TCM Herbal Medicine for Hypothyroidism: Current Evidence and 2 Case Reports

Hypothyroidism is a medical condition characterized by the inadequate production of thyroid hormones by the thyroid gland, which are crucial for regulating the body's metabolism. Typical symptoms associated with hypothyroidism include fatigue and lethargy, heightened sensitivity to cold, constipation, dry and pale skin, brittle nails and hair, facial puffiness, a hoarse voice, unexplained weight gain, muscle discomfort, tenderness, stiffness, weakness, joint pain, swelling, heavier menstrual cycles, and depression symptoms.

In Traditional Chinese Medicine (TCM) theory, the philosophical principles of Yin and Yang characterize hypothyroidism as a common manifestation of "weak Yang." This condition may indicate either a deficiency in Yang, which represents activation, strength, and movement, or an excess of Yin, associated with suppression, tranquility, and stillness. In clinical practice, patients often have mixed causes resulting in a complex pathological picture. Even though Chinese herbal medicine is widely used in China for various diseases, including hypothyroidism, no RCTs were found for Chinese herbal medicine on hypothyroidism [1]. In this article, we will share 2 cases of hypothyroidism managed by Chinese herbal medicine and discuss the TCM herbal theory and the challenges of treatment. [Read more: Balancing the Thyroid with TCM] [Read more: Traditional Chinese Medicine for Thyroid Diseases]

Current evidence on TCM herbal medicine for hypothyroidism

According to a study in 2015[1] in English, no RCTs were found in Chinese herbal medicines for hypothyroidism. A more recent search on the China National Knowledge Infrastructure (CNKI) using the keywords “中藥” (Chinese herbal medicine) and “甲減”(hypothyroidism), 175 articles were found but the types and quality of research are unknown.

A 2021 article from Beijing[2] presented a meta-analysis that investigated the therapeutic efficacy of Chinese herbal prescriptions for subclinical hypothyroidism. The findings indicated that TCM, both alone and in conjunction with conventional therapies, is effective in managing subclinical hypothyroidism. These methods may provide considerable advantages in reducing TSH levels and improving dyslipidemia. 

One study[3] analyzed the TCM syndrome and related influencing factors of Hashimoto’s Thyroiditis (HT) combined with hypothyroidism. Among 232 patients with HT combined with hypothyroidism 219（94.40%）were female and 13（5.60%）were male. The majority of patients were aged between 31 and 60 years, with the highest number falling within the 46 to 60-year age range. The median age of the group was 45 years, and the average age was 43.64±13.41 years. [Read more: How herbal medicine can help balancing hormones]

The distribution of TCM syndrome in 232 patients with HT combined with hypothyroidism was: 

• 93 (40.09%) liver-depression and spleen-deficiency Symptoms: premenstrual breast distension, irritability, stringy pulse, dry and thin stools, tooth-marked tongue, and loose stools

• 66 (28.45%) spleen-kidney-yang-deficiency Symptoms: facial swelling, swollen limbs, low menstrual flow, soreness and weakness of the waist and knees, and lumbago 

• 42 (18.10%) phlegm-stasis interaction Symptoms: numbness of the limbs, dysmenorrhea, neck pain, and dark red tongue

• 31 (13.36%) with qi-yin deficiency Symptoms: thin pulse, dry eyes, panic, night sweats, red tongue, and constipation

Another study published in 2023[4] examined the features of Professor Xiang Nan's approach to treating Hashimoto's thyroiditis in conjunction with hypothyroidism by organizing and analyzing the medical records of patients diagnosed with Hashimoto’s hypothyroidism who received treatment from Professor Xiang Nan at the Department of Thyroid Diseases, Hubei Provincial Hospital of Traditional Chinese Medicine, between October 2020 and June 2022. A total of 248 prescriptions for Hashimoto’s hypothyroidism were included in the study, involving a total of 163 Chinese herbal medicines. The frequency statistics of Chinese herbs showed that the commonly used drugs were 

• Astragalus 黃芪

• Radix Codonopsis 黨參

• Atractylodes 白朮

• Cinnamomum 肉桂

• Poria 茯苓

• Cistanches 肉蓯蓉

• Angelica 當歸

• Radix et Rhizoma 甘草

• Radix Rehmanniae 地黃

• Pericarpium Citri Reticulatae 陳皮

Key TCM Concepts related to hypothyroidism

• Kidney Yang Deficiency:

  In TCM, hypothyroidism is often associated with a deficiency of Kidney Yang. This deficiency leads to a lack of warmth and energy, which manifests as symptoms like fatigue, cold intolerance, and slow metabolism.

• Spleen Qi Deficiency:

  The Spleen plays a vital role in transforming and transporting nutrients. A deficiency can result in symptoms like fatigue, bloating, and weight gain, which are also common in hypothyroidism.

• Liver Qi Stagnation:

  Emotional factors can contribute to Liver Qi stagnation, which can further disrupt the body's balance and exacerbate hypothyroidism symptoms. [5, 6]

In reality, the TCM picture is much more complicated. For instance, the kidney and Liver are known in TCM for sharing the same origin (肝腎同源), when we look for the pathogenesis of the Kidney, we often need to consider other systems simultaneously. 

Kidney Yang deficiency is indeed just a “sign” of low fire energy but it is not always a primary course. A common course of Kidney Yang deficiency as observed in my clinical practice is excessive Liver fire caused by severe Liver Qi Stagnation, known in TCM as 肝鬱化火. When the Liver Qi stagnation is intense, the blood in the liver cannot circulate smoothly. Since the Liver in TCM theory is a “general” 將軍之官, it is responsible for delivering the power from the deep level and lower burner to the whole body. In the case of Liver Qi stagnation, the ministerial fire 相火 is not able to release upward and outward, so it gets stuck and burns out both the Liver and Kidney Yin. When the Kidney loses the Yin energy, according to the Yin and Yang interdependence, the Kidney also loses the Yang energy. This is a very important concept that guides the correct treatment approach. Otherwise, if the TCM physician simply follows the textbook or AI explanation without further defining the TCM pathogenesis, we might end up “putting fuel to the fire”. [Read more: Jing, Qi & Shen: The Three Treasures in Traditional Chinese Medicine] [Read more: Qi deficiency: What is it and how do you manage it?]

Case studies of Chinese herbal medicine for hypothyroidism

Female M, 1976

First visit: 10.1.2022

The patient was diagnosed with hypothyroidism in 2007 when she was 5 months pregnant with her second child. She has been taking Levothyroxine, and the condition is under control with no specific symptoms related to the hypothyroidism. Her sleep and general energy were good. She complained about unstable menstrual flow which is sometimes heavy and sometimes light, with slight abdominal pain, red colour, 5 bleeding days, LMP 20.12.2021, using an intrauterine device for 4 years. Her appetite is good but she did not eat breakfast. 

Tongue was light red, with an obvious crack in the middle, light fur.

Slight heavier and thicker pulse, strong liver pulse, small stomach pulse.  

Treatment: 

For the first 4 visits from 1.2022 to 4.2022, the main focus was to improve her stomach power and digestion, while gently smoothing her liver. From the fifth visit in 5.2022, liver cleansing herbs were added and the patient showed side effects of pain under the ribs. She was instructed to lower the dosage but continue with the herbs.  [Read more: Cook your food - digestive system explained in Traditional Chinese medicine]

On the 8th visit in 7.2022, after a normal baseline blood test, the patient started to halve the dosage of Levothyroxine. Another blood test was done to monitor the effect of the lowered Levothyroxine, and the antithyroglobulin increased to an abnormal level in 8.2022. The thyroid blood test was repeated every 3 months and the number of antithyroglobulin was showing a decresing trend. In the meantime, the patient continue to lower the dosage of Levothyroxine gradually, until 7.2023 it was completely stopped. The patient continued the Chinese herbal medicine until 6.2024, with a total of 30 visits. She was followed up by email afterwards and the thyroid blood test came back normal. 

Female N, 1979

First visit: 16.3.2023

The patient was diagnosed with hypothyroidism in 2019 and was under medication since. She also complained about frequent and recurring middle ear infections and wrist pain. In 10.2021 and 12.2022 she had COVID and lost part of her smell and taste. 

The overall treatment approach is the same as the first case: first check the baseline blood test, then gradually decrease the dosage of Levothyroxine. She stopped the medication completely on 20.4.2024. The blood test on 16.5.2024 showed elevated TSH but back to normal after repeating the liver-cleaning herbs and further adjusting the stress management. 

The key to the successful treatment of hypothyroidism

Both patients in the earlier case exhibited strong determination and confidence in TCM and adhered to the recommended lifestyle and dietary changes throughout the treatment process, despite initial imperfections in their adjustments. In the second case, once the effects of the medication wore off, the previously sufficient dosage of Chinese herbal medicine alone proved ineffective in managing the condition. Rather than increasing the herbal dosage, we engaged in an extensive discussion focused on identifying and alleviating stressors in her life. Fortunately, both patients ultimately reaped the benefits of their efforts. [Read more: 8 Healthy Tips for Thyroid]

Reference: 

1. Ke LQ, Hu Y, Yang K, Tong N. Chinese herbal medicines for hypothyroidism. Cochrane Database Syst Rev. 2015 Feb 12;2015(2):CD008779. doi: 10.1002/14651858.CD008779.pub2. PMID: 25914906; PMCID: PMC10625441.

2. [1]邹林蓁,孟淑华,魏军平.中药复方干预亚临床甲状腺功能减退症疗效的Meta分析[J].世界中西医结合杂志,2021,16(10):1765-1777.DOI:10.13935/j.cnki.sjzx.211001. (Therapeutic Efficacy of Chinese Herbal Prescriptions on Subclinical Hypothyroidism:A Meta-Analysis)

3. 吴天强. 桥本甲状腺炎合并甲减的中医证型分布及相关因素分析[D].黑龙江中医药大学,2023.DOI:10.27127/d.cnki.ghlzu.2023.000350. (Analysis of Tcm Syndrome Type Distribution and Related Influencing Factors of Hashimoto’s Thyroiditis Combined with Hypothyroidism)

4. 张丽华. 向楠教授治疗桥本甲状腺炎合并甲状腺功能减退症用药规律及网络药理学研究[D].湖北中医药大学,2023.DOI:10.27134/d.cnki.ghbzc.2023.000129. (Professor Xiang Nan’s Treatment of Hashimoto’s Thyroiditis Combined with Hypothyroidism and Network Pharmacology)

5. 董昭熙，柳红芳，宿家铭，温雅轩，史扬，郑毅成，郭宇鑫.柳红芳从“乙癸同源”论治桥本甲状腺炎经验.[J].中医药导报,2022,28(12):173-176,180.

6. https://m.fx361.com/news/2023/1217/22778679.html