The Optimal Treatment for Hypothyroidism: Ron Manzanero, MD

His Approach to Treating an Underactive Thyroid

Dr. Ron Manzanero takes an integrative approach to diagnosing and treating hypothyroidism.

One of the leading experts on hormonal health, Ron Manzanero, MD, shares his approach to optimal treatment for hypothyroidism. According to Dr. Manzanero, the key is the word optimal. "I want my patients to feel optimally well. In order for this to happen there is a dance between the physician and the patient that must take place."

Dr. Manzanero feels that the doctor must have a thorough knowledge of the symptoms of hypothyroidism, the physical manifestations of hypothyroidism in the body, the optimal tests to run, and all the various therapeutic options available.

Setting Aside a Doctor's Preconceived Bias

Dr. Manzanero feels that it's important that the doctor removes all bias from his mind and not evaluate patients with preconceived notions. He lists preconceived notions including:

  • Depression needs treatment with an antidepressant drug. (Mood disorders can be a symptom of low thyroid.)
  • Synthroid is all that a hypothyroid patient needs. (Many people only feel optimal when they have some additional T3 added to their prescription. A Greek study confirmed this.)
  • All the doctor needs to evaluate a hypothyroid patient's status is the TSH test. (See below.)
  • Patients will do better on Armour Thyroid. (Sometimes people wrongly assume that "natural' thyroid is better in all cases.)
  • Armour thyroid is not standardized. (There are many unsubstantiated dogmas that are propagated in medical training.)

The Patient's Role

The patient's role in the "dance" is that he or she must learn what the many symptoms of hypothyroidism are and to know in particular their own unique signs and symptoms of low thyroid.

They should be able to report this information to the doctor.

Optimal Wellness in Hypothyroidism

Optimal wellness in hypothyroidism means the complete absence of low thyroid symptoms. Dr. Manzanero says, "The patients will feel they have high energy instead of fatigue, maximal cognitive functioning instead of memory and focus problems, a sense of happiness instead of depression/ anxiety, etc.

"As simple as this sounds, it is amazing how many physicians have forgotten this. Instead, they focus on a single thyroid test, the TSH test, and let that become their sole determining guidepost in managing low thyroid. (Again, this is a dance, a partnership, not a condition that a doctor should have to manage and order for a patient.)"

Tests for Hypothyroidism

For Dr. Manzanero, another part of the equation is the exclusion of physical exam findings and the overreliance of the TSH test. "Many times patients can have a normal TSH test and yet sit there in front of the doctor with physical signs such as, dry parchment-like skin, thinning of the outer third of the eyebrows, dry straw-like hair or thinning of the hair on the scalp and extremities, edema in the tissues, thick callus formation on the soles of the feet, or brittle splitting nails that may have longitudinal ridges present. Also, too often doctors forget to have patients monitor their body temperatures, which can reflect thyroid functioning."

According to Dr. Manzanero, a whole chapter could be written on the laboratory tests. He believes the optimal set of labs should at the very least contain the TSH, free T4, free T3, and thyroid antibodies.

Other tests could include iodine testing, immune cytokine tests (TH1/TH2) pathways, gluten gliadin antibodies, and heavy metal allergy testing. The latter three tests are important in the autoimmune hypothyroidism condition known as Hashimoto's because certain heavy metals and gluten food consumption have been linked to this autoimmune condition.

Free T3 and Free T4 Tests

Dr. Manzanero has more to say about the TSH, free T4, and free T3 thyroid tests. "I find it absurd that my medical training taught me to solely rely on the TSH. Back in the mid-1990's I learned from my patients—much to my embarrassment—about the importance of the free T3 levels.

"A few of my better-educated patients would ask me to include the T3 level in my assessments, and I frankly didn't know why. That wasn't what they taught us in med school. If T3 is the active thyroid hormone in the body, doesn't it make sense to see how much the body is converting from the inactive T4? The reason many of my patients on synthetic T4 replacement are still symptomatically hypothyroid is because they do not optimally convert the T4 into T3. Not checking the T3 level is like the President asking how many barrels of emergency gasoline the National Guard has, and getting an answer in the amount of crude oil. T4 is the crude oil while T3 is like the gasoline. Certain parts of the body will convert the T4 made in the thyroid gland, into the active form, which is T3.

"One other important thing to consider in regards to lab testing, is considering the optimal range. This concept not only applies to just thyroid testing, but to most labs tests. Many physicians simply do not realize that the standard normal ranges are often determined from samplings of sick people. I've done my own in-house observations of optimally fit people and found their TSH levels to be around 1.0 to 2.2. (The free T4 around 1.10 to 1.35, and the free T3 around 3.1 to 3.8.) All of these ranges are well within the so-called 'normal' ranges. Many of the progressive thyroid doctors may have some variations, but we all understand that the current test ranges are substandard."

TSH Test

Dr. Manzanero also finds the reliability of the TSH test to be problematic. "We 'believe' that the test result is correct. However, what about fluctuations in the level, or poor lab calibration? I have found many cases where TSH levels from one day to the next were widely off. I have tested my own blood TSH samples drawn on the same day with three different labs, and had ranges that varied enough to cause concern."

Hormone Interactions

Dr. Manzanero feels that in the end, the thyroid cannot be optimally understood in isolation from other hormone interactions. He is particularly interested in adrenal cortisol levels. One of his mentors, Dr. Datis Kharrazian, has a teaching approach that Dr. Manzanero especially admires, because it demonstrates the complex orchestral arrangement and interactions of all our hormones, foods, gut pathology, and emotional stresses. He also feels that genetics and xenobiotic pollutants that accumulate in our bodies have an impact on thyroid hormone production and/or activity.

Dr. Manzanero has said that some patients do not want to be on hormone therapy. While he recognizes that this is not always feasible, he does his best to look for underlying causes of low thyroid and tries to correct any nutritional deficiencies or imbalances that are in the way of optimal thyroid functioning. When he goes the route of thyroid replacement therapy, he believes in giving the patients as many options possible that get them to optimal functioning. According to Dr. Manzanero:

"I have some patients who feel optimal on Synthroid. In that case, it is not my role to interfere and add in Cytomel (synthetic T3) or switch them to Armour thyroid/ I have found these rare individuals are able to optimally convert the synthetic T4 to T3. Others will need to go on a combination of synthetic T4 with Cytomel, while many do best by going on Armour or Nature-throid (standardized combinations of porcine derived T4 and T3). On some occasions, I may also use individualized combinations of T4 and T3 that have to be compounded."

Helping People Regain Optimal Health

Dr. Manzanero believes that as a physician, he needs to remain flexible enough to find the right combinations of thyroid hormone replacement to help the patients reclaim optimal health. He says. "If my mind is biased to one single approach, the losers in the equation are first the patient, who is deprived of discovering total wellness, and also the doctor. Why the doctor? I cannot imagine practicing medicine constantly having to tell people that nothing is wrong with them because their, TSH test is 'normal,' and then endure hearing their complaints of persistent suffering. I want all people with hypothyroidism to thoroughly learn about their condition and empower themselves with this knowledge—not settling for a suboptimal existence simply because of their doctor's lack of knowledge or bias.

Ron Manzanero, MD is an integrative physician with expertise in hormone balance and pain management. He is the founder of the Austin Integrative Medicine clinic in Austin, Texas.


Manzanero, Ron. Email interview. December 2010.

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