| PDF (Download) | FatigueHyperthyroidIntegrative Medicine | | Date: December 30, 2005 | HC# 090556-295 |
Re: An Integrative Medicine Case Study of a Woman with Fatigue
Little A, Nielsen A, Lee R, Kligler B . Case study in integrative medicine: Hannah T Explore. May 2005;1(3):194-197.
Four practitioners at the Continuum Center for Health and Healing at Beth Israel Medical Center (New York, NY) each discuss their analysis of and contribution to the care of Hannah T., a middle-aged, perimenopausal woman with symptoms of fatigue, recurring minor infections, facial rosacea, and mild depression. She had been previously diagnosed with subclinical hypothyroidism and was taking a low dose of thyroid; while this had somewhat ameliorated her fatigue, her energy level was still low when she sought treatment from the multidisciplinary team. Hannah had a satisfactory marriage but low libido, had one child, and was a professional potter but was not working, citing lack of time.
Little, Assistant Professor of psychiatry at Albert Einstein College of Medicine, discusses Hannah's situation, in which nothing is significantly wrong, but many things are slightly wrong. 'The working diagnosis – fatigue – is one of exclusion.' She first recommends examining 'core beliefs' which may impede improvement, e.g., that one 'cannot get well.' Apparently finding no such barrier in Hannah, Little recommends physical activity to wake up the patient from a state of emotional passivity. She sees the recurring flare ups of minor infection and rosacea as 'intense reaction with no place to go'; that is, blocked creative or generative energy. The over-reaction of inflammation contrasts with the 'under-reactivity' of the patient's behavior. A spiritually based therapy, Little writes, 'could help (Hannah) reengage with what inspires her most deeply; it could fire up her artistic passions and give her a healthier, more creative channel for energy and expression.'
Kligler, a medical doctor and an Assistant Professor of Family Medicine at the Albert Einstein College of Medicine, while noting that this case 'is quite complex – an intersection between possible thyroid dysfunction, perimenopause, depression, and functional fatigue,' focuses on use of thyroid hormone. 'The treatment of hypothyroid symptoms in the context of normal laboratory indicators...has been called...treatment of 'subclinical' hypothyroidism. In fact, the presence of symptoms makes 'subclinical' not the correct label.' Kligler suggests that a more appropriate label would be 'laboratory-euthyroid hypothyroid state,' and that current tests are 'not accurate enough to detect dysfunction either in conversion of T4 to T3 or in the more subtle dimensions of thyroid-related intracellular signaling.' As long as thyroid function remains within normal parameters, use of thyroid hormone for fatigue, dry skin, constipation, etc., 'does not seem to pose any risks.' Since Hannah had benefited from the treatment, her dose (15 mg daily) was continued.
Lee, Medical Director, Visiting Assistant Professor of Clinical Medicine at the University of Arizona Health Sciences and a leading practitioner of integrative medicine, writing from the standpoint of functional medicine, sees Hannah's condition as synergistic rather than related to a single system. Gut dysbosis ('leaky gut syndrome') may be the root of the imbalance, due to the history of antibiotic use without replenishing 'good' microflora. The 'good microflora' are those that optimize absorption and digestion within the intestinal tract. Gut dysbosis can stimulate antigens in the liver and gut activated lymphatic system (GALT), increasing inflammatory cytokine production and, in turn, systemic inflammation. Hannah's early symptoms of menopause may be worsened by dysbosis. Estrogen is excreted in liver and bile after conjugation in the liver. In a dysbotic gut, 'bad' flora uncleave the excretory estrogen product, allowing reabsorption. Thus, an increase in the toxic forms of estrogen (16- hydroxyestrone as opposed to 2 hydroxyestrone) may circulate at higher levels, leading to moodiness, vaginal dryness, misdiagnosed as infection, and low libido. For Hannah, Lee's strategy included daily supplements of acidophilus, green tea (Camellia sinensis) extracts, glutamine, and, alternately, fish oil and flax (Linum usitatissimum) seed meal; increased intake of foods containing indole-3-carbinol (e.g., broccoli [Brassica oleracea v. italicaca]); and fewer high glycemic index foods. In making dietary changes such as these, changes in clinical markers may not be seen for up to two months.
Nielsen, who teaches at Tristate College of Acupuncture as a Professor of East-Asian medicine, writes from the standpoint of East Asian Medicine (EAM). EAM does not view the thyroid in the same way as Western medicine. Functions of the thyroid in Western medicine are seen in EAM as involving several organs and channels. 'In Hannah's case, the thyroid was the branch, not the root, of her problem.' Like Lee, Nielsen's attention was drawn by the repeated use of antibiotics, 'considered 'cold' medicines that can damage the stomach and spleen, interfering with digestion and absorption.' Interestingly, while the patient is described as 'slim' in the case description, Nielsen finds her 'noticeably underweight' with signs of blood deficiency (pale skin, pale tongue, slight menses). 'Errant heat' is also part of her diagnosis, 'manifested as...chronic fungal leukorrhea (yeast [Candida albicans] infection) and constipation and heat in the stomach and lung channels, congesting at the face.' Errant heat accords well with Little's diagnosis of blocked energy leading to inflammation. Nielsen agrees with Little that Hannah's 'generativity' is deficient, and, like Lee, relates this to gut dysbosis: 'The aphorism in EAM...is 'earth feeds all'; in clinical terms...digestion is central to well-being.' Nielsen used acupuncture, unspecified herbs, diet, and 'other recommendations' to restore Hannah's digestion. She particularly discouraged the use of coffee (Caffea arabica). '[C]affeine fatigues people who are already tired. Coffee, even decaffeinated, depletes the Qi [energy or vital force] and can create errant heat in the form of flushing.' Hannah usually ate a lot of bread, and Nielsen eliminated it from her diet, echoing Lee's desire to reduce the glycemic index of Hanna's food choices, but for a different reason: reduction of constipation. Also, 'In many patients, there is a relationship between gluten sensitivity and failing thyroid, and this may explain part of the benefit' of eliminating bread.
Hannah responded well to the multidisciplinary approach. Her various conditions attributed to inflammation cleared and she was no longer constipated. She began to try for another pregnancy before menopause advanced, indicating increased energy and libido. She decided to discontinue thyroid hormone treatment because she considered it unnecessary.
The authors write that there are many ways in which Hannah T.'s problems could have been resolved, but hope that their choices, guided by her wishes, may illuminate how 'diverse voices of the various healing arts...can come together...to offer an approach to treatment much more powerful than that which any...can provide' singly; in this they have succeeded admirably.
— Mariann Garner-Wizard |