Thyroid & Fertility: The Intricate Connection Unveiled

Dr. Amie Hornaman

We have to start with the thyroid being the master gland, and that pretty much runs the show of the body. From your metabolism to the regulation of other hormones, the regulation of your blood sugar, and even dictate whether or not you go to the bathroom every day, it comes back to thyroid function. If we’re dealing with a thyroid gland that isn’t working, maybe it’s under attack, it’s sluggish, or it’s hypo-low and slow. That’s going to have that downstream effect on sex hormones, progesterone, estrogen, and testosterone. then, we can throw in DHEA, pregnenolone, and all the sex hormones in the mix. When the thyroid is off, we start seeing this dysregulation of the sex hormones, whereas in very young women, we might see a drop in progesterone where she looks like she’s headed into perimenopause or menopause.

Progesterone is very important for fertility. We might see this estrogen dominance state or a low or high testosterone state, all of which. You’ve had other guests on here talking about hormones. All of those sex hormones are important for fertility. When the thyroid is off hypo when it’s just not working, we’ll see sex hormone dysregulation. The other thing is the actual ability to get pregnant, and the development of the fetus is very much dependent on thyroid hormones, specifically T4. But we have to bring in T3, which is the active thyroid hormone as well. What we’ll see when a woman is, let’s say, undiagnosed with hypo and she’s had three, four, or five miscarriages, or she’s just struggling with fertility. We see that on both ends, the actual fertility aspect and then the holding of the pregnancy aspect that we see just thrown off. It’s a frustrating struggle for the woman, and it’s coming back to the thyroid. It’s like, if we just optimize the thyroid, get her out of that hypo, and calm down the inflammation of the thyroid during the autoimmune attack that was going on. All systems would start to work together. That was like three answers in one, but it comes back to the thyroid gland being the master gland and having such control over the body.

Aumatma Simmons, ND, FABNE, MS

It has so many interconnections with all the different functions that then impact the sex hormones for fertility in general, the ovaries, as well as pregnancy outcomes. Thank you for sharing that stage for a big overview. Why do so many women get told that their thyroid is normal? I’m putting this in quotes because what is wrong with it?

Dr. Amie Hornaman

You and I have seen so much of this. A woman comes in; she’s, like I said earlier, struggling with fertility—maybe a couple of miscarriages. But my doctor tested my thyroid and told me that I was normal. Then we say, Okay, let’s see those tests. She breaks out a TSH Thyroid-Stimulating Hormone, and it’s within normal limits. Yes, she is correct that TSH is normal. But here’s the problem that does not tell us the whole picture of the thyroid. TSH is a pituitary hormone and is not a thyroid hormone. We have to go deeper and look at free T3. Free T3 is the active thyroid thyroid hormone. It helps to say that T3 is your gas. That’s what gets to the cell, turns on the cell, connects with the cell, and gives you metabolism, blood sugar regulation, sex hormone regulation, and fertility. We have to measure that active thyroid hormone-free T3. We also want to look at free T4. Now T4 is inactive. It’s an inactive thyroid hormone, but it’s the most abundant thyroid hormone that your thyroid gland produces. We want to look at how much of that inactive thyroid hormone you have in your body. Is that adequate? And then we want to look at reverse T3, which is that’s the brakes.  Essentially, reverse T3 is a beautiful thing. It was built into our bodies to protect us. It’s a survival mechanism. If you are in a state of crisis or trauma, you’re in the ICU or ER. The reverse T3 will go up to say that this person doesn’t need to get pregnant, burn fat, or feel good; they just need to survive. But what if that reverse T3 is high when you’re walking around trying to live life, when you’re trying to go to work and take the kids to school and get pregnant, or when you get pregnant again?

We don’t want that reverse T3 elevated because it’s putting your body in survival mode. There are very important tests to look at, and then, of course, we want to see if you have Hashimoto’s; that’s going to be the TPO and the TG antibodies. We want to see if you have autoimmune hypothyroidism, where your body just attacks the thyroid gland. It thinks that it’s an invader; it thinks it’s a bad guy. Your body’s just confused, and it goes out and attacks your thyroid gland. Now that it’s being attacked, it’s not going to work at the top levels; it’s not going to be working at 100%. It’s getting attacked every day. That’s going to play a role in low thyroid hormones as well. We want to check everything. That’s the big problem when women come to us and they’re like, I was told my thyroid is normal. I’m fine. Are you, or aren’t you? We don’t know unless all of those tests are done.

Aumatma Simmons, ND, FABNE, MS

What are all of the tests? Almost every doctor tests TSH. But then T3, T4, free T3, free T4, TPO, and TGA are the antibodies to the thyroid. How frequently do you? I forgot the reverse T3, which is super important. How important are TSI antibodies? How often do you see those elevated? The whole hypothyroid situation, how often do you see that happening?

Dr. Amie Hornaman

It’s much more rare. We see way more Hashimoto’s and low hypothyroid function than we see hyper. Normally when I’m with a patient who has a Grave disease. That is the opposite of Hashimoto’s. With Hashimoto’s, we have the destruction of the thyroid gland and the downregulation, like not enough thyroid hormone being produced. That’s where we’ll see that all those low and slow symptoms—low gut motility, low metabolism, low mood, low brain function—the other side is Grave. That’s where we will test the TSI antibodies, and that’s hyper because that’s where you’re losing weight and you can’t sleep. If you’ve ever seen anyone with thyroid eye disease, they have those bulging eyes. That’s Graves disease. Now what I see is the pendulum swing. I’ll see women who might be graves for a hot minute, but their symptoms are all that of being hypo. They’re like, Wait a minute, I’m not losing weight. I’m getting away. I can’t go to the bathroom every day. I can’t get pregnant. I can’t think. I can’t. They’re swinging to the other side, going into Hashi. In that case, we just have to look at that person as an individual and see the whole picture. But it is interesting when you test TSI especially if someone has any or, in the past, has any hypersymptom, we want to check that.

Aumatma Simmons, ND, FABNE, MS

That is like flexing between hyper-hypo, and hyper-hypo. What’s your assessment of what’s happening to those women?

Dr. Amie Hornaman

Until all autoimmune, so we know with autoimmune there’s that genetic predisposition, there’s leaky gut involved, and there’s a trigger, a stressor. What woman isn’t under stress now? You’re under some stress, and hormonal fluctuations equal stress. Normally, post-pregnancy is when we’ll see a lot of autoimmune conditions come up and turn on because that pregnancy, albeit natural and something you want to go through, is a huge stressor on the body. As women, we tend to forget that because it’s just something that’s built into us. As biological beings, we’re built to reproduce. But it’s such a huge stressor on the body because of the hormone fluctuations that occur. Maybe you’re trying IVF, maybe you’re trying hormones for fertility, maybe you’re trying all these different things, or even just trying, period, to get pregnant. That’s a stressor. That’s where we’ll see huge fluctuations in autoimmune conditions come up. We’ll call it an autoimmune flare or that autoimmune gets activated. That’s where we’ll see someone who does have both sets of antibodies, the TSI and the TFO and TGA  swing back and forth where they might experience a few hyper-symptoms like they’re not sleeping well. They’re more anxious than depressed, yet they still have all of these symptoms over here that they’re complaining about.

Aumatma Simmons, ND, FABNE, MS

In terms of supporting women with hypo, hyper, the fluctuations,  what strategies do you find most useful in helping women have better thyroid function?

Dr. Amie Hornaman

At the end of the day, it doesn’t matter whether you have Hashimoto’s or not, graves, or if you’re just deemed hypo, or if you’re looking at your numbers and you’re like, wait a minute, these are a little bit low, even though they’re in the normal range. First and foremost, across the board, we have to take down inflammation, and this is so cliche. You’ve probably heard many interviews that practitioners talk about inflammation to the point where you’re like, here we go again, more inflammatory talk. But if you think about it, when the body is in that inflamed state, number one, you’re going to get more destruction of the thyroid gland. Let’s take Hashimoto’s, for example. I love using analogies for people to understand. You have these little soldiers and those soldiers. Like I said earlier, you are confused. They go out, and they attack your thyroid. Now, whenever the body is in this inflamed state, when you think of inflammation, you think of high alert.  We’re at war. Those soldiers go out, and they beat up your thyroid gland even more. It’s like two attacks a day. Let’s bring in some new troops. Let’s send them all out at once. This is war; when you’re in that inflamed state, your body can’t heal. Not only can at night heal, but it’s going to get worse, and the whole situation gets worse. What we end up seeing from that inflammation is more destruction of the thyroid gland and fewer thyroid hormones being produced.

Those are going down the toilet. We’re just not having enough T3 and T4 in the mix. The person is suffering because they don’t have those thyroid hormones on board. They can’t get pregnant. Among a list of all these other symptoms, If we can take down that inflammation now, how do we do that? The best and my favorite supplement for autoimmune disease is black cumin seed oil. Black cumin is when you look at the studies, it’s so amazing. Reducing antibodies and lowering inflammation even helps improve insulin resistance, which would be my heart too, of what causes inflammation. You walk around with high insulin and high blood glucose all the time because you’re eating the standard American diet. You’re eating too much sugar; you’re eating processed food and eating garbage. You are going to be inflamed. That insulin, that high insulin, insulin resistance, high glucose, whatever you want to call it or whatever bucket you want to put it in—is causing a ton of inflammation in your body. that alone can trigger the autoimmune attack, not to even mention the gluten, which we know gluten, and again,  here’s another eye roll from the audience. I get it. You’ve heard over and over again to go gluten-free. You’ve either said I can’t go gluten-free because it’s too overwhelming which I call B.S.. After all, there are plenty of gluten-free alternatives out there.

They’re everywhere. Not that they’re the best, but they’re good stepping stones. They’re a nice little crutch for those transitioning to gluten-free. But you have to know why. I’ll either be here. Yes, it’s too hard. I can’t do it, or I just don’t know why I’m doing it. There’s not enough motivation to continue being gluten-free. They’ll say, I’m not celiac, so why am I doing this? Here’s why that gluten molecule looks like your thyroid gland, so it’s no different from soldiers at war. The enemy comes in, and the enemy colors, and they go, enemies are coming in. We had to go to war. We had to go out. We got to fight. We got to battle. Same thing. When you eat gluten, your body thinks that because it looks like the thyroid gland in molecular structure, the enemy is coming in. It’s time for war. It goes out. Again, you get that further destruction of your thyroid gland when you eat gluten. It’s also causing a lot of inflammation. We have that whole tie-in together with the gluten in the processes, the inflammatory foods, high insulin levels, and high glucose levels, just making the whole situation worse. that those simple steps of lowering the inflammation, going gluten-free, doing all the things, get your insulin under control. That’s enough to calm the system down and let the body heal. Now, that’s not to say you might; we can’t say that’s all you need. Maybe you do need some intervention—thyroid hormone replacement, whatever. That’s the first step. That’s a huge step to take.

Aumatma Simmons, ND, FABNE, MS

I love the starting point of very simple things that people can do if they know that they have thyroid issues, or even if they don’t know they have thyroid issues. You have all the symptoms. Your doctor says your thyroid is normal. You can still try to get rid of gluten from your diet and see if your symptoms improve, though you don’t need a diagnosed thyroid condition to make some of these changes.

Dr. Amie Hornaman

You don’t.

Aumatma Simmons, ND, FABNE, MS

Why is it so important for women to pursue and receive appropriate treatment before conceiving through pregnancy and postpartum?

Dr. Amie Hornaman

I’m very passionate about this, and I’ll get into why. First of all, preconception, the ability to get pregnant, to improve your chances of fertility, and to improve your fertility overall, are dependent on proper thyroid hormone balance. When we’re looking at those numbers, if we’re seeing a couple of numbers that are subclinical or low in thyroid function, especially in the functional medicine world, because remember, we’re looking at you from an optimal oil standpoint, We’re not going by those standard lab value ranges that are in your labs. You could go out; you could get all the labs done that we just talked about today. You can look at whether or not it’s black and red, or whether there’s an H-urinal next to it. You might look at it and say, “I’m normal” because you fall within those normal limits. The first thing to mention is that we want you to be optimal. As we’re looking at your labs from an optimal standpoint, we want to get those thyroid hormones into the optimal ranges because that’s where your body is going to function the best, and that’s going to give you the best chance at conception. Hands down. Without it, that’s where we see the multiple miscarriages.

That’s where we have these patients that come in. They’re like, I’ve had two, three, four, or five. We don’t want that. We don’t want anyone to go through that. The stress of that is enough to kick up inflammation as well. It just takes a toll. It’s so, so hard on women. Let’s balance out the thyroid hormones before conception and improve fertility overall. Then, as we get pregnant, you’re carrying the baby. The baby is developing. This is where my story comes in. My stepson is 11, nonverbal, and autistic. When I look at Mom, I see the thyroid and the thickened neck. I see the weight fluctuations. She had trouble conceiving. She had multiple miscarriages. They went to a fertility specialist. They went to a genetics specialist. There’s already something going on with her body. Now, I don’t know what they looked at or what they didn’t look at, but I just see that the baby’s brain development depends on proper thyroid hormone balance. Specifically, this is where T3 comes into play a little bit more. This is where iodine comes from; that’s why a good prenatal always has a little bit of iodine in it.

Aumatma Simmons, ND, FABNE, MS

I’m going to ask you a couple of questions about that. I’ve heard a lot of OB-GYNs say you only need T4 in pregnancy because T3 doesn’t cross the placental barrier. What are your thoughts on that?

Dr. Amie Hornaman

Here’s the thing: We have to look at Mom and remember that reverse T3 that we talked about at the beginning. It’s also important to note that T4 is inactive. It has to convert over to become the active thyroid hormone, T3 In that conversion process, if you picture it, it is like two roads—two roads to choose to go down. We hope that T4 chooses the path you convert over into T3. That’s good. If it chooses the other path, it’s going to convert into reverse T3 and put your body into survival mode. The problem with just giving a woman T4 and not testing her reverse T3 is that you could be putting her body into survival mode.

If she’s not getting enough of the thyroid hormone, there’s no way that the baby is going to develop properly because her body is in shutdown. That I would say, while we do weigh a little bit heavier on the T4 therapy during pregnancy, we still have to be testing all the tests. We still have to be looking at the mom’s free T3 level, and you don’t want to overdose her with T3. We’re not trying to make mom hyper and then have issues with the pregnancy, but you want her to be optimal. It’s the whole picture of getting all the hormones optimal and then the body. Our bodies are so smart that they will know what to do with the developing fetus. It will give the baby what it needs to develop adequately. But if mom doesn’t, if mom’s not optimal, how can the baby be optimal?

Aumatma Simmons, ND, FABNE, MS

That’s a beautiful explanation because I feel like all too often women are getting these messages that are so different from the functional medicine world. I appreciate that insight. Another question that came up for me is the iodine story. There is a lot of debate in the thyroid world about iodine. Let’s just focus on it, specifically pregnancy, because it’s a crucial time when iodine is a necessity. Is there an optimal dose of iodine that women should be getting? Is there such a thing as too much iodine during pregnancy? Are there symptoms from either too much or too little?

Dr. Amie Hornaman

Iodine here, just like you said, is a huge controversy. You can find that 50% of the functional medicine community says no to iodine if you have Hashimoto’s or have a thyroid problem, and the other 50% recognize that it’s beneficial. We have to find a happy ground, so I’m all for it. As a proponent of iodine, I believe that it’s very beneficial to the body, as we mentioned to the baby’s developing brain. When you look at the studies of iodine and fetal development, it’s huge. That is why every prenatal, like a good prenatal hospital, has iodine in it. That’s what I like to call it, dose-wise. If I just had a regular high hypothyroid patient, she’d be in perimenopause or menopause and not worry about getting pregnant. None of that we can increase her iodine just to bring down the reverse T3, to improve thyroid function, to help with her energy, to help with hair loss, fibrocystic breast, and all of that. But with a pregnant woman, I’m going to stick with the iodine that is in the prenatal. Now, how will she know if she’s getting too much or too little?

You can’t tell about the two little ones. You’re not going to notice that, like, I’m not getting enough iodine. Like you would like vitamin D, like, I’m sluggish and I have brain fog, and maybe you’re low in vitamin D. You’re not going to notice that with iodine, but you are going to notice that if you get too much, you will feel hyper. I’ve had some patients take too much, and they’re reporting they’re like, my heart rate’s a little bit increased. I’m sweating all of a sudden. I didn’t sleep last night, but it’s an easy fix. You back off, you listen to your body, and you back off. Take a couple of days off from it, let it clear your system, and then add it back in at a lower dose, more slowly, just to assess your tolerance. But iodine is so fantastic at binding. It’s detoxifying, and it binds to the halides that are toxic to your thyroid. Chlorine and fluoride helps excrete those out of the body, so you can see why it’s so imperative for all of us. But especially during pregnancy and during fetal development.

Aumatma Simmons, ND, FABNE, MS

Thank you. That’s good wisdom. Let’s talk about thyroid health specifically in the postpartum period. You hinted at this earlier when you said a lot of women during pregnancy will develop this autoimmune scenario. According to what I’ve seen, it rarely gets caught in my eyes until after the baby is born. During pregnancy, they’re like, You’re fine; you’re fine; it’s fine. Then postpartum is where we start to see not only the dysfunction in the hormones but also all of the symptoms. I’m curious what you think is happening from that pregnancy to the postpartum period, where there are just a lot more possibilities of autoimmune thyroid conditions popping up, and I feel like a lot of women or even postpartum women ignore the thyroid because they’re like, It’s postpartum, you’re not sleepy. That must be what it is. The reality is that you have a major gland that’s just not functioning anymore.

Dr. Amie Hornaman

Many women get the tag of postpartum thyroiditis, which I say is called Hashimoto’s. Postpartum is just another way of saying, that after you gave birth, your thyroid crapped the bed and isn’t working very well, but why? We have to go back, and we have to look. We have to test everything that we just talked about. We have to check to see if Hashimoto’s did turn on because pregnancy, perimenopause, and menopause are the three big times in a woman’s life when she will notice autoimmune conditions turning on. It’s like the little switch that flips for the opposition. Pregnancy is a big one. As we said earlier, it’s a huge stressor on the body.

Those hormonal fluctuations that occur are a huge stressor on the body. If you get the diagnosis of postpartum thyroiditis, please make sure that you’re testing your TPO and TGA antibodies, because those may have been raised; they’re now being flagged high and you have Hashimoto’s. In my world too, I like those antibodies at zero. Any antibody is a soldier. It’s a soldier that’s attacking your thyroid. My argument is, okay, this time of testing, you have 20 soldiers, but they’re not flagged yet because the standard lab value range goes up to 40. but you still have 20 soldiers. Are we going to wait until you’re 20 pounds heavier, miserable, can’t take care of your baby because you can’t get out of bed, and can’t even think straight, which is part of pregnancy? Postpartum anyway, like you said, like you’re already dealing with all of these symptoms that just come after pregnancy. Now you add on low thyroid function, and those symptoms become toxic, which now becomes unbearable. Why don’t we catch that early on and start with intervention and treatment so that the woman can regain her life a little bit, like being able to take care of herself and her baby to the utmost that she possibly can? Fighting through the sleepless nights and all of the things that come with it.  We can still at least empower her and her body to be more resilient and stronger to make it through that post-pregnancy stay. It’s important to test and treat early.

Aumatma Simmons, ND, FABNE, MS

I agree wholeheartedly. That all too often the women are being told you’re fine, it’s normal, not a big deal, but it ends up being a big deal. To your point, we don’t need to wait till it’s a big deal; let’s deal with it now so that it doesn’t become a problem in the future when it’s going to be a lot harder to treat and a lot harder to turn around. Thank you so much for being with us and for all the wisdom that you shared today. Where can people connect with you?

Dr. Amie Hornaman

You can listen to my podcast, The Thyroid Fixer podcast, on all podcast platforms. Dr. A was a guest on mine as well. You’ll also find I do have an episode in there that speaks specifically to postpartum thyroiditis being Hashimoto’s. You can dive into that a little bit. Then all social media I’m on is Dr. Amie Hornaman, and you can go to my website, dramiehornaman.com, as well.

Aumatma Simmons, ND, FABNE, MS

Love it. Thank you. Thanks for being part of the Beyond Infertility Summit. We’re honored to have you. For those of you listening, we’ll see you again very soon.