This is the first of four CME lectures delivered by Dr. Cady at the 4rth Annual Integrated Medicine For Mental Health Conference in Chicago, IL at McCormick Place, September 21, 2013. In it, he deconstructs the facts and fallacies surrounding the thyroid axis, what should be measured, why it's important, and what happens to patients with suboptimal thyroid status. The scientific literature, quoted right up to the day before the conference started, is extensive and well sourced. Any practicing physician, and certainly any interested patient(s) should familiarize himself or herself with this content.

1. Louis B. Cady, MD – CEO & Founder – Cady Wellness InstituteLouis B. Cady, MD – CEO & Founder – Cady Wellness Institute
Adjunct Asst. Prof of Psychiatry – Indiana University School of Medicine
Department of Psychiatry
Child, Adolescent, Adult, Functional Neuropsychiatry – Evansville, Indiana
4rth Annual MMH CONFERENCE – Chicago, IL.
Saturday, September 21, 2013
This is Your Brain on THYROID

2. Continuing Medical Education Commercial Disclosure Requirement
for Louis B. Cady, M.D.
I, Louis B. Cady, MD, have the following commercial relationships to
disclose:
•Speaker honoraria received from:
• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX
•Speaker’s bureaus (active) for:
• Forest Pharmaceuticals, Sunovion, Shionogi
•Historical data – speaker’s bureau for Bristol-Myers Squibb,
Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil,
Pfizer-Roerig, Sanofi!~aventis, Sepracor, Shire, McNeil, Takeda,
Janssen, Searle, Shire, Takeda, Wyeth-Ayerst

3. “Probably the most interesting period of
medicine has been that of the last few
decades. So rapid has been this advance, as
new knowledge developed, that the truth
of each year was necessarily
modified by new evidence, making
the truth an ever-changing factor.”
- Charles Mayo, MD “Dr. Charlie”
Plummer
Building lobby.
Photo: © Louis
B. Cady, MD
2004

4. “Truth is a constant
variable.”
– William Mayo, MD. “Dr. Will”
Gonda extension, Mayo Clinic Building
2004. © Louis B. Cady, M.D.

5. On my iphone – 9/19/013On my iphone – 9/19/013

6. Purpose of this talk (& challenges):
• Real-world integration of
endocrine concepts.
• “Bridging the gap” between
historical uses of thyroid meds
and enlightened practice.
• Understanding relevance of
thyroid hormone in affective and
cognitive dysfunction
• Review of laboratory testing and
rationale
• Discussion of rational risk-
balancing & integrated treatment
Limitations:
•Only 1 hour!!
•Limited
epidemiology
•No in-depth
focus on
supplements or
iodine deficiency
(or testing or
treatment)

7. How to get the MOST out of this presentation:

8. My bias: whatever works for the
patient; whatever it takes.

11. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS
MEDICAL GUIDELINES FOR CLINICAL PRACTICE
FOR THE EVALUATION AND TREATMENT OF
HYPERTHYROIDISM AND HYPOTHYROIDISM
AACE Thyroid Task Force
Chairman
H. Jack Baskin, MD, MACE
Committee Members
Rhoda H. Cobin, MD, FACE
Daniel S. Duick, MD, FACE
Hossein Gharib, MD, FACE
Richard B. Guttler, MD, FACE
Michael M. Kaplan, MD, FACE
Robert L. Segal, MD, FACE
Reviewers
Jeffrey R. Garber, MD, FACE
Carlos R. Hamilton, Jr., MD, FACE
Yehuda Handelsman, MD, FACP, FACE
Richard Hellman, MD, FACP, FACE
John S. Kukora, MD, FACS, FACE
Philip Levy, MD, FACE
Pasquale J. Palumbo, MD, MACE
Steven M. Petak, MD, JD, FACE
Herbert I. Rettinger, MD, MBA, FACE
Helena W. Rodbard, MD, FACE
F. John Service, MD, PhD, FACE, FACP, FRCPC
Talla P. Shankar, MD, FACE
Sheldon S. Stoffer, MD, FACE
John B. Tourtelot, MD, FACE, CDR, USN
2006 AMENDED VERSION
This amended version reflects a clarification to specify pertechnetate as the
compound attached to 99mTc.
ENDOCRINE PRACTICE Vol 8 No. 6 November/December 2002 457

13. http://www.umm.edu/patiented/articles/how_serious_hypothyroi
• “Thyrotropin (Thyroid-Stimulating Hormone or
TSH). Measuring TSH is the most sensitive
indicator of hypothyroidism.” (hunh?!) –
accessed 9/5/2011
• “…blood tests for measuring levels of
TSH and free thyroxine (T4) are the only
definitive way to diagnose
hypothyroidism” – 10/6/2012

14. http://umm.edu/health/medical/ency/articles/thyr
accessed 8/2/2013

15. 4

16. Releasing
Factors
Releasing
Factors
Adrenal
Gland
Adrenal
Gland OvariesOvariesTesticlesTesticles ThyroidThyroidLiverLiver
Testosterone EstrogenCortisol
DHEA Progesterone
T3 & T4
GHLH & FSH TSHProlactinACTH
IGF-1
Pituitary
Brain
HypothalamusHypothalamus
DHEA

17. What are the TYPES of
hypothyroidism (from the top down)?
• Tertiary hypothyroidism – deficiency in
hypothalamus – not enough TRH
• Secondary hypothyroidism –pituitary
isn’t kicking out enough TSH “your
thyroid labs are ‘just fine’”
• PRIMARY hypothyroidism – where
thyroid gland can’t make thyroid
hormone
– This is the only one that high TSH is good
for diagnosing!!
TSH levels
•Low TSH
•Low TSH
Your doc is
happy!! 
•HIGH TSH
(finally!)

18. “the foot soldier” “the evil twin”
Selenium
required!
FEEDBACK
INHIBITION
CORTISOL
80% of T4
converted in the
Iodine
required
(65% of T4)

19. “the foot soldier” “the evil twin”
Selenium
required!
FEEDBACK
INHIBITION
CORTISOL
80% of T4
converted in the
Iodine
required
(65% of T4)
Conventional medical practice:
-Only TSH is typically considered.
-You get T4 if you’re lucky.
-Ill-considered: “T7”, Total T4, Total T3,
%T3 uptake
-You DON’T get Free T3 or Rev T3
Conventional medical practice:
-Only TSH is typically considered.
-You get T4 if you’re lucky.
-Ill-considered: “T7”, Total T4, Total T3,
%T3 uptake
-You DON’T get Free T3 or Rev T3

20. Must have iodine to make T4!
Source: Office of Dietary Supplements, NIH accessed 8/11/2013
http://ods.od.nih.gov/factsheets/Iodine-QuickFacts/

21. Sources/locations of deficiency:
• Chlorinated or fluorinated drinking water
• Not using iodized salt
• Consumption of NaCL in processed foods
• Consumption of soy & “goitrogens” -
cabbage, broccoli, cauliflower and Brussels
sprouts
• Being pregnant
• People living with iodine deficient soils
eating local foods

22. - Selenium is one of the factors that may affect the risk of cognitive
decline. In selenium deficiency the brain remains selenium replete the
longest suggesting that Se plays an important role in brain functions.
- Results from this study: “Low Se status is a risk factor for cognitive
decline even after taking into account vascular risk factors.”

23. North America 85%
South America 76%
Asia 76%
Africa 74%
Europe 72%
Australia 55%
% Mineral depletion from the soil
during the past 100 years, by continent
Source: UN Earth Summit Report 1992

24. SELENIUM DEFICIENCY in FASEB:
• “Adaptive dysfunction of
selenoproteins from the
perspective of the ‘triage’
theory: why modest
selenium deficiency
may increase risk
of diseases of
aging.”
Foundation of American
Societies for Experimental
Biology
McCann, J, Ames BM. FASEB J.
2011 Jun;25(6):1793-814.

25. “But the doctor told me my thyroid
was fine.”
• Can be “wnl” but suboptimal.
• TSH frequently only thing checked.
• Nothing known about Free T4 or Free
T3.
• Free T4 can be converted to Reverse T3 under
stress (cortisol)
• Free T4 can be underconverted to T3 (Se def).
• Can have normal levels (or slightly elevated
levels) of everything and have auto-immune
thyroid disease.

26. (permission granted to use photos & data)

27. • Early 20’s college student
• Weight gain, fatigue, brain fog
• Saw “numerous” MD’s asking for help
• Told “nothing is wrong with your thyroid;
your labs are fine.”
(permission granted to use photos & data)

28. (permission granted to use photos & data)
(deleted photo)

29. (c) 2013 Louis B. Cady, M.D. - all
rights reserved
A physician’s wife. “Fatigued”
“No sex drive.”

30. Review of all hypothyroid patients in a
private practice in Belgium between
May 1984 and July1997
• 24 hour urine Free T3 correlates better with
clinical status of hypothyroid patients, and
even better than T4 by RIA.
• Conclusions: In this study symptoms of
hypothyroidism correlate best with 24 h
urine free T3.
Baisier WV et al. 2000, Vol. 10, No. 2 , Pages 105-113

31. “the foot soldier”
Selenium
required!
FEEDBACK
INHIBITION
CORTISOL
80% of T4
converted in the
“the evil twin =
REVERSE T3”

32. Why Reverse T3?
• Hibernating bears can:
–Lower temperature 9 – 11
degrees Farenheit
–Reduce their metabolism by
75%
–Drop heart rate from 55 to 9 bpm
• Rev T3 thought to “hibernate”
humans

33. What causes elevation in Rev T3?
• High Cortisol (emotional stress) or high
copper
• Heavy metal toxicity – mercury, lead,
cadmium
• Nutritional starvation
• Selenium or Zinc deficiency
• And high dose of thyroxine
(T4 – a pro-hormone) (!!!)

34. Increased T4 and Rev T3, with dec. Free T3
associated with hypothyroidism at the
TISSUE LEVEL
Van den Beld, AW, et al. Journ Clin Endo Metab. 2005; 90(12):6403-6409
FT3 (pg/dL)
Rev T3 (ng/dL)
>20:1 = optimal
Calculator: http://www.stopthethyroidmadness.com/rt3-ratio/
Notion of “Reverse T3 ratio”

35. ♦ Depressed mood 100%
♦ Reduced energy: 97%3
♦ Fatigue or loss of energy: 94%2
♦ Impaired concentration: 84%3
♦ Tiredness: 73%1
♦ Hypersomnia: 10%–16%4
(Insomnia)
Useful Target Symptoms inUseful Target Symptoms in
Major DepressionMajor Depression
1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J Gen
Pract 1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath et
al. J Affect Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.

36. A FEW common symptoms of
hypothyroidism (adapted from multiple sources)
• Depression, fatigue
• Concentration problems
• Poor cognitive
performance
• Lack of motivation
• Reduced libido
• Psychosis – “myxedema
madness”
• Exacerbation of bipolar
symptoms
• Cold intolerance
• Weight gain
• Slowed relaxation
phase of DTR’s
• Brittle hair/fingernails
• Decreasing eyebrows
• HIGH blood pressure
• Constipation

37. How much subclinical
hypothyroidism?
• 4 – 8.5% of US population (for TSH> 5.1!!)
– Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T4
and thyroid autoantibodies in the United States population (1988–
1994): National Health and Nutrition Examination Survey (NHANES
III) J Clin Endocrinol Metab. 2002;87:489–99.
– Canaris GJ, Manowitz NR, Mayor G, et al. The Colorado Thyroid
Disease Prevalence Study. Arch Int Med. 2000;160:526–3
• UK study (2011): 8% of women over 50 and
men over 65 have under-active thyroid and
100,000 could benefit from treatment
– BBC News 2011 - January 24

38. More studies
• 24.2% of an adult female population in
Puerto Rico = hypothyroid
– Vonzales-Rodriguez LA, et al. Thyroid dysfunction in an adult female
population: A population-based study of Latin American Vertebral
Osteoporosis Study (LAVOS) - Puerto Rico site. P R Health Sci J. 2013
Jun; 32(2):57-62.

39. Modern Medicine’s Paradigm:
Two Standard Deviations – “if you are not
sick, then you must be well.”
“NORMAL”
OPTIMAL?
OPTIMAL
TSH = 0.45 4.12 source:
Percentile (2.5th%
97.5th
% NHANES III

40. Average (normal) or optimal?
• Would you like an normal wife (husband) or
an optimal one?
• Would you like a “normal” marriage or an
exciting and optimal one?
• Would you like a “normal” medical practice
or an incredible, exciting, and (optimal!!)
stimulating one?
• Would you like “normal” thyroid
labs or OPTIMAL ones?

41. Definition of “normal labs”:
“When your lab
values are as
crappy as
everyone else’s.”
- Neal Rouzier,
MD (World Link Medical Seminar II
– Spring 2011)

42. Serum concentrations of Free T3, Free T4, morning cortisol,
afternoon cortisol and change in cortisol concentrations.
Adjustments for: age, sex, body mass index, hypertension, previous
MI, heart failure, diabetes, NY Heart Assn. functional class,
depressive symptoms and anxiety symptoms.
Lower Free T3 = more physical fatigue
Lower Free T4 = more exertional fatigue
Lower morning cortisol and change in cortisol concentration = more
mental fatigue.

43. Aim: evaluate biological factors assoc. with suicide attempts in
naturalistic sample
439 patients with major depression, bipolar and psychotic
disorders consecutively assessed in the ER of an Italian Hospital
(Jan 2008-Dec 2009)
Suicide attempters were 2.27 times less likely to have
higher Free T3 values than non-attempters (odds ratio =
0.44; 95% CI; p=0.01) (prolactin level differences failed to reach
significance)

44. Treatment resistant depression is a common challenge.
Best augmenting strategies available:
-Lithium
-Thyroid hormone
-Anti-anxiety medications
-Atypical antipsychotics.

45. Per HDRS – 17, remission in:
15.9% on Li
24.7% on T3
Per QIDS-SR16, remission in:
13.2% on Li
24.7% for T3 *
* Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial,
Medscape Psychiatry
LEVEL III RESULTS:

46. 63 patients with “subclinical hypothyroidism”
HAM-D and MADRS scales with serum TSH Free T4, free T3
TPO AB and Tg-AB levels
“This study suggests the importance of a psychiatric
evaluation in patients affected by subclinical
hypothyroidism.”
Prevalence of depressive symptoms in this
population was 63.5%
Hunh?

47. Aim: Evaluate relationship of subclinical hypothyroidism and
cognition in the elderly.
- 337 outpatients; {177 = men; 160 = women}
“Patients with subclinical hypothyroidism had a
probability about 2 times greater (RR = 2.028, p<0.05) of
developing cognitive impairment.”
MMSE scores were SIGNIFICANTLY lower in
subclinical hypothyroid patients compared to
euthyroid (p<0.03)

48. Yes, T-3 DOES get into the brain
(Transthyretin = carrier protein)
• Terasaki, T. and Pardridge, W.M.: Stereospecificity of triiodothyronine
transport into brain, liver, and salivary gland: role of carrier- and
plasma protein-mediated transport. Endocrinology, 121(3):1185-1191,
1987.
• http://www.kingpharm.com/uploads/pdf_inserts/Cytomel_PI.pdf.
• Mooradian, A.D.: Blood-brain transport of triiodothyronine is reduced in
aged rats. Mech. Ageing Dev., 52(2-3):141-147, 1990.
• Cheng, L.Y., Outterbridge, L.V., Covatta, N.D., et al.: Film
autoradiography identifies unique features of [125I]3,3'5'-(reverse)
triiodothyronine transport from blood to brain. J. Neurophysiol.,
72(1):380-391, 1994.
• Rudas, P. and Bartha, T.: Thyroxine and triiodothyronine uptake by the
brain of chickens. Acta Vet. Hung, 41(3-4):395-408, 1993.
Or: The idiocy of T4 only thyroid treatment…

49. Transthyretin (a systemic amyloid precursor)
may be protective for Alzheimer’s (Why?)
Li X et al. J Neurosci 2011 Aug 31;31(55):12483-90

50. The Glamorous Grandmother
• 4/8/11 – 80 yo returned to practice. No real
complaints. History of depression. On des-
methylvenlafaxine.
– Daughter “handling her finances”
• 5/2/11 – “doing terrible.”
– TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4
– Fasting BS 120; HgBA1C 6.5%
– Fasting insulin 36 (!!!) {3 – 25}
– Progesterone – 0.2 {0.2 – 1.4 follicular}
– Total testosterone 11
– DHEA-S = 25 MICROgrams/dL (!!)
• Age adjusted {10 – 90} . Optimal = {c. 350-500}
• Rouzier = {300 –females, 600 males}

51. G.G. - interventions 5/2/11 & Follow-up
• Interventions:
– RAISE T4 from 50 to 75 MICROgrams
– DHEA – 25 mg SR q a.m.
– Progesterone 50 mg then 100 mg HS, transdermal.
– Testosterone – 2 mg for one week, then 4 mg
transdermal
– Referred to better MD for intervention with AODM.
• 6/13/2011 – improvement in fatigue. Labs
rechecked.
• 7/11/2011 – “feeling wonderful”

52. G.G. – labs before and after
` 4/11/11 interventions 7/11/11 changes
TSH 3.84 Raise T4 from
50 – 75 ug
0.01 (L) none
FT4 1.16 “ 1.24 “
FT3 2.8 “ 3.3 “
Progesterone <0.2 100mg topical
HS
0.9 None
Testosterone 11 4mg topical 15 4 mg LABIAL
DHEA-S 25 25 mg SR n/a continue

53. The glamorous grandmother – post tune-up:
DHEA, thyroid, testosterone, progesterone
9/28/2011 (permission granted to use photos & data) 01/26/2012
Photos deleted for syllabus materials. The
presenter has permission to use the patient’s
photos during the live presentation only.

54. October 12, 2012 – used with permission
Photos deleted for syllabus materials. The
presenter has permission to use the patient’s
photos during the live presentation only.

55. So what are people doing
out there?
What does the literature say?

56. Health Status, Mood, and Cognition in
Experimentally Induced Subclinical
THYROTOXICOSIS [emphasis Cady]
Samuel MH et al. J Clin Endocrinol Metab May 2008, 3(5):1730-1736
• 33 hypothyroid subjects receiving T4
• Double blind, randomized, cross-over study
of usual dose T4 or higher dose T4
• Mean TSH levels decreased from 2.15 to
0.17 mU/L on “subclinical thyrotoxicosis”
arm (p<0.0001) with NORMAL FREE T4
AND FREE T3 LEVELS.
• So what happened???

57. Health Status, Mood, and Cognition in
Experimentally Induced Subclinical
THYROTOXICOSIS [emphasis Cady]
Samuel MH et al. J Clin Endocrinol Metab May 2008, 3(5):1730-1736
• POMS (Profile of Mood States) confusion,
depression, and tension subscales IMPROVED.
• Motor learning was better
• “These findings suggest that thyroid
hormone directly affects brain areas
responsible for affect and motor
function.”
• Question to ponder: were they really
“thyrotoxic”? Or were they OPTIMIZED?

58. Thyrotopin Levels and Risk of Fatal
Coronary Heart Disease….or
“what they don’t teach you in medical
school or residency”
• The HUNT study – Asvold, BO et al. Arch
Intern Med.2008; 1678(8):855-860
• METHODS: 17,311 women and 8,002 men
with no known thyroid, cardiovascular
disease, or diabetes mellitus at baseline.
• OUTCOME MEASURE: Association
between TSH and fatal CHD

59. The HUNT study – Asvold, BO et al. Arch Intern
Med.2008; 1678(8):855-860 – cont.
• Median follow up of 8.3 years
– 228 women & 182 men died of CHD
• TSH levels of those that DIED:
– 0.50 – 3.5 mIU/L
• 192 women
• 164 men
• “Thyrotropin levels within the reference
range were positively associated with CHD
mortality (in women, but not men).”

60. Want to place your
bets??
• Reference range 0.50 – 1.4 mIU/L
= RR of 1
• {1.5 – 2.4 mIU/L} = RR of 1.41
• {2.5 – 3.5 mIU/L} = RR of 1.69Asvold, BO et al
The higher you go
(w/TSH), the higher your
risk.

61. Rhee CM et al. J Clin Endocrinol Metab. 2013 Jun; 98(6):2326-36.
“Subclinical hypothyroidism vs.
euthryoidism was associated with
greater mortality in those with CHF
but not in those without.” [Adj. hazard
ratio = 1.44X, CI = 95%]
“Subclinical hypothyroidism vs.
euthryoidism was associated with
greater mortality in those with CHF
but not in those without.” [Adj. hazard
ratio = 1.44X, CI = 95%]

62. Association of thyroid dysfunction with
depression in a teaching hospital
Ojha SO et al. J Nepal Health Res Counc. 2013 Jan;11(23):30-4
• 70 patients diagnosed with first episode
depression - selected by random sampling
– 21% found to have thyroid dysfunction of some
type
–11% were found to have
SUBCLINICAL HYPOTHYROIDISM
• Conclusions: “…thyroid dysfunction is
common in depressed patients…”

63. So what does the American Association of
Clinical Endocrinologists (ACEE) say?
• “The upper limit of TSH
should remain at 4.5
mIU/L, rather than 3.0-3.5 as
some other organizations have
suggested.”
–Source: Subclinical Thyroid Disease –
Guidelines & Position Statements.
April 10, 2013, retrieved 6/16/2013

64. Lab values – one more time…”4.5” is where the
American Assn. of Clin. Endocrinologists want
the highest level of TSH
TSH = 0.45 4.12 source:
Percentile (2.5th%
97.5th
% NHANES III
4.5 is the
upper limit
they want –
this is at c.
the 99th
%

65. The perils of pharmacology
• “Too much… of
a good thing… is
WONDERFUL.”
– Mae West

66. A word of caution, and a reflection on the
Glamorous Grandmother
• OPUS (Osteoporosis & Ultrasound Study) - 2,940
POST-menopausal women 6 year prospective
study
– 1,278 healthy euthyroid average 68yo women
selected
19 yrs post-menopausal who did not take any
medication that might affect their bones.
• The higher one's FT3 and/or FT4, the lower one's
BMD and the greater one's risk of non-vertebral
fracture. FT4 <0.88ng/dL had better outcomes than
those w/FT4 >1.12ng/dL.Source: Murphy E, et al. Thyroid function within the upper normal range is associated with
reduced bone mineral density and an increased risk of nonvertebral fractures in healthy
euthyroid postmenopausal women. J Clin Endocrinol Metabl. 2010 Jul;95(7):3173-81. with
commentary adapted from Alvin Lin, MD Las Vegas, NV.

67. Does Grandma have to pick between
optimally euthyroid or osteoporotic?
• 57 yo MWF transferred to me - 11/19/2009
– On Prometrium, Androgel (??? Tiny dose), Bi-
est, Estriol pV, and Norditropin (which was
subsequently able to be tapered with DHEA)
– Armour thyroid – 30 mg
• PMH
– TSH of 6.89 in June 2007
– Bone densitometry – within normal limits
• PE – hint of thyromegaly.
– Neuro – normal DTR’s, normal exam

68. Case study – a woman with her TSH
“suppressed” from 1.19 to 0.10 (L)
` 1/4/11 3/1811 5/16/11 11/14/2012
Thyroid Rx 75ug T4 /
15 ug T3
75ug T4 /
10 ug T3
100 ug T4/ 5
ug T3 bid
100 ug T4/ 5 ug T3
bid
TSH {0.34-
4.72}
0.12 1.19 0.06 (L) 0.10 (L)
FT4 {0.6 – 1.8} 0.5 (L) 0.5 (L) 0.9 0.6 (L)
FT3 {2.0 – 4.4} 2.8 3.2 3.7 3.4
Rev T3 Within
normal
limits
Within
normal
limits
Within
normal limits
Within normal limits
NORMAL
???????

69. Case study – a woman with her TSH
“suppressed” “The Rest of the Story”
` 1/4/11 3/18/11 5/16/11 11/14/2012
Estradiol
{12.5-166.3}
0.12 21.2 53.3 15.1
Progesterone 1.9 2.0 2.4 2.0
Testosterone,
total
50 41 118 (H) 60
LH/FSH 53.9/86.4 59.6/94.9
DHEA-S 314.2 363.8 573.1 (draw
after Rx)
481.1 (H)
25-OH Vit D 53.7
NTx-
Telopep
7.5 {6.2-
19.0}
On triple Hormone RX, DHEA, Vit D & MVI
Bone loss of a teen – 20 yo

70. OK – but what about HEART DISEASE
risk?
• Citation: Subclinical hypothyroidism and the risk of
coronary heart disease: a meta-analysis.
Rodondi N et al. Amer. Jour of Med. July 2006,
119, 541-551. (meta-analysis)
• Medline search from 1966- April 2005
– 14 observational studies met criteria
• Subclinical hypothyroidism (elevated TSH, normal
T4) increased odds ratio of CHD to 2.38
(CI 1.53-3.69) after adjusting for risk factors

71. Thyroid replacement on lipid parameters
• Population based cross-sectional study with
26 elderly patients with subclinical
hypothyroidism(SCH) compared with 31
patients with clinical hypothyroidism (CH)
• Both groups treated with T4 for 3 months.
• Decreased total cholesterol/HDL
(p<0.0001) and LDL/HDL ratios (p=0.0004)
were greater in patients with SCH
Source: Arinzon, Z et al. Arch Gerontol Geriatrics 44(2007)13-19.

72. Thyroid replacement on lipid parameters
Source: Arinzon, Z et al. Arch Gerontol Geriatrics 44(2007)13-19.
• “It was shown that THR (thyroid
replacement) among patients with
SCH is beneficial not only by
improvement in lipid profile, as well
as by improvement in cognitive and
functional status, but also in
decreased blood pressure and
BMI.”

73. An opposing view:
• “Thus, any abnormal thyroid function tests
in psychiatric patients should be viewed with
skepticism. Given the fact that thyroid
function test abnormalities seen in non-
thyroidal illness usually resolve
spontaneously, treatment is generally
unnecessary, and may even be potentially
harmful.”
• Dicerman AL, Barnhill JW. Abnormal thyroid
function tests in psychiatric patients: a red
herring? Am J Psychiatry. 2012 Feb;169(2):127-33

74. Thyroid treatment riffs:
• “Compounded slow-release T3 has been
suggested for use in combination with T4,
which proponents argue will mitigate many
of the symptoms of functional
hypothyroidism and improve quality of life.
This is still controversial and is rejected by
the conventional medical establishment.”
– Todd, C H (2010). "Management of thyroid
disorders in primary care: challenges and
controversies". Postgraduate Medical Journal
85 (2010): 655–9.

75. Rx controversies:
• “As of 2012 there are no controlled trials
supporting the preferred use of desiccated
thyroid hormone over synthetic L-thyroxine
in the treatment of hypothyroidism or any
other thyroid disease.”
– American Thyroid Association
– 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.

77. 70 patients- ages 18-65 years of age. w/ primary hypothyroidism on
stable T4 for 6 months.
70 patients- ages 18-65 years of age. w/ primary hypothyroidism on
stable T4 for 6 months.
Randomized to either dessicated thyroid extract (DTE) or T4 for 16
months, then crossed over for another 16 months.
Randomized to either dessicated thyroid extract (DTE) or T4 for 16
months, then crossed over for another 16 months.
RESULTS:
- “No differences in symptoms” and neurocognitive measures.
RESULTS:
- “No differences in symptoms” and neurocognitive measures.
BUT:
-DTE patients lost 3 lbs!
-48.6% of patients (n=34) PREFERRED DTE.
-Those patients preferring DTE lost 4 lbs during the DTE treatment
and subjective symptoms were all significantly better
while taking DTE as per general health questionnaire-12
and thyroid symptom questionnaire.
BUT:
-DTE patients lost 3 lbs!
-48.6% of patients (n=34) PREFERRED DTE.
-Those patients preferring DTE lost 4 lbs during the DTE treatment
and subjective symptoms were all significantly better
while taking DTE as per general health questionnaire-12
and thyroid symptom questionnaire.

78. “Conclusions”:
- DTE therapy did not result in a significant improvement in quality of
life; however, DTE caused modest weight loss and nearly half (46.8%)
of the study patients expressed preference for DTE over L-T4.
DTE therapy may be relevant for some
hypothyroid patients.” [Can you believe it????]
“Conclusions”:
- DTE therapy did not result in a significant improvement in quality of
life; however, DTE caused modest weight loss and nearly half (46.8%)
of the study patients expressed preference for DTE over L-T4.
DTE therapy may be relevant for some
hypothyroid patients.” [Can you believe it????]

79. Rx:
• Synthroid ® (levothyroxine)
• Cytomel ®
(Tri-iodothyronine – “T3”)
– Instant release (cheap!)
– Compounded in SR capsule
(easier dosing)
• Armour® thyroid (brand or
generic) = T4 + T3
• Naturethroid = T4 + T3 –
better tolerated in some

80. Holistic Rx:• Background:
– There are 4 molecules of iodine on T4
(thyroxine = thyroid hormone) and 3
molecules of iodine on T3, active thyroid
hormone.
– T4 is made up of 63% iodine.
– How can we make them if we don’t have
enough iodine?
• Filter your drinking water.
• Iodine supplementation as needed after
testing

81. Dx:
• TSH
• Free T4
• Free T3
• Reverse T3
• If indicated:
– Anti-thyroid antibodies (anti-
TPO)
– Anti-thyroglobulin antibodies
– Thyrotropin receptor
antibodies (TRAb’s)
• We typically do not do:
– Total T4, Total T3, or thyroid
reuptake
Test! Test! Test!

82. So what the
heck am I
supposed to
do with this
stuff?

83. Thyroid “by the numbers.”
1. Review this lecture.
2. Go get good training. (Neal Rouzier, MD)
3. PSYCHIATRISTS! Acknowledge that “T3 augmentation” is
in your literature and it is your RIGHT TO PRACTICE IT.
4. Therapists/other practitioners: wake up! Don’t fall into trap
of “blaming” the functionally hypothyroid patient. REFER!
5. Start LOW.
6. Go SLOW.
7. Test test test test test.
– MUST GET BASELINE (which typically hasn’t been done).
– If you are unsure or nervous, TEST.
– MONITOR THE THERAPY.
1. Explain “Goldilocks and the Three Bears” to your patients
and start LOW, giving them some flexibility.

84. Two books:

85. “Sit down before fact as
a little child,
be prepared to give up
every preconceived
notion,
follow humbly wherever
… nature leads,
or you shall learn
nothing.”
- Thomas H. Huxley

86. Contact information:
Louis B. Cady, M.D.
www.cadywellness.com
www.facebook.com/cadywellness
www.tms-relief.com
Office: 812-429-0772
E-mail: lcady@cadywellness.com
4727 Rosebud Lane – Suite F
Interstate Office Park
Newburgh, IN 47630 (USA)
@LouisCadyMD
@TMS4depression
Once more…. 
Where to “get the slides” -
Syllabus
www.slideshare.net/lcadymd
Cady Wellness Institute
app.