. Many need the addition of T3. If the patient continues to have symptoms on levothyroxine-only, there are further treatment options such as liothyronine/levothyroxine (T3/T4 combination), liothyronine-only, natural thyroid extract medication (e.g. brand name Armour or Nature-Throid) [37-40, 44, 46-51]. Each patient must develop an individualized treatment plan with their attending doctor. For more information on treatment options, please see our About Treatment page.
Do you have supporting evidence for treatment options beyond levothyroxine that doctors are finding helpful?
Yes. Please see a comprehensive list of sources in “The Need for Additional Treatment Options” section on our supporting Research, Articles, and Videos page. Some patients with thyroid disease find that T4-only therapy provides sufficient treatment. Other times, patients remain symptomatic and may need T3/T4 combination methods or T3-only for efficient symptom relief. For more information on treatment options, please see our About Treatment page.
I was told that natural desiccated thyroid medication is unstable and contains Impurities. Is this true?
In the case of the U.S., all prescription thyroid medications, natural or synthetic, must adhere to stringent pharmaceutical standards established by the United States Pharmacopeia (USP) and the Food and Drug Administration (FDA). Common natural desiccated thyroid brands such as Nature-Throid or Armour have never been recalled for inconsistent hormone levels or impurities [55-56]. Additionally, physician reports and patient experience have indicated that natural desiccated thyroid medication is consistent and effective in many patients [47, 50-52, 54]. A recent, randomized double-blind study compared natural desiccated thyroid to levothyroxine. Endocrinologist Thanh Hoang, MD presented the results of this study which stated that 49% of the patients preferred natural desiccated thyroid medication, 32.9% had no preference, and 19% preferred levothyroxine. The researchers concluded that desiccated thyroid extract is a safe alternative for patients with hypothyroidism despite normal TSH measurements while taking levothyroxine alone [52-53]. There have been no studies indicating inconsistencies or impurities with desiccated thyroid extract. Many practitioners are finding that T3/T4 combination methods, including desiccated thyroid extract, are effective methods for treating hypothyroidism [37-40, 44, 46-51]. For more information about treatment options, please see our About Treatment page and our supporting Research, Articles, and Videos page.
Will prescribing T3 cause cardiovascular problems?
A growing number of studies have concluded that the addition of T3 (liothyronine) is beneficial and safe in many patients when administered with proper dosing [37-40, 46-51, 58]. Patients with low levels of triiodothyronine (T3) are actually at risk of heart disease, cholesterol abnormalities, and increased mortality associated with heart attacks. T3 replacement therapy for these low levels can be a safe and effective therapy to reverse and prevent cardiac abnormalities [57, 59]. T3 is approximately four times more potent than T4. If taken at too high of a dose, it can be very stimulating, similar to caffeine. Sensitive patients may have palpitations, racing heart or an irregular rhythm. However, careful administration of T3 can be an effective treatment option for some patients [60].
When starting T3-containing therapies, my patient's TSH lab value becomes suppressed. Is this harmful?
It is normal for TSH to become suppressed within a patient when a T3-containing medication is prescribed (e.g. T3-only, T3/T4 combination, natural dessicated thyroid). In the case of thyroid cancer patients, TSH must be suppressed in order to prevent recurrence. As a pituitary hormone, TSH signals the thyroid gland to increase or decrease its own output of thyroid hormones. If a patient is taking a T3-containing medication, the body will recognize the increase of T3 and will produce less TSH since less stimuli is needed on the thyroid gland to produce thyroid hormones [46, 61]. As long as the patient is not displaying signs of hyperthyroidism from over-medication, T3 administering can be a helpful treatment option.
How do you evaluate thyroid hormone replacement effectiveness?
The treatment goals for thyroid disease are to reverse clinical progression and to correct metabolic problems as evidenced by optimal blood levels of TSH, Free T3, Free T4, Reverse T3 and patient symptom report. It is important to note that patients may have normal lab results in acceptable ranges or even optimal ranges, but still demonstrate symptoms of hyperthyroidism or hypothyroidism. Thyroid hormone treatment is an individualized treatment process and dosing adjustments should based on both the clinical symptoms and lab results that serve as a guide [62]. Please refer to our About Testing page for a guideline in optimal ranges. You may also wish to view our Continuing Education page for opportunities in seminars and training programs.
(Back to Top)
Why is there a need for treatment options for hypothyroidism when levothyroxine monotherapy is the gold-standard?
Mounting research and physician reports indicate that thyroid hormone imbalance can be treated in many ways depending on the cause of the imbalance and its severity. Thyroid treatment options and dosing are as varied as the individual patient. It is common for hypothyroid patients to be prescribed levothyroxine-only (T4-only) therapies sold under various brand names, however, many patients continue to be symptomatic on T4-only [46-51]. Many need the addition of T3. If the patient continues to have symptoms on levothyroxine-only, there are further treatment options such as liothyronine/levothyroxine (T3/T4 combination), liothyronine-only, natural thyroid extract medication (e.g. brand name Armour or Nature-Throid) [37-40, 44, 46-51]. Each patient must develop an individualized treatment plan with their attending doctor. For more information on treatment options, please see our About Treatment page.
Do you have supporting evidence for treatment options beyond levothyroxine that doctors are finding helpful?
Yes. Please see a comprehensive list of sources in “The Need for Additional Treatment Options” section on our supporting Research, Articles, and Videos page. Some patients with thyroid disease find that T4-only therapy provides sufficient treatment. Other times, patients remain symptomatic and may need T3/T4 combination methods or T3-only for efficient symptom relief. For more information on treatment options, please see our About Treatment page.
I was told that natural desiccated thyroid medication is unstable and contains Impurities. Is this true?
In the case of the U.S., all prescription thyroid medications, natural or synthetic, must adhere to stringent pharmaceutical standards established by the United States Pharmacopeia (USP) and the Food and Drug Administration (FDA). Common natural desiccated thyroid brands such as Nature-Throid or Armour have never been recalled for inconsistent hormone levels or impurities [55-56]. Additionally, physician reports and patient experience have indicated that natural desiccated thyroid medication is consistent and effective in many patients [47, 50-52, 54]. A recent, randomized double-blind study compared natural desiccated thyroid to levothyroxine. Endocrinologist Thanh Hoang, MD presented the results of this study which stated that 49% of the patients preferred natural desiccated thyroid medication, 32.9% had no preference, and 19% preferred levothyroxine. The researchers concluded that desiccated thyroid extract is a safe alternative for patients with hypothyroidism despite normal TSH measurements while taking levothyroxine alone [52-53]. There have been no studies indicating inconsistencies or impurities with desiccated thyroid extract. Many practitioners are finding that T3/T4 combination methods, including desiccated thyroid extract, are effective methods for treating hypothyroidism [37-40, 44, 46-51]. For more information about treatment options, please see our About Treatment page and our supporting Research, Articles, and Videos page.
Will prescribing T3 cause cardiovascular problems?
A growing number of studies have concluded that the addition of T3 (liothyronine) is beneficial and safe in many patients when administered with proper dosing [37-40, 46-51, 58]. Patients with low levels of triiodothyronine (T3) are actually at risk of heart disease, cholesterol abnormalities, and increased mortality associated with heart attacks. T3 replacement therapy for these low levels can be a safe and effective therapy to reverse and prevent cardiac abnormalities [57, 59]. T3 is approximately four times more potent than T4. If taken at too high of a dose, it can be very stimulating, similar to caffeine. Sensitive patients may have palpitations, racing heart or an irregular rhythm. However, careful administration of T3 can be an effective treatment option for some patients [60].
When starting T3-containing therapies, my patient's TSH lab value becomes suppressed. Is this harmful?
It is normal for TSH to become suppressed within a patient when a T3-containing medication is prescribed (e.g. T3-only, T3/T4 combination, natural dessicated thyroid). In the case of thyroid cancer patients, TSH must be suppressed in order to prevent recurrence. As a pituitary hormone, TSH signals the thyroid gland to increase or decrease its own output of thyroid hormones. If a patient is taking a T3-containing medication, the body will recognize the increase of T3 and will produce less TSH since less stimuli is needed on the thyroid gland to produce thyroid hormones [46, 61]. As long as the patient is not displaying signs of hyperthyroidism from over-medication, T3 administering can be a helpful treatment option.
How do you evaluate thyroid hormone replacement effectiveness?
The treatment goals for thyroid disease are to reverse clinical progression and to correct metabolic problems as evidenced by optimal blood levels of TSH, Free T3, Free T4, Reverse T3 and patient symptom report. It is important to note that patients may have normal lab results in acceptable ranges or even optimal ranges, but still demonstrate symptoms of hyperthyroidism or hypothyroidism. Thyroid hormone treatment is an individualized treatment process and dosing adjustments should based on both the clinical symptoms and lab results that serve as a guide [62]. Please refer to our About Testing page for a guideline in optimal ranges. You may also wish to view our Continuing Education page for opportunities in seminars and training programs.
Related Conditions and Disorders
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How is thyroid hormone affected by adrenal dysfunction?
Adrenal dysfunction often accompanies thyroid problems. Adrenal dysfunction can be defined as imbalanced cortisol levels that exist between Cushing’s disease (life-threatening high cortisol presentation) and Addison’s disease (life-threatening presentation of low cortisol). When cortisol levels are not optimal, thyroid hormone may not be utilized properly and a patient may experience heart-racing, over-stimulation, and increased fatigue when beginning thyroid medication. Adequate cortisol levels throughout the day must be in place for a patient to successfully tolerate thyroid hormone. Many physicians find that the sensitive 24-hour saliva cortisol/DHEA test to evaluate adrenal function is an excellent tool to detect suboptimal cortisol levels, particularly because it provides a more complete picture than a single cortisol blood test [63-65]. For more information regarding this topic, please see the category of “The Connection Between Adrenal Function and Thyroid Health” within our Research, Articles, and Videos page.
What common deficiencies or disorders are common with thyroid disease?
Physicians are finding that thyroid disease is often concurrent with vitamin and mineral deficiencies such as low levels of vitamin B12, vitamin D, iron and/or ferritin. It is common to have any one of these deficiencies in thyroid patients, and a deficiency may impact the body’s utilization of thyroid hormone. Many practitioners have also discovered that adrenal dysfunction adversely affects the necessary conversion of T4 to T3. Testing cortisol levels throughout the day should be incorporated with thyroid testing procedures. Sex hormone panel should also be included as all hormones of the body are interrelated. Low thyroid hormone, for instance, can result in sex hormone abnormalities. Additionally, there is a high correlation between autoimmune thyroid disease, systemic lupus, rheumatoid arthritis, systemic sclerosis, mixed connective tissue disease, Sjogren’s syndrome and polymyositis/dermatomyositis. Patients with these conditions have many times the prevalence of autoimmune thyroid disease than the general public [66]. Please refer to our About Thyroid Disease page and our About Testing page for more information on related deficiencies and disorders.
(Back to Top)
How is thyroid hormone affected by adrenal dysfunction?
Adrenal dysfunction often accompanies thyroid problems. Adrenal dysfunction can be defined as imbalanced cortisol levels that exist between Cushing’s disease (life-threatening high cortisol presentation) and Addison’s disease (life-threatening presentation of low cortisol). When cortisol levels are not optimal, thyroid hormone may not be utilized properly and a patient may experience heart-racing, over-stimulation, and increased fatigue when beginning thyroid medication. Adequate cortisol levels throughout the day must be in place for a patient to successfully tolerate thyroid hormone. Many physicians find that the sensitive 24-hour saliva cortisol/DHEA test to evaluate adrenal function is an excellent tool to detect suboptimal cortisol levels, particularly because it provides a more complete picture than a single cortisol blood test [63-65]. For more information regarding this topic, please see the category of “The Connection Between Adrenal Function and Thyroid Health” within our Research, Articles, and Videos page.
What common deficiencies or disorders are common with thyroid disease?
Physicians are finding that thyroid disease is often concurrent with vitamin and mineral deficiencies such as low levels of vitamin B12, vitamin D, iron and/or ferritin. It is common to have any one of these deficiencies in thyroid patients, and a deficiency may impact the body’s utilization of thyroid hormone. Many practitioners have also discovered that adrenal dysfunction adversely affects the necessary conversion of T4 to T3. Testing cortisol levels throughout the day should be incorporated with thyroid testing procedures. Sex hormone panel should also be included as all hormones of the body are interrelated. Low thyroid hormone, for instance, can result in sex hormone abnormalities. Additionally, there is a high correlation between autoimmune thyroid disease, systemic lupus, rheumatoid arthritis, systemic sclerosis, mixed connective tissue disease, Sjogren’s syndrome and polymyositis/dermatomyositis. Patients with these conditions have many times the prevalence of autoimmune thyroid disease than the general public [66]. Please refer to our About Thyroid Disease page and our About Testing page for more information on related deficiencies and disorders.
References
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2. Kalra S, Khandelwal, SK. Why are our hypothyroid patients unhappy? Is tissue hypothyroidism the answer? Indian Journal of Endocrinology and Metabolism. 2011 July; 15 (Suppl2): S95–S98.
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4. Schwartz E, Morelli V, Holtorf K. Hormone Replacement Therapy in the Geriatric Patient: Current State of the Evidence and Questions for the Future. Estrogen, Progesterone, Testosterone, and Thyroid Hormone Augmentation in Geriatric Clinical Practice. Clinics in Geriatric Medicine. 2011; 561–575.
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7. Holtorf, K. Reverse T3 is the best measurement for tissue thyroid levels. Report on the 2005 study, Thyroid hormone concentrations, disease, physical function and mortality in elderly men. Holtorf Medical Group. 2014. Retrieved from www.holtorfmed.com/download/thyroid-fatigue-and-weight-loss/Reverse_T3_is_the_Best_Measurement_of_Tissue_Thyroid_Level.pdf.
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11. De Los Santos ET, Mazzaferri EL (1988). Sensitive thyroid-stimulating hormone assays: Clinical applications and limitations. Comprehensive Therapy. 1988; 14(9): 26-33.
12. van den Beld AW, Visser T, Feelders R, Grobbee R, Lamberts, WJ. Effect of Exogenous Thyroid Hormone Intake on the Interpretation of Serum TSH Results. The Journal of Clinical Endocrinology & Metabolism. 90 (12): 6403-6409.
13. Chopra IJ, Solomon DH, Hepner GW, Morgenstein AA. Misleadingly low free thyroxine index and usefulness of reverse triiodothyronine measurement in nonthyroidal illnesses. Ann Intern Med. 1979;90(6):905–12.
14. Linnoila M, Lamberg BA, Potter WZ, Gold PW, Goodwin FK. High reverse T3 levels in manic and unipolar depressed women. Psych Res. 1982;6:271-276.
15. Forestier E, Vinzio S, Sapin R, Schlienger JL, Goichot B. Increased Reverse T3 is Associated With Shorter Survival in Independently-living Elderly. The Alsanut Study. Eur J Endocrinol 2009;160(2):207-14.
16. Shomon, M. The Optimal Treatment for Hypothyroidism: Dr. Kent Holtorf Shares His Approach to Treating an Underactive Thyroid. About.com Thyroid Disease. Updated December 22, 2010. Retrieved from http://thyroid.about.com/od/hypothyroidismhashimotos/a/The-Optimal-Treatment-For-Hypothyroidism.htm.
17. Promberger R, Hermann M, Ott J. Hashimoto's Thyroiditis in Patients With Normal Thyroid-stimulating Hormone Levels. Expert Rev Endocrinol Metab. 2012;7(2):175-179.
18. Ott J, Promberger R, Kober F, Neuhold N, Tea M, Huber JC, Hermann M. Hashimoto's thyroiditis affects symptom load and quality of life unrelated to hypothyroidism: a prospective case–control study in women undergoing thyroidectomy for benign goiter. Thyroid. 21, 161–167 (2011).
19. Shomon M. Do You Need Preventive Thyroid Treatment? Treating Antibodies When TSH is Normal. About.com Thyroid Disease. February 10, 2014. Retrieved from http://thyroid.about.com/od/hypothyroidismhashimotos/a/preventative.htm.
20. Shomon, M. The Optimal Treatment for Hypothyroidism: Dr. Kent Holtorf Shares His Approach to Treating an Underactive Thyroid. About.com Thyroid Disease. Updated December 22, 2010. Retrieved from http://thyroid.about.com/od/hypothyroidismhashimotos/a/The-Optimal-Treatment-For-Hypothyroidism.htm.
21. Shomon, M. What is the Optimal TSH Level for Thyroid Patients? About.com Thyroid Disease. Updated April 05, 2014. Retrieved from http://thyroid.about.com/od/gettestedanddiagnosed/a/optimaltsh.htm.
22. Vanderpump MP, Tunbridge WM, French,JM, Appleton, D., Bates, D, Clark F, Grimley Evans, Hasan DM, Rodgers H, Tunbridge, F. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995 Jul;43(1): 55-68.
23. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer, CA, Braverman, LE. Serum TSH, T4, and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey. J Clin Endocrinol Metab. 2002 Feb;87(2):489-99.
24. Lee, SL. When is the TSH normal? New criteria for diagnosis and management. Lecture presented at 12th Annual Meeting of the American Association of Clinical Endocrinologists (AACE), San Diego, CA, May 14, 2003 (thyroidtoday.com).
25. Pacchiarotti A, Martino E, Bartalena L, Aghini-Lombardi F, Grasso L, Buratti L, Falcone M, Pinchera A. Serum free thyroid hormones in subclinical hypothyroidism. Journal of Endocrinological Investigation. 1986 Aug;9(4):315-9.
26. Myers, A. 10 Signs You Have A Thyroid Problem And 10 Solutions for It. Amy Myers, MD. 2010-2014. Retrieved from http://www.dramymyers.com/2013/02/14/10-signs-you-have-a-thyroid-problem-and-10-solutions-for-it/
27. Shomon, M. The Optimal Treatment for Hypothyroidism: Ron Manzanero, MD. About.com Thyroid Disease. Updated December 22, 2010. Retrieved from: http://thyroid.about.com/od/hypothyroidismhashimotos/a/The-Optimal-Treatment-For-Hypothyroidism-Ron-Manzanero-Md.htm
28. Shomon, M. Thyroid Blood Tests. About.com. Updated May 29, 2014. Retrieved from http://thyroid.about.com/od/gettestedanddiagnosed/a/bloodtests.htm.
29. Living with Graves’ Disease. Updated February 1, 2010. Retrieved from http://www.livingwithgravesdisease.com/diagnosis/lab-tests.
30. Boillet, D., and A. Szoke. Psychiatric manifestations as the only clinical sign of hypothyroidism. Apropos of a case. L'Encephale 24.1 (1997): 65-68.
31. Carta, Mauro G., et al. A case control study on psychiatric disorders in Hashimoto disease and Euthyroid Goitre: not only depressive but also anxiety disorders are associated with thyroid autoimmunity. Clinical Practice and Epidemiology in Mental Health 1.1 (2005): 23.
32. Boillet, D., and A. Szoke. Psychiatric manifestations as the only clinical sign of hypothyroidism. Apropos of a case. L'Encephale 24.1 (1997): 65-68.
33. Carta, Mauro G., et al. A case control study on psychiatric disorders in Hashimoto disease and Euthyroid Goitre: not only depressive but also anxiety disorders are associated with thyroid autoimmunity. Clinical Practice and Epidemiology in Mental Health 1.1 (2005): 23.
34. Hage, Mirella P., and Sami T. Azar. The link between thyroid function and depression. Journal of thyroid research 2012 (2011).
35. Haggerty Jr, John J., et al. The presence of antithyroid antibodies in patients with affective and nonaffective psychiatric disorders. Biological psychiatry 27.1 (1990): 51-60.
36. Rack, Sarah Kotchen, and Eugene H. Makela. Hypothyroidism and depression: a therapeutic challenge. Annals of Pharmacotherapy 34.10 (2000): 1142-1145.
37. Cooper-Kazaz, Rena, et al. Combined treatment with sertraline and liothyronine in major depression: a randomized, double-blind, placebo-controlled trial. Archives of general psychiatry 64.6 (2007): 679-688.
38. Bunevičius, Robertas, et al. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. New England Journal of Medicine 340.6 (1999): 424-429.
39. Nygaard, Birte, et al. Effect of combination therapy with thyroxine (T4) and 3, 5, 3′-triiodothyronine versus T4 monotherapy in patients with hypothyroidism, a double-blind, randomised cross-over study."European Journal of Endocrinology 161.6 (2009): 895-902.
40. Acosta, Brenda M., and Antonio C. Bianco. New insights into thyroid hormone replacement therapy. F1000 Medicine Reports 2 (2010).
41. Michalopoulou, Georgia, et al. High serum cholesterol levels in persons with 'high-normal'TSH levels: should one extend the definition of subclinical hypothyroidism?. European Journal of Endocrinology 138.2 (1998): 141-145.
42. Kanaya, Alka M., et al. Association between thyroid dysfunction and total cholesterol level in an older biracial population: the health, aging and body composition study. Archives of Internal Medicine 162.7 (2002): 773-779.
43. Lam, Karen SL, Man Kam Chan, and Rose TT Yeung. High-density lipoprotein cholesterol, hepatic lipase and lipoprotein lipase activities in thyroid dysfunction—effects of treatment. QJM 59.2 (1986): 513-521.
44. Celi, Francesco S., et al. Metabolic effects of liothyronine therapy in hypothyroidism: a randomized, double-blind, crossover trial of liothyronine versus levothyroxine. The Journal of Clinical Endocrinology & Metabolism96.11 (2011): 3466-3474.
45. Garber, Jeffrey R., et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine Practice 18.6 (2012): 988-1028.
46. Appelhof, Bente C., et al. Combined therapy with levothyroxine and liothyronine in two ratios, compared with levothyroxine monotherapy in primary hypothyroidism: a double-blind, randomized, controlled clinical trial. The Journal of Clinical Endocrinology & Metabolism 90.5 (2005): 2666-2674.
47. Baisier, W. V., J. Hertoghe, and W. Eeckhaut. Thyroid insufficiency. Is thyroxine the only valuable drug?. Journal of Nutritional and Environmental Medicine 11.3 (2001): 159-166.
48. Chakera, Ali J., Simon HS Pearce, and Bijay Vaidya. Treatment for primary hypothyroidism: Current approaches and future possibilities. Drug design, development and therapy 6 (2012): 1.
49. Escobar-Morreale, Héctor F., et al. Only the combined treatment with thyroxine and triiodothyronine ensures euthyroidism in all tissues of the thyroidectomized rat. Endocrinology 137.6 (1996): 2490-2502.
50. Das, Gautam, and Shweta Anand. "Does synthetic thyroid extract work for everybody?." Endocrine Abstracts. (2007) 13 P316.
51. Pritchard, Eric K. Reducing the Scope of Guidelines and Policy Statements in Hypothyroidism. Journal of Orthomolecular Medicine 28.2 (2013).
52. Hoang, Thanh D., et al. "Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study." The Journal of Clinical Endocrinology & Metabolism 98.5 (2013): 1982-1990.
53. Costa, S. Desiccated thyroid extract a safe alternative to levothyroxine. Endocrine Today. June 17, 2013. Retrieved from:
http://www.healio.com/endocrinology/highlights-from-endo-2013/desiccated-thyroid-extract-a-safe-alternative-to-levothyroxine-in-hypothyroidism
54. Friedman, T.C. Hypothyroidism Diagnosis. Good Hormone Health, Theodore Friedman, MD, PhD. Retrieved from www.goodhormonehealth.com/Hypothyroidism-finaln.pdf
55. Nature-Throid. Nature-Throid vs. Synthetic Thyroid. Retrieved from http://www.nature-throid.com
56. Shomon, M. Armour Thyroid Recall: Do You Need to be Concerned? About.com Thyroid Disease. Updated February 11, 2011. Retrieved from
http://thyroid.about.com/b/2011/02/11/armour-thyroid-recall-do-you-need-2011.htm
57. Cerillo, Alfredo Giuseppe, et al. The Low Triiodothyronine Syndrome: A Strong Predictor of Low Cardiac Output and Death in Patients Undergoing Coronary Artery Bypass Grafting. The Annals of thoracic surgery 97.6 (2014): 2089-2095.
58. Lowe, John C., et al. Effectiveness and safety of T3 (triiodothyronine) therapy for euthyroid fibromyalgia: a double-blind placebo-controlled response-driven crossover study. Clinical bulletin of myofascial therapy 2.2-3 (1996): 31-57.
59. Weltman, N. Y., et al. Low-dose T3 replacement restores depressed cardiac T3 levels, preserves coronary microvasculature, and attenuates cardiac dysfunction in experimental diabetes mellitus. Molecular medicine (Cambridge, Mass.) (2014).
60. Murfin, M. Using T3 for Symptoms of Hypothyroidism. Retrieved from https://suite.io/melissa-murfin/2d6h2qa
61. Shomon, M. The Optimal Treatment for Hypothyroidism: Theodore Friedman, MD. About.com Thyroid Disease. Updated May 30, 2014. Retrieved from
http://thyroid.about.com/od/hypothyroidismhashimotos/a/Optimal-Treatment-For-Hypothyroidism-Friedman.htm
62. Carlson, R. Article 1: Treatment of Thyroid. Hoye’s Pharmacy. Retrieved from: http://www.hoyespharmacy.com/page/view/practitioners/64-guest-articles-from-our-medical-practitioner-partners.html
63. Pick, M. Adrenal Dysfunction. Women to Women. Retrieved from: http://www.womentowomen.com/adrenal-health-2/adrenal-dysfunction/
64. Shomon, M. The Scientific Validity of Adrenal Fatigue and Mild Adrenal Insufficiency. About.com Thyroid Disease. Updated November 4, 2010. Retrieved from: http://thyroid.about.com/b/2010/11/04/scientific-validity-adrenal-fatigue.htm
65. Cheikin, M. Adrenal Fatigue: A Debt Worse Than Credit Cards. Center for Optimal Health. May 2007. Retrieved from: http://www.c4oh.org/articles_free/adrenal_fatigue.pdf
66. Biró, Edit, et al. Association of systemic and thyroid autoimmune diseases. Clinical rheumatology 25.2 (2006): 240-245.
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16. Shomon, M. The Optimal Treatment for Hypothyroidism: Dr. Kent Holtorf Shares His Approach to Treating an Underactive Thyroid. About.com Thyroid Disease. Updated December 22, 2010. Retrieved from http://thyroid.about.com/od/hypothyroidismhashimotos/a/The-Optimal-Treatment-For-Hypothyroidism.htm.
17. Promberger R, Hermann M, Ott J. Hashimoto's Thyroiditis in Patients With Normal Thyroid-stimulating Hormone Levels. Expert Rev Endocrinol Metab. 2012;7(2):175-179.
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19. Shomon M. Do You Need Preventive Thyroid Treatment? Treating Antibodies When TSH is Normal. About.com Thyroid Disease. February 10, 2014. Retrieved from http://thyroid.about.com/od/hypothyroidismhashimotos/a/preventative.htm.
20. Shomon, M. The Optimal Treatment for Hypothyroidism: Dr. Kent Holtorf Shares His Approach to Treating an Underactive Thyroid. About.com Thyroid Disease. Updated December 22, 2010. Retrieved from http://thyroid.about.com/od/hypothyroidismhashimotos/a/The-Optimal-Treatment-For-Hypothyroidism.htm.
21. Shomon, M. What is the Optimal TSH Level for Thyroid Patients? About.com Thyroid Disease. Updated April 05, 2014. Retrieved from http://thyroid.about.com/od/gettestedanddiagnosed/a/optimaltsh.htm.
22. Vanderpump MP, Tunbridge WM, French,JM, Appleton, D., Bates, D, Clark F, Grimley Evans, Hasan DM, Rodgers H, Tunbridge, F. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995 Jul;43(1): 55-68.
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24. Lee, SL. When is the TSH normal? New criteria for diagnosis and management. Lecture presented at 12th Annual Meeting of the American Association of Clinical Endocrinologists (AACE), San Diego, CA, May 14, 2003 (thyroidtoday.com).
25. Pacchiarotti A, Martino E, Bartalena L, Aghini-Lombardi F, Grasso L, Buratti L, Falcone M, Pinchera A. Serum free thyroid hormones in subclinical hypothyroidism. Journal of Endocrinological Investigation. 1986 Aug;9(4):315-9.
26. Myers, A. 10 Signs You Have A Thyroid Problem And 10 Solutions for It. Amy Myers, MD. 2010-2014. Retrieved from http://www.dramymyers.com/2013/02/14/10-signs-you-have-a-thyroid-problem-and-10-solutions-for-it/
27. Shomon, M. The Optimal Treatment for Hypothyroidism: Ron Manzanero, MD. About.com Thyroid Disease. Updated December 22, 2010. Retrieved from: http://thyroid.about.com/od/hypothyroidismhashimotos/a/The-Optimal-Treatment-For-Hypothyroidism-Ron-Manzanero-Md.htm
28. Shomon, M. Thyroid Blood Tests. About.com. Updated May 29, 2014. Retrieved from http://thyroid.about.com/od/gettestedanddiagnosed/a/bloodtests.htm.
29. Living with Graves’ Disease. Updated February 1, 2010. Retrieved from http://www.livingwithgravesdisease.com/diagnosis/lab-tests.
30. Boillet, D., and A. Szoke. Psychiatric manifestations as the only clinical sign of hypothyroidism. Apropos of a case. L'Encephale 24.1 (1997): 65-68.
31. Carta, Mauro G., et al. A case control study on psychiatric disorders in Hashimoto disease and Euthyroid Goitre: not only depressive but also anxiety disorders are associated with thyroid autoimmunity. Clinical Practice and Epidemiology in Mental Health 1.1 (2005): 23.
32. Boillet, D., and A. Szoke. Psychiatric manifestations as the only clinical sign of hypothyroidism. Apropos of a case. L'Encephale 24.1 (1997): 65-68.
33. Carta, Mauro G., et al. A case control study on psychiatric disorders in Hashimoto disease and Euthyroid Goitre: not only depressive but also anxiety disorders are associated with thyroid autoimmunity. Clinical Practice and Epidemiology in Mental Health 1.1 (2005): 23.
34. Hage, Mirella P., and Sami T. Azar. The link between thyroid function and depression. Journal of thyroid research 2012 (2011).
35. Haggerty Jr, John J., et al. The presence of antithyroid antibodies in patients with affective and nonaffective psychiatric disorders. Biological psychiatry 27.1 (1990): 51-60.
36. Rack, Sarah Kotchen, and Eugene H. Makela. Hypothyroidism and depression: a therapeutic challenge. Annals of Pharmacotherapy 34.10 (2000): 1142-1145.
37. Cooper-Kazaz, Rena, et al. Combined treatment with sertraline and liothyronine in major depression: a randomized, double-blind, placebo-controlled trial. Archives of general psychiatry 64.6 (2007): 679-688.
38. Bunevičius, Robertas, et al. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. New England Journal of Medicine 340.6 (1999): 424-429.
39. Nygaard, Birte, et al. Effect of combination therapy with thyroxine (T4) and 3, 5, 3′-triiodothyronine versus T4 monotherapy in patients with hypothyroidism, a double-blind, randomised cross-over study."European Journal of Endocrinology 161.6 (2009): 895-902.
40. Acosta, Brenda M., and Antonio C. Bianco. New insights into thyroid hormone replacement therapy. F1000 Medicine Reports 2 (2010).
41. Michalopoulou, Georgia, et al. High serum cholesterol levels in persons with 'high-normal'TSH levels: should one extend the definition of subclinical hypothyroidism?. European Journal of Endocrinology 138.2 (1998): 141-145.
42. Kanaya, Alka M., et al. Association between thyroid dysfunction and total cholesterol level in an older biracial population: the health, aging and body composition study. Archives of Internal Medicine 162.7 (2002): 773-779.
43. Lam, Karen SL, Man Kam Chan, and Rose TT Yeung. High-density lipoprotein cholesterol, hepatic lipase and lipoprotein lipase activities in thyroid dysfunction—effects of treatment. QJM 59.2 (1986): 513-521.
44. Celi, Francesco S., et al. Metabolic effects of liothyronine therapy in hypothyroidism: a randomized, double-blind, crossover trial of liothyronine versus levothyroxine. The Journal of Clinical Endocrinology & Metabolism96.11 (2011): 3466-3474.
45. Garber, Jeffrey R., et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine Practice 18.6 (2012): 988-1028.
46. Appelhof, Bente C., et al. Combined therapy with levothyroxine and liothyronine in two ratios, compared with levothyroxine monotherapy in primary hypothyroidism: a double-blind, randomized, controlled clinical trial. The Journal of Clinical Endocrinology & Metabolism 90.5 (2005): 2666-2674.
47. Baisier, W. V., J. Hertoghe, and W. Eeckhaut. Thyroid insufficiency. Is thyroxine the only valuable drug?. Journal of Nutritional and Environmental Medicine 11.3 (2001): 159-166.
48. Chakera, Ali J., Simon HS Pearce, and Bijay Vaidya. Treatment for primary hypothyroidism: Current approaches and future possibilities. Drug design, development and therapy 6 (2012): 1.
49. Escobar-Morreale, Héctor F., et al. Only the combined treatment with thyroxine and triiodothyronine ensures euthyroidism in all tissues of the thyroidectomized rat. Endocrinology 137.6 (1996): 2490-2502.
50. Das, Gautam, and Shweta Anand. "Does synthetic thyroid extract work for everybody?." Endocrine Abstracts. (2007) 13 P316.
51. Pritchard, Eric K. Reducing the Scope of Guidelines and Policy Statements in Hypothyroidism. Journal of Orthomolecular Medicine 28.2 (2013).
52. Hoang, Thanh D., et al. "Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study." The Journal of Clinical Endocrinology & Metabolism 98.5 (2013): 1982-1990.
53. Costa, S. Desiccated thyroid extract a safe alternative to levothyroxine. Endocrine Today. June 17, 2013. Retrieved from:
http://www.healio.com/endocrinology/highlights-from-endo-2013/desiccated-thyroid-extract-a-safe-alternative-to-levothyroxine-in-hypothyroidism
54. Friedman, T.C. Hypothyroidism Diagnosis. Good Hormone Health, Theodore Friedman, MD, PhD. Retrieved from www.goodhormonehealth.com/Hypothyroidism-finaln.pdf
55. Nature-Throid. Nature-Throid vs. Synthetic Thyroid. Retrieved from http://www.nature-throid.com
56. Shomon, M. Armour Thyroid Recall: Do You Need to be Concerned? About.com Thyroid Disease. Updated February 11, 2011. Retrieved from
http://thyroid.about.com/b/2011/02/11/armour-thyroid-recall-do-you-need-2011.htm
57. Cerillo, Alfredo Giuseppe, et al. The Low Triiodothyronine Syndrome: A Strong Predictor of Low Cardiac Output and Death in Patients Undergoing Coronary Artery Bypass Grafting. The Annals of thoracic surgery 97.6 (2014): 2089-2095.
58. Lowe, John C., et al. Effectiveness and safety of T3 (triiodothyronine) therapy for euthyroid fibromyalgia: a double-blind placebo-controlled response-driven crossover study. Clinical bulletin of myofascial therapy 2.2-3 (1996): 31-57.
59. Weltman, N. Y., et al. Low-dose T3 replacement restores depressed cardiac T3 levels, preserves coronary microvasculature, and attenuates cardiac dysfunction in experimental diabetes mellitus. Molecular medicine (Cambridge, Mass.) (2014).
60. Murfin, M. Using T3 for Symptoms of Hypothyroidism. Retrieved from https://suite.io/melissa-murfin/2d6h2qa
61. Shomon, M. The Optimal Treatment for Hypothyroidism: Theodore Friedman, MD. About.com Thyroid Disease. Updated May 30, 2014. Retrieved from
http://thyroid.about.com/od/hypothyroidismhashimotos/a/Optimal-Treatment-For-Hypothyroidism-Friedman.htm
62. Carlson, R. Article 1: Treatment of Thyroid. Hoye’s Pharmacy. Retrieved from: http://www.hoyespharmacy.com/page/view/practitioners/64-guest-articles-from-our-medical-practitioner-partners.html
63. Pick, M. Adrenal Dysfunction. Women to Women. Retrieved from: http://www.womentowomen.com/adrenal-health-2/adrenal-dysfunction/
64. Shomon, M. The Scientific Validity of Adrenal Fatigue and Mild Adrenal Insufficiency. About.com Thyroid Disease. Updated November 4, 2010. Retrieved from: http://thyroid.about.com/b/2010/11/04/scientific-validity-adrenal-fatigue.htm
65. Cheikin, M. Adrenal Fatigue: A Debt Worse Than Credit Cards. Center for Optimal Health. May 2007. Retrieved from: http://www.c4oh.org/articles_free/adrenal_fatigue.pdf
66. Biró, Edit, et al. Association of systemic and thyroid autoimmune diseases. Clinical rheumatology 25.2 (2006): 240-245.
(Back to Top)
