April 10, 2019 at 12:42 pm #3223Maddi RidleyParticipant
I have been seeing this lady for some time as her private GP for Hypothyroidism – her latest blood results indicated over treatment with levothyroxine (TSH 0.02, normal T4 and T3) so I reduced her dose of levothyroxine from 50mcg od to alternative of 50/25mcg od. This triggered a severe return of her symptoms of hypothyroidism with extreme tiredness/joint pain/lethargy/ dizziness and stomach bloating. She returned to see me for a functional assessment –
Breast fed NVD at term, Nil significant childhood illness, 2x pregnancies (high BP during preg) On HRt after hysterectomy 10 years ago. Hypothyroidism diagnosed one year later aged 47 years. Followed by several years of stressful events – dog died, husband diagnosed with Parkinson’s, food poisoning. Aged 53 she developed symptoms of anxiety, panic and depression for which she was treated with mirtazipine by her GP. aged 56 she developed stomach bloating and reflux approx one hour after eating.
Her main issue is her symptoms of anxiety – I am concerned these may be related to her thyroid but her thyroid parameters are in normal range including T4 and T3
She has had a york test done which indicated diary intolerance which she has cut out – I have also asked her to follow a gluten and sugar free diet and take Sacchromyces boulardii which she says have improved her gut symptoms.
I did a nordic lab CSAPx2 test – this showed no dysbiotic flora/many yeast (microscopic)
A cortisol stress test was done by herself which showed low cortisol evening and night levels – consistent with evolving (phase 2) HPA axis dysfunction.
I would be very grateful for any advice for further testing for this lady esp from a thyroid point of view as I feel her symptoms of anxiety are related to thyroid function.
Thanks in advance – Maddi
Posted by Maddi Ridley on 10/6/17
April 10, 2019 at 12:44 pm #3225Carrie Decker, NDModerator
Thank you for posting this woman’s case here. There are a variety of things which may help to improve her symptoms and bring her back to balance – I will try to briefly touch on the thoughts I have and things I have seen helpful.
Concerning her thyroid dysfunction, has it ever been determined if it is an autoimmune condition? With autoimmune disease, there are many additional considerations for management including gluten elimination, selenium, and anti-inflammatories for the management of antibodies, as well as further investigation into if there may be heavy metals and chronic/latent viral issues contributing to immune dysregulation. If her antibodies have never been assessed this would be the next course of action I would take, particularly as the thyroid is much more labile then and can alternate from hyper- to hypo- very rapidly.
Concerning her hormone replacement therapy, is this oestrogen replacement only or does it include progesterone therapy? When hormones are out of balance, and progesterone is low, this can be a significant contributor to anxiety. I have found many women, post-hysterectomy and even those who are having anxiety prior to menses to have anxiety improve with the addition of topical or oral progesterone, which you are able to do as a physician. I find sensitive clients, such as this woman sounds like, to do much better with topical application rather than oral therapy and usually start them with a metred 20mg dose daily to rub into inner thighs/abdomen/underarms once a day.
An additional thing which can contribute to thyroid symptoms such as fatigue is poor cellular health and energy production. With chronic oxidative stress and cumulative environmental toxicity, the delicate cellular machinery which depends on functional membranes for transfer of nutrients and hormones (like thyroid!) in, waste out, and cellular communication do not function optimally. Mitochondrial dysfunction also becomes an issue when cellular membranes are damaged, impairing cellular production of energy. Supporting the health of the cell with phospholipid membrane lipid replacement therapy can, for these reasons, improve a variety of symptoms over time. Lipid replacement therapy has been studied and found to improve fatigue in individuals with chronic fatigue, cancer, and aging associated fatigue. There are specific phospholipid combinations which have been studied for this purpose (one being listed below) and phosphatidyl choline also is an option.
Nicolson GL. Lipid Replacement/Antioxidant Therapy as an adjunct supplement to reduce the adverse effects of cancer therapy and restore mitochondrial function. Pathol Oncol Res 2005; 11: 139-144. http://tinyurl.com/za8bbjx
Nicolson GL. Lipid replacement/antioxidant therapy for anti-aging, fatigue and restoration of
mitochondrial function. AgroFood High Tech 2004; 15(3): 20-23. http://tinyurl.com/gu6e2bu
It may be complementary to support lipid replacement therapy with antioxidant supplements, which also have been studied independently in settings of anxiety and depression. Vitamin C and N-acetylcysteine both have been studied extensively in psychiatric settings, including in clinical trials.
Deepmala, et al. Clinical trials of N-acetylcysteine in psychiatry and neurology: A systematic review. Neurosci Biobehav Rev. 2015 Aug;55:294-321. http://tinyurl.com/p8urvkh
de Oliveira IJ, et al. Effects of Oral Vitamin C Supplementation on Anxiety in Students: A Double-Blind, Randomized, Placebo-Controlled Trial. Pak J Biol Sci. 2015 Jan;18(1):11-8. https://tinyurl.com/y6tvwxm7
Vitamin C is an important cofactor for the synthesis of several hormones and neurotransmitters made in the adrenal gland. Perhaps not surprisingly, the adrenal glands are one of the organs with the highest concentration of vitamin C, hence as a therapy it may support their function under stress. Ascorbic acid enhances the production of norepinephrine from dopamine, while deficiency has been shown to be associated with lower levels of dopamine and serotonin metabolites. Low plasma ascorbic acid levels have been shown to be associated with major depression. Vitamin C has been shown to positively impact symptoms of anxiety and depression in double-blind, randomized, placebo-controlled trials, possibly attributable to its action as an antioxidant.
Patak P, et al. Vitamin C is an important cofactor for both adrenal cortex and adrenal medulla. Endocr Res. 2004 Nov;30(4):871-5. https://tinyurl.com/y7s4mxyy
May JM, et al. Ascorbic acid efficiently enhances neuronal synthesis of norepinephrine from dopamine. Brain Res Bull. 2013 Jan;90:35-42. https://tinyurl.com/yao6ukpc
Ward MS, et al. Behavioral and monoamine changes following severe vitamin C deficiency. J Neurochem. 2013 Feb;124(3):363-75. https://tinyurl.com/yc22xbpb
Amr M, et al. Efficacy of vitamin C as an adjunct to fluoxetine therapy in pediatric major depressive disorder: a randomized, double-blind, placebo-controlled pilot study. Nutr J. 2013 Mar;12(1):1. https://tinyurl.com/y7j52z2a
A garum armoricum Ling-fish-based food concentrate has been shown to balance adrenal function or dysregulated HPA function under stress as well as supporting the mood and sleep. This food concentrate (http://tinyurl.com/pntrrf4) contains polypeptides that act as precursors to neurotransmitters such GABA, encephalins and endorphins. I have found this support to work very well with individuals with anxiety and adrenal fatigue/stress for these reasons. They can exert a regulatory effect on the nervous system, potentially enabling the organism to adapt to stressful conditions. It also contains the essential omega-3 fatty acids, DHA and EPA. These are precursors of the prostaglandins and prostacyclins, cellular chemical mediators which help regulate the main biological functions of the body, including the noradrenergic functions of the central nervous system.
An acronym we were taught to remember when considering what might promote reflux is C.R.A.P. The letter C refers to Coffee, Cigarettes, Chocolate, Corticosteroids; R refers to Refined carbohydrates and Rx (prescriptions) that relax LES (anticholinergics, calcium channel blockers, beta-agonists for asthma); A refers to Acidic foods, Alcohol, Allergic foods, Aspirin (NSAIDS); and finally the letter P refers to Pop (soda), Peppermint, Packing in food at bedtime, and Progesterone (pregnant women). Do run through this list to consider if there are any which stand out as items which may be an issue for him.
Allergic foods (also food sensitivities) are part of the considerations for the letter A. I have seen many individuals in my practice have significantly improved reflux by elimination of food sensitivities as indicated by an IgG food sensitivity test – http://tinyurl.com/lnxe5cr. More extensive food sensitivity testing options are also available through companies such as Cyrex Labs – http://tinyurl.com/opd3u74 and Genova Diagnostics – http://tinyurl.com/qgnkd7w. Food sensitivities such as this are different from actual food allergies, which it sounds like he has been tested for already.
Food sensitivity testing is often one of the first things I suggest for clients with reflux or gastritis, along with the usage of a complete digestive enzyme to support digestion of all foodstuffs which may worsen the problem especially when the reflux is severe. There are many ways that antigenic foods can lead to symptoms of reflux, but one explanation that I find to best explain physiology is that with consumption of antigenic foods that the body is reactive to the intestinal motility is altered, and this may create a reflux of the things back into the stomach and upwards.
Another issue which may present with symptoms of reflux is small intestinal bacterial overgrowth (SIBO). SIBO can be assessed for with a breath test through Regenerus Labs (codes which cover SIBO are CMI26 and CMI27), and they can be contacted at http://www.regeneruslabs.com or by email on email@example.com or tel +44 (0)333 9000 979. Biolab in London also offer a breath test for SIBO and can be contacted at http://www.biolab.co.uk or tel 020 7636 5959 / 5905.
Breaking food down to amino acid constituents, thereby decreasing antigenicity, via digestive enzymes and other digestive support will help to decrease reactivity and promote appropriate mechanisms to restore barriers and functionality in the gut. I have seen the use of supplements including digestive enzymes help to resolve reflux at times as well. As the mucosal boundary is where many of the pancreatic enzymes are activated, when it is damaged it can lead to poor breakdown of food substances, further contributing to symptoms and inflammation.
You may want to incorporate other agents which support the gastric mucosa integrity both at a cellular level and to support the mucosal barrier. Some considerations include hydrolysed collagen, L-glutamine, aloe vera juice, saccharomyces boulardii, and slippery elm. However, if SIBO is a significant issue you may find that slippery elm and other things which are high in polysaccharides are not very well tolerated and lead to an increase in bloating.
Epithelial Growth Factor (EGF) is a polypeptide that stimulates growth and repair of epithelial tissue such as the oral mucosa and gastrointestinal epithelium. EGF is a normal constituent of saliva production during the act of eating, is also secreted into the gut lumen and found in colostrum and milk. Salivary EGF also upregulates small intestinal absorption of electrolytes and nutrients. Michael Ash has written more about the use of epithelial growth factor in the resource “Epithelial Growth Factor for Reduced Gut Permeability / Pathogen Attachment and Nutrient Uptake” which can be found here – http://tinyurl.com/qf2qbr6. Glutamine has been shown to support integrity of intestinal permeability, as well as slippery elm powder, and N-Acetyl-D-Glucosamine.
Anxiety can dramatically impact gastrointestinal symptoms and vice versa. Chamomile and fennel are herbs that I often recommend to clients who tend to run at higher stress levels, and have digestive symptoms of nervous dyspepsia and/or poor digestion. Lemon balm also is an excellent nervine with digestive properties. Finding a quality chamomile and brewing a very strong tea or making a tincture for use before and/or after meals will support her normal stomach acid secretion as it is a mildly bitter herb. In addition to their anti-spasmodic effects, chamomile, fennel, and lemon balm all also help to reduce anxiety. Each of these can be used as teas which generally is the best approach for sensitive patients with gastric upset.
A hiatal hernia adjustment can be helpful to reduce symptoms of acid reflux as well. A hiatal hernia is an outpouching of the stomach above the diaphragm. Symptoms of acid reflux are common with a hiatal hernia. A hiatal hernia adjustment can be performed by applying pressure and pulling distally on the epigastric region, drawing the stomach and viscera distally. I perform this type of adjustment in my practice on individuals with symptoms of acid reflux often, and was trained in my schooling to do this. You may wish to recommend that your client finds an individual trained in this manipulation or if you are comfortable either do it yourself or recommend that your client request a partner or close friend to do so. She also may perform this manipulation on herself although I do find that it is more effective if someone trained does so. A video demonstrating this type of self-massage can be found here – http://tinyurl.com/olwd3po.
There are several other questions on the Clinical Education group pertaining to the topic of heartburn, reflux, and GERD which you may find useful. To look for these simply use the Search function at the top right of the page when you are within the group and query any of these topic words. Here are links to a few of those responses for you:
http://tinyurl.com/paux9sk – 68 yr old on PPIs wishing to come off them
http://tinyurl.com/m8yz5v5 – 83 yr old on PPIs & reference to the Tuesday Minute on the subject of GERD.
http://tinyurl.com/puk3z5l – 43 yr old with GERD and on PPIs
http://tinyurl.com/za2wppd 22yo female reflux relaxed oesophagul sphincter – long term solutions?
Because anxiety, depression, and panic attacks can be related to many, many things, I strongly encourage patients who are struggling with these issues to also seek the support of a therapist as nutritional strategies only address one part of the picture.
The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
Intenzyme Forte™ (BRC): 1 with breakfast & 1-2 with lunch & dinner. http://tinyurl.com/ndqfvak Digestive enzymes without additional HCl.
Full Spectrum Digest (ARG): 1 – 2 capsules shortly before meals. http://tinyurl.com/p4p65vh
Sano-Gastril® (ARG): 1 to 3 tablets chewed or sucked, between meals, or as needed. http://tinyurl.com/37deycf Helps to neutralise excess acid without raising the stomach pH excessively and stimulates gastric mucus secretion.
Teas: Fennel, chamomile, and lemon balm as needed to support reduction of digestive pain, reflux, and anxiety.
NT Factor ATP Lipids (ARG): ¼ – ½ teaspoon two times daily. http://tinyurl.com/n7b7sap Phospholipid combination that supports cellular membrane and mitochondrial repair, and has been studied in settings of fatigue.
Micro Liposomal Vitamin C (ARG): 1 tsp twice daily. Provides highly absorbed vitamin C with phospholipids for cellular membrane repair. https://tinyurl.com/create.php
Bio-3B-G (BRC): 1-2 tabs with each meal http://tinyurl.com/ose948a Active B vitamin formula designed to support the nervous system.
Stabilium 200 (ARG): 4 gel caps daily away from food, possible gradually decreasing after 1 month. http://tinyurl.com/3x35v63 Garum armoricum which supports improved resilience to physical and emotional stress.
Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
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