Adapted and expanded from Hashimoto’s Protocol: A 90-Day Plan for Reversing Thyroid Symptoms and Getting Your Life
I wanted to shed some light on the role of stress and sleep in Hashimoto’s. We know that stress is never helpful, right? One of the earliest cases of thyroid disease was actually connected to a woman who was thrown down a flight of stairs in a wheelchair—how’s that for stressful!
Over the last few years, I’ve had a chance to work with over one thousand people with Hashimoto’s and have found that most cases of Hashimoto’s involve stress….
You may really resonate with constantly feeling stressed out. If this is you, you need to know that the stress is not serving you. Stress puts us in a fight, flight, freeze, and break-down state, and shifts our body away from a rest, digest, relax and heal state.
Healing happens when we are not stressed, and if you want to heal your body, I hope that having this awareness will empower you to change the habit of being stressed. Please note, while you may not be able to control the circumstances in your life, you can empower yourself on how you respond and react to them. I’ll write more about this one day soon!
There are obvious sources of stress which include deadlines, traffic, a past history of trauma, and current stressful life situations.
There are also not so obvious sources of stress, such as hidden infections, inflammation, and sleep deprivation. In this article, let’s cover sleep deprivation.
The hypothalamic-pituitary-adrenal (HPA) axis is an intricate system of direct and indirect feedback mechanisms that regulate the body’s reaction to stress. The HPA axis plays a significant role in regulating the immune system, digestion, energy usage, mood, and sexuality. It is controlled by hormones which are altered when the body experiences stress.
When our HPA axis is stressed and not working properly, this can lead to symptoms like fatigue, poor immune function, blood sugar imbalances, inflammation, and irritability—collectively known in alternative medicine circles as “adrenal fatigue.”
Sleep deprivation is such a powerful stressor for the HPA axis that it’s actually what scientists use to induce HPA axis dysfunction in laboratory animals!
Most people with Hashimoto’s have some degree of adrenal fatigue (in fact, 90% of those I have tested do), and in my survey of 2000+ people with Hashimoto’s, “a lack of sleep” is the most frequently cited reason why people with Hashimoto’s feel worse.
You may be sleep deprived simply because of the quantity of your sleep, or because you’re not sleeping enough. This could be due to insomnia, due to waking up too early, staying up too late, or even drinking too much caffeine, which prevents us from getting into the deeper and most restful sleep phases.
You may also be sleep deprived because of the quality of your sleep. What’s surprising for many people is that they may even be sleep deprived if they’re sleeping enough hours… One of the reasons for poor sleep quality could be due to a silent condition known as sleep apnea.
The Sleep Apnea & Hashimoto’s Connection
Over the last few years, three of my clients have presented with adrenal fatigue that just wouldn’t budge! They were struggling with their energy levels, and standard adrenal protocols of adaptogenic herbs, B vitamins, vitamin C, sleeping more, de-stressing—and even adrenal hormones weren’t helping!
Whenever this happens, I always go back through all of their intake documents and labs to see if anything is missing…
Sure enough, one of the clients had sleep apnea and refused to use her CPAP, one of the treatment devices for sleep apnea. Another one reported that she tended to snore, and a third one had a scalloped tongue, but they hadn’t been tested for sleep apnea, so I recommended that they get tested.
Over the next 6 months, the two ladies with suspected sleep apnea were found to have it, and all three of them embarked on treatments for the condition.
They reported that addressing their sleep apnea helped them feel significantly less tired and helped them to normalize their adrenal function and reduce their thyroid antibodies.
Research has linked sleep apnea, an increasingly common cause of sleep deprivation, to Hashimoto’s. Studies have found that 25-35% of people with hypothyroidism also have sleep apnea.
Now the question is… does hypothyroidism cause sleep apnea, or does sleep apnea cause hypothyroidism?
As with most triggers that are known to cause and exacerbate Hashimoto’s, it turns out that sleep apnea and Hashimoto’s are a bit of a vicious cycle situation.
While hypothyroidism can cause sleep apnea due to protein deposition in the upper airway, increased risk of obesity, and abnormal control of ventilation, researchers wanted to know if obstructive sleep apnea (OSA) itself could be a potential trigger in Hashimoto’s.
They studied the incidence of thyroid antibodies in people with and without sleep apnea. A 2012 study published in Endocrine Journal showed that 53.2% of people with obstructive sleep apnea were positive for thyroid peroxidase (TPO) or thyroglobulin (TG) antibodies, or both, and thus had some stage of Hashimoto’s [Read more about the 5 stages of Hashimoto’s.]
Some of the people in the study group still had “normal” TSH numbers so they had not yet developed hypothyroidism, suggesting that OSA may be a causative factor for Hashimoto’s. (1)
The researchers concluded that “repetitive episodes of oxygen deprivation followed by reoxygenation result in a generation of reactive oxygen species which can up-regulate inflammatory pathways activating the Th-1 immune pathway which has been implicated in Hashimoto’s.” In other words, long-term obstructive sleep apnea can increase the risk of Hashimoto’s and is an important trigger to consider. (1)
In this same study, researchers learned that the more severe the sleep apnea, the more likely the subjects were to have Hashimoto’s. Other notable findings included:
- Males with sleep apnea were especially likely to have Hashimoto’s; 66% of men with sleep apnea had Hashimoto’s antibodies!
- People with sleep apnea and Hashimoto’s had a higher number of thyroid antibodies (compared to those with Hashimoto’s who did not have sleep apnea); those with OSA had TGAb in the 1,000 IU/ml range, while people without had TGAb in the 400 IU/ml range.
- People with sleep apnea and Hashimoto’s also had a higher number of TPO antibodies; those with sleep apnea had an average of 4,490 IU/ml compared to those without who had an average of 650 IU/ml. (1)
What Is Sleep Apnea
Sleep apnea is a chronic health condition that has been associated with low-grade inflammation in the body and is characterized by pauses in breathing while one is sleeping. As these pauses in breathing and lack of oxygen wake people up intermittently throughout the night (though they don’t usually remember it), the result is often un-refreshing, fragmented sleep despite sleeping longer than usual.
There are three types of sleep apnea: central sleep apnea, obstructive sleep apnea, and a mixed variation where elements of both types of sleep apnea are seen where the interruption in breathing happens because of a blockage of airflow. In CSA, the person stops breathing because of “forgetting” to breathe or a lack of effort in breathing.
The most common type of sleep apnea is obstructive sleep apnea, or OSA.
What Are The Symptoms and Who Is at Risk
Obstructive sleep apnea affects about 2-9% of women and as many as 24% of men. Risk factors for sleep apnea include obesity, enlarged tonsils, enlarged tongue, having a small jaw, allergies, sinus problems, a deviated septum, and acid reflux.
The classical symptoms of sleep apnea include snoring, difficulty in waking up, restless sleep, nasal speech, mouth breathing, attention deficit disorder (especially in children), fatigue, and nasal congestion. Please note, not all of these need to be present for a person to have sleep apnea.
Furthermore, a scalloped tongue, which is often seen in thyroid disease, has also been correlated with sleep apnea.
What is a scalloped tongue?
A scalloped tongue happens when a person’s tongue is too big for their mouth and spends too much time resting against one’s teeth. The scalloped tongue has ridges and wavy edges around its borders and is frequently seen in those with Hashimoto’s and hypothyroidism.
In a 2005 study, Weiss and colleagues were able to compare the rates of sleep apnea and scalloped tongue.
They found that 70% of people with sleep apnea had tongue scalloping, while only 1 person of the 7 people in the control group (without sleep apnea) had a scalloped tongue. Furthermore, on a scale of scalloping from 0-3, with 3 being the most severe, the person without sleep apnea had a scalloping rating of 1, the lowest of the rating. The researchers did not specify whether the higher degree of scalloping was predictive of higher rates of sleep apnea, but I would encourage anyone with a scalloped tongue to get checked out.
People who snore at night and/or have a scalloped tongue should be suspected to have sleep apnea until proven otherwise!
Testing for Sleep Apnea
Sleep studies are considered the most reliable testing for sleep apnea and other sleep disorders. A sleep study involves sleeping at a specialized lab where the person’s vital signs, brain activity, and breathing patterns are recorded and monitored.
Sleep Apnea Protocols
The most well-known treatment for sleep apnea is the continuous positive airway pressure (CPAP) machine, which is used to maintain breathing.
My clients have also reported benefits from using a dental device (known as a mandibular advancement device), which is a type of retainer-like appliance that is worn overnight to gently open airways.
CPAP stands for “continued positive airway pressure” and is a non-surgical therapy usually used as the first line of treatment for obstructive sleep apnea. It is a small machine that uses mild air pressure in order to keep your airways open while you sleep. It contains a mask that goes over the nose and mouth, so it may take some getting used to! However, it is the chosen treatment for severe cases of sleep apnea for a reason. When used correctly and consistently, it is extremely effective in cutting down on daytime sleepiness; reducing or eliminating snoring; lessening chances of cardiovascular problems and stroke; improving cognitive function and memory; and, as I mentioned, treating sleep apnea is an important step in addressing symptoms of Hashimoto’s and hypothyroidism.
Side effects of CPAP are congestion, runny nose or dry mouth. The mask may be uncomfortable and need adjustments to get the perfect fit for you. Maintaining cleanliness of the mask in addition to replacing it as recommended are essential in lessening discomfort. (6)
An added benefit to those of you who have adrenal fatigue is that use of the CPAP machine has been proven to lower evening cortisol levels. A 2011 study that researched the effect of the CPAP on cortisol levels revealed that just two weeks of CPAP treatment lowered morning cortisol levels. After three months, evening cortisol levels were lowered. This is good news for people who are prone to hyperarousal and lack of replenishing sleep! It can be deduced that the longer and more consistent the CPAP treatment, the greater the positive effect on the HPA Axis. Although I would not recommend running out and getting a CPAP machine without getting a proper sleep apnea diagnosis, it does amplify the many benefits of treating sleep apnea as you work to address the many symptoms of Hashimoto’s. (5)
Mandibular Advancement Therapy
A mandibular advancement device (MAD) moves the lower jaw forward, allowing for a better flow of oxygen to the airway while we sleep. This type of device may be especially helpful for those who have a small or receding jaw, or for those with an enlarged tongue that can block the airway. (6)
Much like a retainer, the mandibular advancement devices work best when they are fitted to your mouth. While the MAD is not as well known as the CPAP, the devices have shown to be equally effective, even in cases of severe sleep apnea (6, 8)
Root Causes & Food Pharmacology
I also recommend digging for additional root causes like food sensitivities, nutrient deficiencies, and infections that could contribute to symptoms of sleep apnea and Hashimoto’s and really looking at the body as a whole.
First and foremost, we have to start with nutrition. Eating an anti-inflammatory diet, like the Autoimmune Paleo diet, can help reduce some of the inflammation that may be correlated with sleep apnea, and figuring out your nutrient deficiencies can improve how you feel, as well as potentially improve the sleep apnea.
While more studies are needed, by looking at root causes, we may see an improvement and resolution of both Hashimoto’s and sleep apnea. Here are some examples:
A 2012 case study reported that a 24-year old who received treatment for Leigh disease, a neurological condition, had an improvement in not just the Leigh disease symptoms but also showed an improvement of his sleep apnea documented by a sleep study that occurred one year after his initial diagnosis and treatment plan was started.
Interestingly, the recommended treatment for Leigh’s disease consists of many nutrients I already recommend for people with Hashimoto’s, including CoQ10, thiamine, carnitine, vitamin C, and vitamin E.
Thiamine, specifically, has been a life-changing nutrient for many people with Hashimoto’s. Read more about thiamine in this article.
As enlarged tonsils can be a trigger for sleep apnea, and the Epstein-Barr virus can cause enlarged tonsils, I recommend testing for Epstein-Barr and other infections to determine if they are the cause for the enlarged tonsils, which could then contribute to sleep apnea and/or Hashimoto’s.
You can find more information about root cause testing including a questionnaire to help you prioritize in the Advanced Protocols of Hashimoto’s Protocol.
I would love to hear from you!
Your feedback helps me to help others! Do you have a scalloped tongue? Have you been tested for sleep apnea? Have you considered sleep apnea as a possible root cause? If so, what has worked for you to address sleep apnea?
Because it is so prevalent among those with Hashimoto’s, I recommend that you get tested for sleep apnea, especially if you snore or have a scalloped tongue. To discover additional root causes, please consider joining my Hashimoto’s Self-Management Program or pick up a copy of Hashimoto’s Protocol: A 90-Day Plan for Reversing Thyroid Symptoms and Getting Your Life Back and Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause.
- Bozkurt N, Karbek B, Cakal E, Firat H, Ozbek M, Delibasi T. The association between severity of obstructive sleep apnea and prevalence of Hashimoto’s Thyroiditis. Endocrine Journal. 2012;59(11):981-988. doi:10.1507/endocrj.ej12-0106.
- Magrini A, Pietroiusti A, Coppeta L et al. Shift Work and Autoimmune Thyroid Disorders. International Journal of Immunopathology and Pharmacology. 2006;19(4):31-35.
- Mermigkis C, Bouloukaki I, Mastorodemos V et al. Medical treatment with thiamine, coenzyme Q, vitamins E and C, and carnitine improved obstructive sleep apnea in an adult case of Leigh disease. Sleep and Breathing. 2013;17(4):1129-1135. doi:10.1007/s11325-013-0816-5.
- Mete T, Yalcin Y, Berker D et al. Relationship between obstructive sleep apnea syndrome and thyroid diseases. Endocrine. 2013;44(3):723-728. doi:10.1007/s12020-013-9927-9.
- Raff H, Ettema S, Eastwood D, Woodson B. Salivary Cortisol in Obstructive Sleep Apnea: The Effect of CPAP. Endocrine. 2011;40(1):137-139. doi:10.1007/s12020-011-9474-1.
- Serra-Torres S, Bellot-Arcís C, Montiel-Company J, Marco-Algarra J, Almerich-Silla J. Effectiveness of mandibular advancement appliances in treating obstructive sleep apnea syndrome: A systematic review. The Laryngoscope. 2015;126(2):507-514. doi:10.1002/lary.25505.
- Weiss T. Association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Otolaryngology – Head and Neck Surgery. 2003;129(2):P179-P180. doi:10.1016/s0194-5998(03)01047-7.
- White D, Shafazand S. Mandibular Advancement Device vs CPAP in the Treatment of Obstructive Sleep Apnea: Are they Equally Effective in Short Term Health Outcomes?. Journal of Clinical Sleep Medicine. 2013. doi:10.5664/jcsm.3008.