An overview of thyroid diseases
The thyroid is an endocrine gland situated in the neck at the level of the cricoid cartilage at the base of the larynx and extending from the level of the fifth cervical vertebra down to the first thoracic. It is butterfly shaped with 2 elongated lateral lobes with superior and inferior poles connected by a median isthmus. The gland contains two hormones, L-thyroxine (tetraiodothyronine, T4) and L-triiodothyronine (T3). Affecting between one and two percent of the population worldwide, thyroid disease is among the most common endocrine disorders. Thyroid disorders and thyroid cancer disproportionately affect women.
Thyroid disorders may at first appear quite simple as they consist either of excess production of T3 and T4 (hyperthyroidism/thyrotoxicosis) or insufficient production (hypothyroidism). Hyperthyroidism is a vata or vata-pitta disorder with symptoms that include fine tremor, weight loss, loose stools, insomnia, anxiety, heat sensitivity and a sensation of being "tired from the neck down." The main diseases that relate to hyperthyroidism are toxic nodular goitre and Grave's disease. Goitre, exophthalmos or bulging eyes and pretibial myxedema (a diffuse, non-pitting oedema and thickening of the skin on the anterior aspect of the lower legs) are characteristic of Grave's disease. Hypothyroidism is a disorder of vata, kapha and medas. Symptoms of hypothyroisism include weight gain, sluggishness, constipation, cold sensitivity and impaired short term memory. Hypothyroid disorders include Hashimoto's thyroiditis, silent thyroiditis and post partum thyroiditis. Hashimoto's is a painless, diffuse enlargement of the thyroid gland which typically occurs in a young or middle-aged woman. In silent (painless) thyroiditis there is an initial thyrotoxic phase, which later swings into hypothyroidism and, finally, a return to euthyroidism. Post-partum throiditis is silent thyroiditis occurring in the first six moths after delivery. This condition affects from 3-8% of all deliveries and disproportionately affects women with insulin dependent diabetes (1, 2). Goitre, or enlarged thyroid, is described in Charak as galagraha, a kapha condition (3).
Auto-immunity and the thyroid
The reason thyroid disorders are not so simple as they at first appear is that all the conditions mentioned above are basically auto-immune. Thus ultimately there is one thyroid disease--auto-immune thyroid disease (AITD)--manifesting in a variety of overlapping syndromes. The same patient can be thyrotoxic at some points in the course of their illness and hypothyroid at other points. AITD is an example of organ-specific auto-immune disease and relates to khavaigunya in the thyroid gland that is genetically based. Hashimoto's thyroiditis and hypothyroidism may occur together with other auto-immune endocrine disorders--Addison's disease, diabetes mellitus, hypogonadism, hypopara-thyroidism, and pernicious anemia. This is described as polyglandular failure syndrome. There is also an increased incidence of auto-immune connective tissue disorders including Sjogren's syndrome, (4) fibromyalgia and rheumatoid arthritis. (5) Grave's disease is associated with increased incidence of other auto-immune conditions including pernicious anemia, vitiligo, alopecia, angioedema, myasthenia gravis and idiopathic thrombocytopenic purpura and, to a lesser extent, systemic lupus erythematosus.
Dignostics and referral
Darshanam or inspection is used to evaluate the thyroid gland by noticing if there is an enlargement in the neck that moves on swallowing. The thyroid gland can then be gently palpated (sparshanam). A palpable mass that moves on swallowing is goitre. Note whether the goitre is soft and diffuse or nodular and irregular. A mass that does not move on swallowing is probably an enlarged cervical lymph node. Examination of the carotid pulse will indicate the presence of vata, pitta or kapha in the thyroid. Basal temperature is crucial in the assessment of thyroid function. If the basal temperature is consistently below 97.8F, there is a hypothyroid condition irrespective of normal blood tests. Basal temperature is determined first thing in the morning before the patient has moved and generated heat. The blood test most frequently done is TSH (thyroid stimulating hormone) a pituitary hormone that is in inverse ratio to thyroid function. Thus an elevated TSH indicates hypothyroidism and a low TSH indicates thyrotoxicosis. Although the standard reference range is 0.4 -5.0 uIU/mL, many endocrinologists accept that subclinical hypothyroidism may occur with numbers in the upper limit of the normal range. Life-threatening complications of thyroid disease include thyroid storms, atrial fibrillation and myxedema (thyroid failure). For this reason, it is wisest for the Ayurvedic practitioner to work alongside an endocrinologist. In particular, nodular goitre must be referred to exclude thyroid cancer.
Thyroid disease in Ayurvedic practice
The thyroid conditions most effectively managed by the Ayurvedic practitioner are subclinical Grave's disease and subclinical hypothyroidism. In addition, all patients with AITD should have the benefit of pancha karma and Ayurvedic diet and herbs to help improve their auto-immune status and preclude further complications such as fibromyalgia. As with all auto-immune conditions, it is essential to eliminate dietary allergens that may be increasing reactivity, gluten and dairy being the most critical. Soy is a goitrogenic food and should be eliminated in patients with goitre.
Subclinical Grave's Disease
A twenty seven year old mother of three with vata prakruti had a previous history of Grave's disease treated with methamezole. When she was pregnant with her second child, she was treated with PTU (Propylthiouracil) as this is safer during pregnancy. During this pregnancy her Grave's disease went into remission at five months. She continued in remission through the course of her third pregnancy, but when she was three months post partum she started getting an 'electrical feeling' which she knew was symptomatic of thyrotoxicosis. Her heart rate remained normal. Tests showed subclinical hyperthyroidism. Note that she shows a perfect example of overlapping syndromes. Given that she had goitre but no exophthalmos or pretibial myxedema, did she really have a recurrence of Grave's disease or had she developed post partum thyroiditis? In any case, her endocrinologist suggested that since her lab tests were subclinical, she "should try a natural approach," so she presented for Ayurvedic treatment.
As always, Ayurvedic management addresses the underlying doshic imbalance (vata and pitta) with dosha pratyanika (combats the dosha) herbs, diet and lifestyle measures. An ideal vyadhi pratyanika (combats the disease) for thyrotoxicosis is Shankhapushpi, which has been found in clinical trials to be more effective than neomercazole, an antithyroid drug (7). There is also some evidence that Tulsi may be of value in hyperthyroidism (8). Kaishore Guggulu is always recommended in auto-immune conditions, as is Amlaki. She was recommended a pitta soothing diet and yoga routine and was asked to take warm milk with Cardamom at bedtime. To pacify vata she did regular self abhyanga with Sesame oil.
It is important to note that Ashwagandha is a thyroid stimulant and is not recommended in hyperthyroid conditions. There have been two documented case reports of thyrotoxicosis following administration of Ashwagandha, one in the author's own practice (publication pending) and one published in the Netherlands (9).
Subclinical hypothyroidism is a condition where the patient is symptomatic for hypothyroidism in terms of cold sensitivity, weight gain, constipation, fatigue, headache, muscle aches, hair loss, dry skin, low libido and menstrual irregularities, yet their thyroid tests are within the normal range. Typically, TSH is at the high end of the reference range. They may have a visible goitre. They are suffering from a subclinical form of AITD. These patients often respond well to Ayurvedic management of their condition. Basal temperature can be used as an objective measure of the success of treatment.
A typical thyroid formula includes Punarnava as dosha pratyanika for kapha and good remedy for goitre, Guduchi as an immunomodulator for auto-immunity, Guggulu to improve thyroid hormone production (10) and Chitrak to kindle agni. Trim Support, which contains shilajit, traditionally used to enhance metabolic rate, as well as Punarnava, Chitrak and Guggulu, is a good supplement for subclinical hypothyroidism with weight gain. There is an intimate connection between thyroid and liver function. "The liver has an important role in thyroid hormone metabolism and the level of thyroid hormones is also important to normal hepatic function and bilirubin metabolism... thyroid diseases are frequently associated with liver injuries or biochemical test abnormalities...Liver diseases are also frequently associated with thyroid test abnormalities or dysfunctions." (11) Hence Liver Support is valuable in subclinical thyroiditis, particularly in terms of maximising conversion of T4 to the more highly active T3. (12). Asanas important for hypothyroid disease include sarvangasana and matsyasana. The mantra hrim can be used to strengthen the thyroid gland through opening the throat chakra. Although iodine is an essential nutrient for the production of thyroid hormones, practitioners should hesitate before recommending iodine supplementation or ipodine containing herbs such as bladderwrack or Irish moss. There is a body of evidence suggesting that excess iodine consumption is implicated in Hashimoto's thyroiditis (13) and that iodine restriction can be of benefit (14).
Although all patients with AITD can benefit from complementary Ayurvedic therapies, subclinical conditions can be most effectively managed by the Ayurvedic practitioner with good relief of troublesome symptoms.
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Weetman AP. Postpartum thyroiditis and insulin-dependent diabetes mellitus: an important association. J Clin Endocrinol Metab 1994;79:7-9.
Charak samhita, sutrasthana, ch xviii vs 22.
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Doerge DR, Sheehan DM Goitrogenic and estrogenic activity of soy isoflavones. Environ Health Perspect. 2002 Jun;110 Suppl 3:349-53
Gupta R. C. et al, Probable modes of action of Shankhapushpi in the management of thyrotoxicosis, Ancient Sci Life, 1,46, 1981.
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Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.
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