Q&A With Integrative Physician Dr. David Borenstein

"My Approach to Thyroid Treatment and Hormone Balance"

David Borenstein, M.D, integrative physician thyroid hormone
David Borenstein, M.D. is an integrative physician in New York City who focuses on thyroid and hormonal health. David Borenstein, MD

David Borenstein, M.D. is an integrative physician in private practice in New York City. He specializes in rehabilitative medicine, thyroid, adrenal and reproductive hormone balance. This is one in a series of interviews with practitioners who treat thyroid disease from varying perspectives and approaches.

Mary: Can you share a bit about your educational background?

David: I attended medical school in Israel, at the Technion Faculty of Medicine in Haifa.

I returned to the U.S. to do my internship at Staten Island University Hospital and my residency at Stony Brook University Hospital in New York. I've done additional training in radiation oncology and acupuncture, and am certified with both the American Academy of Anti-Aging Medicine and the American Academy of Environmental Medicine. I've been in practice for more than a decade and now have a private practice in holistic, integrative and rehabilitative medicine in Manhattan.

Mary:When did you decide to become a physician?

David: Honestly, I never knew a time when I didn't want to be physician. From when I was a little child, I always knew in my heart that being a doctor was my goal. I couldn't see myself doing anything else.

Mary: Your training was in conventional medicine. How did you end up becoming an "integrative" physician?

David: Like many physicians, I completed my medical education with a bias against integrative medicine.

But fresh out of my residency, I needed to supplement my income while I was building up my practice. So I worked at an integrative medical center a few days a week. Slowly, I started to apply the things I was learning - and saw that integrative treatments were working. I was so impressed with how effective many of these treatments were that I eventually did additional training in integrative medicine and incorporated more integrative approaches into my overall philosophy.

Mary:What is your favorite part about being a doctor?

David: For me, the greatest feeling of accomplishment comes from helping make real changes in people's lives, especially after they've been through a difficult time. Many come to me after they've seen numerous practitioners and had little or no improvement - or they're even worse than when they started. We work together to help them get properly diagnosed and apply integrative treatments. They improve tremendously. Knowing that I've helped them is the greatest feeling in the world.

Mary: What is the most frustrating part of being a doctor for you?

David: It has to be dealing with the bureaucracy of medicine. When I was participating in a number of insurance programs, I faced serious time limitations. Insurance didn't allow me to spend as much time as I would like to with a patient. I would have loved to spend an hour with every patient, but insurance pays only for the first seven to eight minutes of a visit; after that, I was working for free.

That's frustrating.

Mary: What do you feel that a holistic or integrative doctor like yourself brings to thyroid care, in contrast to conventional practitioners?

David: As an integrative physician, I'm making a diagnosis, recommending treatment and monitoring results based not only on a few lab results, but also on a number of diagnostic criteria and tests, detailed medical history and symptoms. In addition, I am able and willing to consider a much wider variety of treatment options. With hypothyroidism, for example, the typical conventional doctor looks at the TSH test and prescribes levothyroxine. They do not go beyond this narrow approach.

I regularly evaluate not only the TSH test, but Free T3, Free T4 and Reverse T3 and antibodies. I also carefully look for other health issues - like adrenal dysfunction and gut disturbances - that are associated with, or may complicate, the thyroid situation.

Mary: What is your favorite kind of patient?

David: Some of my favorite patients come in very prepared and knowledgeable. They're concise, they explain their symptoms and history proactively. When I tell them I'm going to order this or that test, they know exactly what I'm talking about. They are informed, and that makes the appointment more productive because we have more time to explore and explain the treatments.

Mary: Do you have any tips to make a visit more productive for you and your patients?

David: I always encourage patients to bring a pen and pencil and take notes during an appointment. I've also found that it can be very helpful for patients to bring along someone they trust as an advocate. That person can help by asking questions that the patient might forget, and even take notes. I've even had an entire family sit in on an appointment.

Mary: Some physicians seem to resent patients who come to an appointment with all sorts of printed studies and articles. Some even refer to them derisively as "googlers" or "petits papiers" (little papers) patients. What are your thoughts about this?

David: I have no problem with patients who come in with stacks of articles and research, unless it's going to take too much time from their visit. The most important part of the visit is for me to get to know the patient, listen to them and understand their symptoms. So, if it's done judiciously, that's fine. A couple of pages are fine. But reams of paper will take away from the patient's time and doesn't serve either of us.

Mary: How do you feel about opinionated/empowered thyroid patients who come in with ideas about what they want, in terms of treatment?

David: My goal is to have a collaborative relationship with my patients. So while I appreciate patients who have preferences about what they want, our decisions have to make sense for them medically. For example, I've had many patients come in who feel strongly that they want natural desiccated thyroid for their hypothyroidism. And when I look at their test results, they have a high Free T4, a high Reverse T3 and a low Free T3. That's not the profile of a patient I typically want to put on Armour Thyroid. They require a tailored approach that may include a T3-only treatment or slow-release T3 and reduction in the T4.

Mary: When you see a woman who is suffering from fatigue, depression or mood changes, struggling to lose weight or other similar symptoms, besides blood tests, what process do you typically go through to get to a diagnosis?

David: For me, a thorough history and physical examination are crucial and will offer a great deal of information. I palpate the thyroid, feeling for enlargement and nodules. I check hair and eyebrows, looking for changes in texture and sparse or bare patches. I check the Achilles reflex, pulse and blood pressure. I want to hear about symptoms, look for signs of a low thyroid or other hormonal imbalances, and pay particular attention to such symptoms as fatigue, weight gain, brain fog, swelling, hair loss, brittle nails and constipation, among others.

I also ask patients about bloating, sugar cravings and sinus congestion - which are often seen in patients who have underlying yeast overgrowth. I ask about difficulty getting out of bed, higher energy at night, dark circles under the eyes, low blood pressure, exercise intolerance and salt cravings, which can be signs of an adrenal imbalance. I look for signs and symptoms of perimenopause and insulin resistance. And, of course, family history of thyroid and autoimmune disease in general. It’s no longer a surprise to me how many patients tell me that a mother or grandmother had some sort of thyroid disorder.

Mary: Do you think thyroid diagnosis and treatment have changed since you first went into practice. If so, how?

David: Among endocrinologists, I have seen little change in diagnosis and treatment. Like any field of medicine, it takes years before the findings and literature become applicable in clinical practice. There appears to be more openness among primary care and integrative physicians, however. Integrative doctors in particular seem to be more interested in, and open to, the latest thinking and findings.

Mary: How has your treatment of thyroid patients changed since you went into practice?

David: Initially, I started using levothyroxine drugs like Synthroid, along with everyone else. Now, I have a whole arsenal of approaches, including natural thyroid drugs, compounded/ slow-released T3, fast release T3 and such supplements as selenium, tyrosine and ashwaganda, among others. I am also more likely to integrate related approaches, including ferritin, vitamin D, B vitamin deficiencies, adrenal support and other treatments that can support and affect the thyroid.

Mary: Do you have a philosophy or overall approach to treating thyroid/adrenal/reproductive hormone imbalances?

David: First of all, I want to emphasize that every patient is different. Each patient is an individual. So, in my experience, it’s important for patients and practitioners alike to recognize that one size does not fit all.

Second, I think it’s extremely important to address adrenal function as a foundation before attempting to balance other hormones. I’m a big believer in addressing adrenals concurrently or before thyroid replacement. To evaluate the adrenals, I typically run a four-point saliva cortisol and DHEA-S, and I also use blood tests to evaluate morning cortisol, aldosterone and ACTH.

To treat adrenal imbalances, I often use nutritional supplements along with dietary recommendations, stress reduction, exercise modification and a focus on improving sleep. Supplements I have recommended for adrenal support include adrenal glandulars, vitamin C, licorice, ginseng and ashwaganda, among others.

If patients have high cortisol at night, I often recommend phosphatidyl serine, l-theanine, and calming herbs. Nutritionally, I counsel patients to follow a low-glycemic diet, avoiding sugar, coffee and other stimulants. When medication is needed, I prescribe the minimum amount of low-dose hydrocortisone (Cortef), with the goal of short-term, judicious use so as to allow other factors to help restore adrenal balance.

Third, it’s also important to consider the reproductive hormones and how they interact with the adrenals and the thyroid. In particular, with perimenopausal women, I’m often looking at the progesterone levels. In women with low progesterone, supplementing with progesterone can often provide tremendous benefits. I also look for estrogen dominance - whether due to low estrogen with very low progesterone, or high estrogen versus lower progesterone. Again, addressing the adrenals and supplementing with progesterone are often crucial to restoring balance in the overall hormonal system. There’s also a concept called the "cortisol steal," where chronic stress means that the body decreases production of the sex hormones and aldosterone. Helping the adrenals can help prevent this. When appropriate, I also prescribe bioidentical hormones as needed.

Mary: What lab tests do you feel are essential to making an accurate and thorough thyroid diagnosis?

David: For my patients, a basic thyroid panel includes the TSH test, Free T4, Free T3, thyroid antibodies and Reverse T3 tests.

Mary: Thyroid disease is often written off as a whiny, overweight, middle-aged women's disease. Or it's simplified as "easy to diagnose, easy to treat." Why do you think thyroid disease is so misunderstood by patients and physicians?

David: When there is the perception that there’s a "quick fix," it’s often looked down on, and that’s especially an issue when it comes to weight loss. Since weight problems are prevalent in America, the idea that thyroid may be a cause has wrongly been translated into a quick-fix solution. While in reality patients may have thyroid issues causing weight issues, thyroid problems are now a surprising stumbling block for many doctors when dealing with overweight patients. Meanwhile, I can’t tell you how many patients I have who diet, exercise and do everything right, and they still can’t lose weight because they have an undiagnosed or poorly treated thyroid condition.

And I understand their frustration. We all tend to believe that if we eat right and exercise, there’s no way we should gain weight or have difficulty losing weight. Yet, here are millions of people who try their best and have trouble. Something is missing, something we’re not recognizing, that hormones are a key factor, in particular, thyroid, insulin resistance and adrenal function.

Mary: Many thyroid patients struggle with and complain about weight issues. What factors do you consider in patients who face this challenge?

David: Any time a patient comes with trouble losing weight, we look at thyroid and of optimizing their thyroid treatment. In addition, I look at fasting insulin and hemoglobin A1C to assess for insulin resistance, which I’ve found is frequently an underlying issue that is making it harder for thyroid patients to lose weight. When we find insulin resistance, I can then work with the patient to develop a plan that includes the appropriate low-glycemic diet, exercise/muscle-building activity, medications when necessary (like metformin or Byetta, for example) and nutritional supplements such as vitamin D and chromium picolinate.

Mary: You use low dose naltrexone (LDN) as a treatment for autoimmune diseases, including Hashimoto’s and Graves’ disease. Can you share a bit more about your use of LDN?

David: I will prescribe LDN for Hashimoto’s patients after we’ve worked together to address other issues, including selenium supplementation, a gluten-free diet and resolving gut issues to fix leaky gut. If, despite all these interventions, they’re not making progress, then I consider LDN. I find it particularly of interest when patients have other concurrent autoimmune diseases, such as patients I’ve seen who had Hashimoto’s along with multiple sclerosis, rheumatoid arthritis or irritable bowel syndrome. With LDN, you may be able to address multiple medical issues with one medication. In Hashimoto’s patients, I have seen antibody numbers coming down dramatically, a substantial reduction in symptoms and, ultimately, patients requiring less thyroid medication to maintain better quality of life and symptom resolution.

And while I typically like Graves’ disease patients to also work with an endocrinologist, my Graves’ disease patients also have had success using LDN, especially when combined with nutritional changes.

Mary: If you had just one piece of advice for thyroid patients, what would it be?

David: I would say, "Be your own advocate!" It’s your own health. Truly, no one will care more about your own health than you. Keep learning; keep reading; be sure to ask for copies of your test results; don’t be afraid to ask questions. And when in doubt, always get a second opinion.

Source:

Mary Shomon telephone interview with David Borenstein, MD December 2011

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