Aviva Romm on the Reasons for Hypothyroidism & More Thyroid Insights

Dr. Aviva Romm, a Yale-trained physician, midwife, herbalist, and mother of four, didn’t take the most conventional path to the career she’s built today. But the different stops on her journey enriched her understanding of women’s unique health needs and introduced her to the area that has become one of her specialties: thyroid health. Watch or read our interview with The Adrenal Thyroid Revolution author to learn about the reasons for hypothyroidism, the differences between Hashimoto’s vs. hypothyroidism, how to interpret TSH ranges, and much more. 
*The video above is a short clip from our interview with Dr. Aviva Romm. Click here to watch the whole thing.*
You can also listen to an audio version of the interview on The WellBe Podcast. 

Charting an Unconventional Career Path

At the age of 15, Dr. Romm was able to test out of high school, secure a scholarship, and begin a pre-med track at college. But instead of becoming a female Doogie Howser, she quickly did a total 180. “Within a few months, I basically took a left turn, became a vegetarian hippie, studying herbal medicine, ecology, history of women’s health,” she says. “And that led me to really take a deep dive into natural medicine and midwifery.” 
At the time, the wellness landscape was quite different and much smaller. There were only a handful of books on herbal medicine, and the term “integrative medicine” hadn’t even been coined yet. So in order for her to pursue her area of interest, she apprenticed with various midwives and herbalists, getting hands-on training and experience. Ultimately, she became a home-birth midwife and herbalist and did that for two decades. 
Then, after 20 years of practicing, she decided to go back to school to get her MD. Dr. Romm explains that she did this for a variety of different reasons, most of them having to do with the fact that women’s health issues were still being medically marginalized, and that women were looking for alternatives but didn’t know where to turn. 
“I wanted to be a force for changing medical practice so that women could go into the hospital or a medical office and not be dismissed for their concerns or treated in a gender-biased way, which is really still shockingly kind of rampant in conventional medicine.”
So she did four years of medical school at Yale (after having four kids!), plus an internship in internal medicine and a residency in family medicine, with a specialty in integrative medicine and obstetrics. “I have now a combined 36 years of study and practice of midwifery, herbal medicine, and conventional medicine,” Dr. Romm says.

The Reasons for Hypothyroidism and Other Thyroid Issues

One of Dr. Romm’s main areas of focus is thyroid health. For those unfamiliar with thyroid health, it may seem like this is a small piece of the wellness puzzle, but it’s actually a hugely important issue — especially for women. Just consider the fact that one woman in eight will develop a thyroid disorder during her lifetime, and that women are five to ten times more likely than men to have thyroid problems. Even scarier? Up to 60% of those with thyroid disease are unaware of their condition. In other words, Dr. Romm has her work cut out for her.
But why are thyroid issues so rampant? What are the reasons for hypothyroidism and other thyroid problems? As Dr. Romm explains, the thyroid — and the entire endocrine system, of which the thyroid is a part — is extremely sensitive, and a wide range of factors affect it, from stress to nutrition to environmental toxins and more.
In terms of environmental toxins, endocrine disruptors are one of the most insidious reasons for hypothyroidism. These are compounds that act like hormones, thus disrupting our endocrine (hormonal) system. One example is BPA, which is found in plastics and binds to our hormone receptors. While people tend to think of estrogen or testosterone when they hear about hormone disruption, Dr. Romm explains that many of these toxins are actually thyroid disruptors as well, binding to the thyroid and blocking its ability to function properly. 
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One of the other big reasons for hypothyroidism is nutritional deficiencies. Dr. Romm told us that, according to the NHANES study from the CDC, 16% of Americans don’t get a daily amount of vegetables, and 14% don’t get a daily amount of fruit. Accordingly, huge numbers of American adults are low in nutrients that are critical for thyroid function, such as iodine, selenium, and vitamin D. This low nutrient status, in turn, exacerbates one of the other reasons for hypothyroidism — stress — which impacts sleep, another factor that affects the thyroid, and a vicious cycle is set in motion. 
For women, another one of the reasons for hypothyroidism has to do with the interaction between thyroid and estrogen. Dr. Romm explains that there are three types of estrogen and that at different times in our life, different levels of these estrogen types are present. These different types of estrogen have different effects on the thyroid, so many women will experience thyroid issues at major hormonal milestones during their life: their childbearing years, pregnancy and breastfeeding, perimenopause, etc.
Despite all of the real, documented reasons for hypothyroidism that women experience, many women remain misdiagnosed due to sexism and gender bias in the medical field. Dr. Romm says that the symptoms caused by thyroid issues — depression, poor sleep, anxiety, hair loss, brain fog, and weight gain — are often dismissed by doctors, especially when they come from women. “We’re much more likely to be dismissed as neurotic or complaining or making something out of nothing,” Dr. Romm says, illustrating one of the patterns against which she hopes to be a force for change.

Hashimoto’s vs. Hypothyroidism: What’s the Difference?

When people talk about thyroid problems, you’ll often hear about Hashimoto’s disease, and sometimes you’ll even hear people use that term interchangeably with hypothyroidism. But are they the same thing? And if not, what’s the difference? Dr. Romm broke down all the nuances of Hashimoto’s vs. hypothyroidism for us.
As she explains, hypothyroidism refers to a slow-functioning thyroid, and Hashimoto’s is an autoimmune form of that condition. In other words, hypothyroidism encompasses any situation in which a person has a thyroid that works slowly, and Hashimoto’s is one specific variation. 
The way to tell whether someone has Hashimoto’s — rather than a thyroid that functions slowly for other reasons — is by looking at their antibodies. “If a person has elevated antibodies and slow thyroid function together, then they have Hashimoto’s,” Dr. Romm explains. “If they have elevated antibodies but their thyroid function is normal, then they are more at risk for developing Hashimoto’s later in life. If they have abnormal thyroid labs that show a slow-functioning thyroid but their antibodies are totally normal, then it’s not autoimmune hypothyroidism.”
So if you have hypothyroidism but not Hashimoto’s, what could the cause be? In addition to the reasons for hypothyroidism outlined above — nutritional deficiency, stress, and estrogen levels — Dr. Romm points to a few other potential causes. For one, it could be transient thyroiditis, which means inflammation in the thyroid. This often happens when somebody catches a viral infection that triggers inflammation, and it generally resolves itself when the virus runs its course. 
One of the less common but quite concerning reasons for hypothyroidism is permanent thyroid damage caused by external events, such as extreme radiation. “I have patients who grew up in Eastern Europe and were exposed to the Chernobyl fallout, and that caused radioactive thyroid damage,” Dr. Romm says. “Their thyroids will never function normally. They’ll always need thyroid medication to support it because it was so damaged by the radiation fallout.”

The Relationship Between the Thyroid and the Adrenals (and Every Other Bodily System)

As the title of Dr. Romm’s book — The Adrenal Thyroid Revolution — suggests, there is a strong link between the thyroid and the adrenal glands. But what, exactly, is that relationship? It all comes down to the way that stress affects the thyroid. 
See, our adrenal glands are our “fight-or-flight” organ, producing the stress hormone cortisol to help us respond to danger and stress in our environment. When we experience an acutely stressful event, our cortisol levels spike. As Dr. Romm explains, the cortisol is there to protect us from whatever we’re up against: “It’s basically providing a buffer to support you through stress.” 
But when we’re under chronic stress, either physical or mental, our cortisol levels stay elevated, and this is when issues arise. The cortisol is telling your body that there’s a danger present, and so you need to dial things back to conserve energy so you can heal or fight off the present danger. And in order to dial things back, the thyroid comes into play. “If you think about your thyroid, it’s a lot like a thermostat in your house controlling how much energy you burn,” says Dr. Romm. “The adrenals tell the thyroid to turn down the thermostat.”
Cortisol from the adrenal glands can “turn down the thermostat” in your body in a few different ways:
  1. Blocking the production of thyroid hormones
  2. Blocking the ability of thyroid hormones to get converted from inactive to active
  3. Blocking your cells from using thyroid hormone 
Regardless of how it happens, once your thyroid has dialed things back — aka become slower-functioning, aka hypothyroidism — the result is the same. “You feel more tired, you gain a little weight because you’re not metabolizing as much, your brain feels a little foggy, you might not sleep as well, you feel more restless and agitated,” says Dr. Romm. 
So the adrenals and the thyroid are intimately connected via cortisol, but the importance of the thyroid doesn’t stop there. According to Dr. Romm, the thyroid impacts countless other systems and functions in the body, including your brain and cognitive abilities, your heart rate, your metabolism, your reproductive system, your digestive system, and more. “It really kind of affects pretty much every aspect of our well-being,” she says.

Thyroid Testing: TSH Ranges and When to Get a Complete Thyroid Panel 

Given how important the thyroid is, it makes sense to get your thyroid health checked if something feels off. But how do you get properly tested for thyroid issues? It’s more complicated than the standard tests you’ll get at your annual check-up. Luckily, Dr. Romm explained everything you need to know about thyroid testing, including how to interpret TSH ranges and when to get a complete thyroid panel. 
When you go to a conventional doctor and tell them that you suspect you have a thyroid issue, the standard of care is to check just one lab test: the thyroid-stimulating hormone, or TSH, which is the hormone produced in your brain that tells your thyroid to start producing active thyroid hormone. Then, the doctor will see if your levels are in “normal” TSH ranges, with low TSH indicating that your thyroid is functioning well, and high TSH indicating that your thyroid is functioning slowly or poorly. 
Dr. Romm explains it like this: “It’s like if you knock on someone’s door and they don’t answer, you’re going to knock louder and louder until somebody finally answers, and that’s what your brain is trying to do.” In this analogy, the knocking is the TSH being sent out by your brain, but instead of trying to get someone to answer the door, you’re trying to get your thyroid to start producing active thyroid hormone. 
But here’s the thing: according to Dr. Romm, there’s more to the equation than high or low TSH ranges. “If you get your TSH checked, and it’s either too high or too low, it can tell you that you have a thyroid problem,” she says. “But all it can really tell you is whether you have a high-functioning or low-functioning thyroid.” 
In other words, it can’t tell you why your thyroid is over- or under-functioning, or if you have an autoimmune condition like Hashimoto’s or Graves’ disease (a form of hyperthyroidism). For that, you’d need to get an antibody test, but many conventional doctors skip over that step, simply diagnosing the patient with hypo- or hyperthyroidism and prescribing medication. Dr. Romm takes a different approach, prescribing TSH and antibodies tests at the same time so that she can rule out more possibilities and save patients an extra visit. 
What’s more, you could still have a problem even if your levels are within “normal” TSH ranges. That’s because even if your brain is sending out a normal amount of TSH, you might still not be producing the kinds of thyroid hormones you need. “You can have totally normal TSH but all the symptoms of hypothyroidism, because it could be that your cells aren’t using it or your liver is not converting it to the active kind,” says Dr. Romm.  “There are a lot of nuances to how one would interpret this testing.” For this reason, Dr. Romm often recommends testing for free T3 and free T4, the active and inactive thyroid hormones, respectively. 
Adding a whole extra layer to this is the fact that there are many different schools of thought when it comes to interpreting TSH ranges, and many conventional doctors take a very narrow view of the issue, assuming that anybody with “normal” TSH has a healthy thyroid. But, says Dr. Romm, that normal range is way too large, with anything up to 4.8 or 5 — and sometimes even up to 10 — considered normal, despite the fact that studies have shown that a TSH of over 3.5 can cause thyroid symptoms. So if a patient’s test comes back as a 4.6, which falls just below the cap of 4.8, many doctors will dismiss the patient’s complaints. “You’re feeling like crap and can barely get out of bed in the morning and they’re telling you, ‘You’re fine,’ but you’re only two-tenths of a degree off from the actual abnormal level, right?” says Dr. Romm. “So sometimes you have to advocate for yourself too and remind doctors, ‘Look, it’s not just the numbers. It’s the numbers and how I feel.’”
To ensure you’re fully covered with regard to thyroid testing, Dr. Romm recommends seeing a doctor who has a holistic understanding of thyroid health and TSH ranges and getting a complete thyroid panel. That includes testing for TSH, free T3, free T4, and the two different thyroid antibodies, anti-thyroid peroxidase, and anti-thyroglobulin. She calls this collection of tests “the best complete package.” 
BTW, tracking your thyroid numbers (and other lab results) can be incredibly helpful in terms of monitoring and improving your health over time. To help you do that, we created a FREE downloadable chart where you can record all your results!
Aviva Romm on the Reasons for Hypothyroidism & More Thyroid Insights

Conclusion: What to Remember About Thyroid Health

Thyroid health is a complex subject, but way too important to ignore. Here are the big takeaways:
  • There are a number of possible reasons for hypothyroidism and thyroid dysfunction, including an autoimmune condition, stress, lack of sleep, nutritional deficiencies, significant hormonal shifts, environmental toxins, or permanent thyroid damage. 
  • Hashimoto’s vs. Hypothyroidism: Hashimoto’s disease is an autoimmune form of hypothyroidism, or slow-functioning thyroid. 
  • The thyroid and the adrenal glands are very intimately connected, because of the stress hormone cortisol. Our adrenals produce cortisol, which tells our thyroid that we’re in a crisis and causes it to slow down to conserve energy.
  • The thyroid impacts almost every aspect of our well-being, from cognitive abilities to reproductive organs to digestive health and more. 
  • If you think you might have a thyroid issue, you should get tested by a doctor who takes a holistic approach to interpreting TSH ranges and ask for a complete thyroid panel, not just a TSH test.
Have you ever experienced thyroid problems? How did you resolve them? Let us know in the comments below.
Watch our whole interview with Dr. Aviva Romm to learn how pregnancy impacts thyroid issues (and vice versa), why your healthy TSH range change as you get older, the relationship between thyroid and fertility, how she determines a course of treatment for her patients, which medications she turns to first if she’s prescribing pharmaceuticals, what lifestyle and environmental changes she recommends to treat thyroid symptoms, which supplements are most important for thyroid health and much more. You can also listen to the podcast episode.
You can also listen to an audio version of the interview on The WellBe Podcast. 

The information contained in this article comes from our interview with Dr. Aviva Romm, MD. Her qualifications and training include graduating from the Yale School of Medicine, and a residency in Family Medicine with Obstetrics at the Tufts Family Medicine Residency. She is also a midwife and herbalist. You can learn more about her here.
  1. Weng, CH, et al. Thyroid disorders and breast cancer risk in Asian population: a nationwide population-based case–control study in Taiwan. BMJ Open. 2018.
  2. Patterson, BH, et al. Fruit and Vegetables in the American Diet: Data From the NHANES II Survey. Am J Public Health. 1990 Dec; 80(12).
  3. Fatourechi,V. Subclinical Hypothyroidism: An Update for Primary Care Physicians.Mayo Clin Proc. 2009 Jan; 84(1): 65–71.
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