Listen to our full interview on the podcast:
Listen to our follow up Q&A:
Dr. Aimee: Fertility and thyroid is something that so many of my patients ask me about, so it is so great that I finally have an expert on my show.
Dr. Aimee: Fertility and thyroid is something that so many of my patients ask me about, so it is so great that I finally have an expert on my show.
Dr. Christine Maren: I am so happy to be here. It’s one of my favorite things to talk about.
Dr. Aimee: I would love to hear more. Why is it one of your favorite things to talk about?
Dr. Christine Maren: Thyroid is near and dear to my heart. I’m a thyroid patient myself. So is my sister, and my other sister, and my mom, and my mother-in-law and so many other women I know… and aside from my family, just so many of my patients.
I see people change their lives and change their family’s lives when they get their thyroid treatment. It is a big deal in terms of quality of life, really. And, as you know, fertility and pregnancy outcomes.
Dr. Aimee: Fertility and thyroid is something that so many of my patients ask me about, so it is so great that I finally have an expert on my show.
Dr. Christine Maren: I am so happy to be here. It’s one of my favorite things to talk about.
Dr. Aimee: I would love to hear more. Why is it one of your favorite things to talk about?
Dr. Christine Maren: Thyroid is near and dear to my heart. I’m a thyroid patient myself. So is my sister, and my other sister, and my mom, and my mother-in-law and so many other women I know, but besides my family, just so many patients.
I see people change their lives and change their family’s lives when they get their thyroid treated the right way. It is a big deal in terms of quality of life, really.
Dr. Aimee: So, you have a very personal story related to it, but tell us more about why you also went into medicine and chose your specialty.
Dr. Christine Maren: That’s a blast from the past. Actually, I was a finance major. Little known fact about me. I graduated from the University of Colorado at Boulder Leeds School of Business. During that time, I studied abroad in Mexico and I also did an honors program called Presidents Leadership Class. Both of those things just really instilled in me a sense of service, and as cliché as it sounds, I really wanted to help people.
My goal was to find a profession where I was really helping people. I remember sitting in finance class and my friend sat down next to me, and at that time he opened the newspaper and he was reviewing the stock market, and I was thinking to myself “I could care less about that.” I was a group fitness instructor and was reading about health and fitness and nutrition, and I was really into that.
So I made a big change after my time abroad, and started my pre med studies. I started taking organic chemistry and I loved it (most people dread that class!). I found that I was really into the sciences.
After I finished my undergraduate degree, I went on to osteopathic medical school. I was really in this very holistic mindset, just part of my upbringing, and part of my environment. I went to undergrad in Boulder and was surrounded by acupuncture and Reiki and holistic modalities. I also had hormonal struggles myself when I was in college, and the thing that helped me was acupuncture, so I already gravitated to a more holistic path.
Dr. Aimee: Where do you practice?
Dr. Christine Maren: I am licensed in Colorado, Michigan, and Texas, so I have a virtual practice in all of those states. Long story, but I went to med school in Chicago, met my husband who was a military doctor, and we traveled around because of that. He was honorably discharged and we’re now settled in Colorado, so I’m back home and close to family.
Dr. Aimee: You shared a little bit about having a personal connection to the thyroid. Do you also have a personal connection to fertility, that you’d be willing share?
Dr. Christine Maren: I do. Much of my story really started with pregnancy struggles. In residency, I had my first daughter. My husband and I actually got pregnant pretty easily, but I had some unexpected complications. I had gestational diabetes, and zero traditional risk factors. I really dove head first into nutrition at that point. I checked my blood sugar four times a day because I was really determined to avoid medications. I wanted to have a healthy pregnancy and I wanted to find some answers about what was going on.
Fast forward several years, my husband had deployed and when he came home, we were on a timeline to have our second baby. It took us about four months to get pregnant and then I had a miscarriage. My intuition told me there was something wrong with me, because meanwhile I’d been dealing with new digestive issues, skin rashes and just felt off. And then it happened again.
At that point I was like, “All right. I need to figure out what is wrong. Something’s going on with my body.” And indeed it was. That was my deep dive into functional medicine and the time when my professional and personal lives collided. I saw a fertility doctor who was wonderful, but ultimately my diagnosis was unexplained, and I felt like, “Well, there’s got to be an explanation somewhere.” And that’s when I became a functional medicine patient.
Eventually we had our second child, thanks to thyroid medication and progesterone. I got my health back after that, and I was feeling really good… and then I got a surprise: baby number three. She’s wonderful and I love her to death.
I tell my patients, “When you get your health back, often your fertility comes back too.” Obviously there’s a lot of factors there, but underlying health is one of them.
Dr. Aimee: I agree. Let’s talk a little bit more about fertility and the thyroid gland, but let’s just start off with the basics. Can you just talk to us about the thyroid gland?
Dr. Christine Maren: The thyroid gland is a gland in your neck. It’s a really important gland that produces thyroid hormone, and thyroid hormone controls a lot of things in our body. When we talk about fertility and hormones, it regulates ovulation. For hypothyroid you might not ovulate. It is also important with our periods. People who have irregular periods might have problems with thyroid.
Thyroid also regulates metabolism. When we think about things like blood sugar, cholesterol, weight; thyroid is in charge of that, along with gut health. I talk about gut health all the time and thyroid regulates your gut viscera. This is why people with hypothyroidism are often constipated. It is a really important gland that I think is underappreciated sometimes.
Dr. Aimee: What are some of the most common thyroid issues that you see? You did mention hypothyroidism. What are some other ones?
Dr. Christine Maren: Hypothyroidism is the most common. The reason for that is often Hashimoto’s, which is an autoimmune disease which causes a thyroid condition over time. Hashimoto’s is an immune system problem, but then over time can cause hypothyroidism. Some people are overtly hypothyroid and are identified by their primary care doctor because their TSH is extremely high and it’s very obvious, but for many people, it’s less obvious.
Their labs are not totally obvious, and it might not be clear for a decade, but they’re still struggling with hypothyroid type symptoms. So sometimes that can be auto-immune in nature, but it can also be related to different nutrient deficiencies. Iodine is actually a player. That’s a bit controversial, but it is an important nutrient that affects our thyroid function.
Dr. Aimee: What are some of the symptoms of a thyroid disorder? You mentioned sometimes people are struggling. Can you describe the struggles that someone with a thyroid disorder might have?
Dr. Christine Maren: Aside from infertility and irregular periods and constipation, it is cold intolerance, this feeling of cold to the bone, like you can’t really warm up. Weight gain resistance. Not everybody with a thyroid disorder is overweight, but sometimes people can’t lose weight because they have hypothyroidism. Hair loss, thinning hair, thinning of the outer third of the eyebrow, dry skin, sometimes muscle aches. Depression and mood is a big symptom. Sometimes people also have episodic anxiety.
If somebody is wearing a traceable, like I wear my Oura ring and can follow my heart rate, but you might notice that you have a slow heart rate or a low body temperature, which goes along with that cold intolerance. And just this overwhelming feeling of fatigue and exhaustion.
Dr. Aimee: What tests should someone be sure to ask for from their doctors?
Dr. Christine Maren: A TSH, that is what you’re going to get. I would always ask for a free T4 and a free T3. Now, a lot of people are resistant to a free T3, (which I will explain more), but I find that to be helpful. I also like to look at a reverse T3 and I always order a thyroid peroxidase and thyroglobulin antibodies, because if it is auto immune in nature, that is a nice thing to know.
I have a different approach when it is auto immune than when it is not. In residency, I was taught to sometimes order a TSH with reflux. That means if the TSH is abnormal, then you will also get a free T4. The normal range for TSH, is wide: 0.5 to 4.5 are the general reference ranges for that. Many would argue that the upper limit of normal might be more like 2.5.
Dr. Aimee: You mentioned something that I think people will wonder about. What is the difference between if you have the thyroid antibodies versus if you do not, when it comes to management of your thyroid?
Dr. Christine Maren: This is my approach in functional medicine, whenever there is an autoimmune disease, there is this triad that we know about. This is research from Alessio Fasano, but basically the triad of autoimmunity is: a genetic predisposition, environmental trigger, intestinal permeability.
Intestinal permeability is a big one. It has to do with gut health. Leaky gut is the name that goes around, but if you really look and dive into the scientific literature, it’s just about intestinal permeability, and often that’s about underlying gut infections and gluten sensitivity.
Dr. Aimee: Is there really a connection between thyroid and fertility? I know in your personal experience you felt like there was, but I think so many patients go to their doctors and sometimes they get the eye roll. Tell us more about the facts related to that.
Dr. Christine Maren: Literature establishesthe upper limit of normal for TSH at 4.5, but we’ll give a little leeway when somebody’s starting to get pregnant in the upper limit of normal, so maybe 2.5. We’re a little bit more strict about it when somebody is actually trying to get pregnant. Your thyroid plays such a ovulating (so that you can get pregnant), and in maintaining a healthy pregnancy.
A lot of people who are functionally hypothyroid are not always identified. If you just look at TSH and do not see the free T4 and free T3 levels, the diagnosis gets missed. At the very least you got to ask for TSH free T3, free T4. And, you want to keep in mind that a patients wants to be in the upper limit of what’s considered normal when we talk about free T4 and free T3, and in the lower range of what’s considered normal when we talk about TSH.
Dr. Aimee: Moving forward, I will be adding free T3 to my panels, because right now I just do TSH and free T4, so thank you for your advice. Truly, just being in the normal range isn’t enough. You want to look at the whole pattern.
Dr. Christine Maren: It is so true. Free T3, it can fluctuate a lot, so check it. Timing is really important, so if you have a patient who is on thyroid medication, if it’s levothyroxine, I like to check their labs before they take their medication. If it is Armour or some natural desiccated thyroid or even Cytomel, which is synthetic T3, I like to take their thyroid labs after they take their medication, between four to six hours.
Timing is everything when we’re talking about free T3, otherwise it’s all over the map and it’s really hard to know what’s going on. But if somebody’s free T3 is 2.5, 2.2, that’s way too low. They should be in the threes. It’ll feel like they’ll feel much better if they’re in the threes.
Dr. Aimee: What is the connection between thyroid and pregnancy?
Dr. Christine Maren: In that first trimester especially, it is important to have optimal levels of thyroid function, especially T4. The fetus really needs to see optimal levels of T4, not so much T3. It is a balance. There are increased rates of miscarriage. Throughout pregnancy, you can have increased complications like high blood pressure, preterm labor, pregnancy loss, basically.
Dr. Aimee: And pre-conception, how long should a woman wait to try and conceive if, she has been diagnosed with hypothyroidism? Is just making sure your TSH is normal enough or should there be a period of time where it’s normal for a set number of weeks or months before she should try? What is your advice related to that?
Dr. Christine Maren: Get it normalized. If you are switching medication, your TSH is going all over the place. Get on the right dose of medication and find out what your dose is. As soon as you get pregnant, you’re going to need to increase that dose by 30%, and it’s really hard to know what dose to increase by 30%, if you don’t even know your dose at baseline. It’s a big deal for a successful pregnancy.
Dr. Aimee: How often do you recommend a woman get her levels checked if she working on finding the right dose for her body?
Dr. Christine Maren: If she is pregnant, I would do it every four weeks. If she’s trying to get pregnant, probably every six weeks. It takes TSH a bit to normalize, so if you switch your thyroid medicine and take it two weeks later, your TSH won’t have adjusted yet. So four weeks at the minimum, probably six weeks.
Dr. Aimee: And then what happens postpartum? After you’ve delivered a baby, what happens with thyroid function?
Dr. Christine Maren: A lot of different things can affect thyroid function at that point. The first thing to consider is auto immune. I like to screen all of my patients. I think every woman should really be screened for thyroid conditions postpartum. Autoimmunity is something we know is triggered by pregnancy. Having a baby is a huge risk factor. At that point, you want to look for any sign of Hashimoto’s.
The other thing that can happen postpartum, usually about four months later, is postpartum thyroiditis. It is not as common as auto-immunity, but it happens. So, if a new mom is super anxious, and lose all their baby weight and they cannot sleep (even though they’re super tired) and they’re hyperthyroid — it’s often because they have postpartum thyroiditis. And then they crash, and they are so tired, and a common response is to way, “Well, yeah, you’re a new mom. Of course, you’re tired.”
It’s important to be aware of these things and know what we can screen for. Often many of the symptoms of hypothyroidism are the symptoms of pregnancy or being a new mom. Yeah, it’s exhausting sometimes. It’s tiring. But looking at those labs is simple, and it’s not super expensive.
The other piece that I think about postpartum is a lot of stress and adrenal demand. Our HPA axis, that is our hypothalamus, pituitary, adrenal, thyroid gonad, HPA TG axis can really be influenced when we’re waking up every two hours to breastfeed and all of this.
It is good for new moms to understand that it is a lot of stress. Sometimes I will use adaptogenic supplements for postpartum. Also, postpartum depletion. There’s a lot of nutrients that are a big deal with thyroid function. Women might be struggling postpartum, maybe even postpartum depression. Even the American Thyroid Association agrees, we should screen everybody who has postpartum depression for thyroid disorders.
Dr. Aimee: At what point should a woman have her thyroid checked after she has delivered to make sure that she’s not dealing with postpartum thyroid issues?
Dr. Christine Maren: My vote would be six weeks and six months. And then probably again at a year.
Dr. Aimee: When you are diagnosed with something, I think sometimes people get worried that number one, they should worry, and then number two, that they need to be on something for the rest of their life. I feel like that’s the number one question I get asked, “Now that I’ve been diagnosed with this, do I really have to take this for the rest of my life?” And a lot of people do not want to.
What kind of advice would you have for patients who are worried about that?
Dr. Christine Maren: It depends. Not everybody does have to be on it for the rest of their life, but often people do. I think if you have some underlying autoimmune Hashimoto’s that isn’t addressed, yes, your dose is going to keep increasing if you never address that immune component, because there will be continued destruction of the thyroid gland. But, if you’re on the right dose of thyroid hormone, it can be such a game changer in quality of life that most people don’t want to go off of it after they realize, “Oh my gosh, it was like the lights turned on. That depression is gone or lifted, or finally I can lose the 10 pounds that I haven’t been able to lose, or my blood sugar looks better, or my cholesterol.”
There are so many benefits to optimal thyroid function. I always think about this risk-benefit ratio.
What are the risks? There is the risk of managing somebody on too much medication.
There are a lot of benefits. And what do we want? I think, “What, would I rather take a thyroid hormone or would I rather take a cholesterol medication, a blood sugar medication and an antidepressant?”
Dr. Aimee: Oh, that is a great point for sure. You mentioned your own thyroid journey and you talked about something, you said, “I worked really hard.” For people who want to know what they can do that’s in their control to improve own thyroid function, what can you share with us about that?
Dr. Christine Maren: I think nutrition and lifestyle goes a long way.
What does that mean? In terms of nutrition: eating real whole foods. I’m gluten-free. I eat a lot of vegetables and a lot of plants. I eat more of maybe a plant-based, paleo style diet, if you want to put a name on it. I am not super strict about that, but I am very strict about gluten-free and dairy-free and I try to do low sugar.
I try to preach balance, but I think for many people, especially those of us who have antibodies or autoimmune disease, it is important to be gluten-free. And that really just goes for Hashimoto’s, not necessarily somebody who just has suboptimal thyroid function. But really getting nutrient dense foods, so your thyroid relies on things like iron, and selenium, and zinc and vitamin A. Exercise too improves your thyroid hormone receptor sensitivity. All of those things are a big deal.
I think in terms of lifestyle: sleep. Sleep is a huge issue. What I see happening is that your thyroid makes T4, the gland makes T4, it converts from T4 to T3 in your peripheral tissues, and some of it diverts to reverse T3. That’s totally a normal thing our body does, but sometimes we divert a lot of it to reverse T3, and reverse T3 is like putting the brakes on, whereas free T3 is putting the gas on. So when I see a ton of reverse T3 I’m thinking high stress or not sleeping, inflammation, toxins, infections, all of this.
Healthy living is important and, embracing a low toxin lifestyle. If you’re wanting to become a mom, you might be already keyed into this because it’s important during pregnancy, of course, and it’s important for fertility and it’s important for your baby. Try to get rid of some of the toxins in your home. The thyroid is a magnet for toxins. Things like fluoride, and chlorine, and plastics, and heavy metals, all of those can worsen thyroid function.
Dr. Aimee: Everything that you have mentioned are the exact same things that I tell people that can improve embryo quality, right?
And, these things can improve sperm and egg quality, and thereby improve embryo quality, so very good advice to live by. I love how you said, “Preach balance.” There are certain patients where gluten-free is important and others where it may not be.
Dr. Christine Maren: Some people are probably better off not going gluten-free. Just some, but sometimes what happens is people replace gluten with rice flours and high sugar, gluten-free stuff. That stuff’s not healthy. There’s a balance. If you have auto-immunity, go gluten-free.
Dr. Aimee: Thank you so much for all your amazing thyroid advice. Can you just tell us a little bit more about where patients and people in general can find you? And you have a podcast. I’d love for you to talk about that.
Dr. Christine Maren: I have a new project launching called Hey, Mami. Mami is M-A-M-I. That, we are on Instagram at Heymami.life and we’re launching a podcast and loved having you as a guest. So we’re super excited to launch that. It’s going to be really good. You can find me at Dr. Christine Maren on Instagram and on Facebook. I’m on Instagram a lot and you’ll find me there. My website is drchristinemaren.com and all my clinical information is there.
Dr. Aimee: Awesome. Well, thank you again.
Dr. Christine Maren: Thank you.
Catch more of me and topics like this through The Egg Whisperer Show. Episodes are live-streamed on YouTube, Facebook, Twitter, IGTV and Apple Podcasts on Wednesdays at 7PM PST. Sign up to get my newsletter. Tune in to The Egg Whisperer Show on YouTube. and Sign up for The Egg Whisperer School.
