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Which Stage of Hashimoto’s Are You In?

Knowing your stage of Hashimoto’s can help you better manage this autoimmune thyroid condition.
Which Stage of Hashimoto’s Are You In?
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Hashimoto’s thyroiditis is a common autoimmune condition that affects your thyroid gland, leading to various symptoms and potential complications. Hashimoto’s is also the most common cause of hypothyroidism in the United States. Understanding the different stages of Hashimoto’s can be crucial for effective management and treatment. By recognizing the signs and symptoms associated with each stage, you can work closely with your healthcare providers to optimize your care and improve your quality of life. Let’s explore the stages of Hashimoto’s thyroiditis to help you identify where you may be in your journey with this condition.

Stage 1: Increased risk

At this first stage, the main characteristic is an increased risk of Hashimoto’s thyroiditis or other autoimmune diseases due to a genetic predisposition. At this stage, your thyroid will function normally, and your thyroid levels, including the thyroid peroxidase (TPO) antibody test used to diagnose Hashimoto’s, are all likely to be normal.

You are more susceptible to developing an autoimmune condition, but there’s no guarantee that you will, in fact, develop Hashimoto’s or any other disease. Many people at this stage are unaware of their increased risk.

What to do?

  • Monitor your symptoms
  • Get your thyroid tested regularly
  • Consider lifestyle changes
  • Get your thyroid tested immediately if you become pregnant and have any hypothyroidism symptoms

Stage 2: The trigger stage

Usually, in people who have a genetic predisposition to autoimmune disease or Hashimoto’s, there is a trigger that seems to mark the official start of disease activity.

Gender plays a role in the onset of Hashimoto’s, as the condition is more common in women than in men. Hormonal changes, such as pregnancy or menopause, can trigger the development of Hashimoto’s in some cases. Additionally, certain hormonal imbalances, such as high levels of estrogen, may increase the risk of developing the condition.

Environmental factors can also contribute to the onset of Hashimoto’s. Exposure to certain chemicals, pollutants, toxins, and infections can trigger an autoimmune response in susceptible individuals. Acute stress – such as surgery or injury – is a known trigger. Chronic stress and inadequate sleep can also weaken the immune system, making individuals more susceptible to autoimmune disorders like Hashimoto’s.

Diet and nutrient deficiencies can also play a role in the development of Hashimoto’s. A diet high in gluten, processed foods, sugar, and inflammatory fats can contribute to inflammation and autoimmune responses in the body. Certain nutrient deficiencies, such as iodine, selenium, and vitamin D, can also impact thyroid function and increase the risk of developing Hashimoto’s.

Keep in mind that not everyone with a genetic propensity to autoimmune or Hashimoto’s disease will develop a condition in response to a trigger.

What to do?

Stage 3: Activation and infiltration

With the onset of a trigger factor, the Hashimoto’s disease process activates. Your immune system starts creating antibodies that mistakenly recognize part of your thyroid gland as a foreign body and begin to attack and infiltrate it, causing inflammation.

This occurs on a small scale, and some people won’t feel any symptoms. Others may have various symptoms, including fatigue, brain fog, mood changes, and weight gain.

At this stage, your thyroid is usually close to fully functional. Your thyroid will probably still produce thyroid hormone, so thyroid stimulating hormone (TSH) levels will usually fall within the reference range. Your TPO antibodies may fall at the high end of the reference range or be elevated. Even if TPO antibodies are not elevated, a thyroid ultrasound may also show characteristic changes to your thyroid gland that indicate Hashimoto’s.

If you have elevated antibodies or an abnormal ultrasound, you may be formally diagnosed with Hashimoto’s at this stage. If your free thyroxine (Free T4) and free triiodothyronine (Free T3) levels are still in the reference range, you will not typically be offered treatment with thyroid hormone replacement medication.

This stage can last several years, and it’s actually the best stage for receiving a diagnosis because by making lifestyle changes, you may be able to prevent Hashimoto’s from progressing to subclinical or full-blown hypothyroidism.

What to do?

  • Monitor your symptoms
  • Get your thyroid tested regularly
  • Prioritize healthy lifestyle changes, including avoiding toxic exposures, sleep, nutrition, and stress management
  • Talk with your doctor if you are planning to get pregnant
  • Get your thyroid tested immediately if you become pregnant

Stage 4: Subclinical hypothyroidism

At this stage, the antibody attack on the thyroid gland becomes stronger and more efficient, working more quickly to attack your gland. It’s at this point that the gland’s ability to produce enough thyroid hormone starts to flag. Thyroid tests may show a slightly higher TSH level, usually still within the reference range or right on the border of the upper end of the range. Even with a normal range TSH level, you will typically have Free T4 levels that fall in the low end of the range or are below the cutoff.

With subclinical hypothyroidism, Some people at this stage are still asymptomatic. Others begin to experience hypothyroidism symptoms, including fatigue, brain fog, weight gain, hair loss, and cold sensitivity. You may also start to notice goiter (swelling of the thyroid gland.)

If your TSH level is still within the normal range, your doctor will likely recommend “expectant management.” This means you will be regularly monitored for any changes in thyroid hormone levels and be prescribed medication only when your thyroid blood values are clearly out of the “normal” range.

It’s also common during this stage for thyroid levels – and symptoms -- to fluctuate as increasing damage to the thyroid makes it more erratic in releasing thyroid hormone.

If you’re diagnosed at this stage, you still have an opportunity to keep your thyroid gland functional and avoid progressing to full, overt hypothyroidism by following a healthy lifestyle.

What to do?

  • Take any prescribed thyroid medications regularly and correctly. (Read How and When to Take Thyroid Medication for helpful guidelines.)
  • Monitor your symptoms
  • Get your thyroid tested regularly
  • Prioritize healthy lifestyle changes, including avoiding toxic exposures, sleep, nutrition, and stress management
  • Talk with your doctor if you are planning to get pregnant
  • Get your thyroid tested immediately if you become pregnant

Stage 5: Full-blown Hashimoto’s/hypothyroidism

Most Hashimoto’s diagnoses occur during this stage. At this point, the thyroid can’t produce enough thyroid hormone to maintain normal function, and the existing damage prevents the thyroid gland from meeting the body’s needs.

Typically, the TSH level will become elevated or high-normal, and Free T4 and Free T3 levels are at the low end of the range or below normal.

It’s crucial to have enough thyroid hormones for essential bodily functions such as metabolism, brain function, and body temperature regulation. This is why, at this stage, many patients experience a full range of hypothyroidism symptoms. You will likely start feeling increasingly tired and begin experiencing many other symptoms with increasing frequency and intensity.

To compensate for the loss of thyroid function, this is the point when thyroid hormone replacement medication can help alleviate your symptoms and restore you to thyroid balance.

At the same time, balancing thyroid hormones won’t do much to prevent the immune system from further destroying your thyroid gland. You can, however, continue to focus on healthy lifestyle changes to reduce inflammation and slow down the immune attack on the gland.

What to do?

  • Take your thyroid medications regularly and correctly
  • Monitor your symptoms
  • Get your thyroid tested regularly
  • Prioritize healthy lifestyle changes, including avoiding toxic exposures, sleep, nutrition, and stress management
  • Talk with your doctor if you are planning to get pregnant
  • Get your thyroid tested immediately if you become pregnant

Stage 6: Thyroid atrophy

The end stage of Hashimoto’s is when your thyroid has become so irreversibly damaged that the gland atrophies and shrinks and becomes unable to produce thyroid hormone.

Not everyone with Hashimoto’s reaches this stage, but if you do, it means that you will rely on life-long thyroid hormone replacement medication. Healthy lifestyle changes can complement your treatment, but replacing the missing thyroid hormone becomes essential.

What to do?

  • Take your thyroid medications regularly and correctly
  • Monitor your symptoms
  • Get your thyroid tested regularly
  • Prioritize healthy lifestyle changes, including avoiding toxic exposures, sleep, nutrition, and stress management to help minimize autoimmunity
  • Talk with your doctor if you are planning to get pregnant
  • Get your thyroid tested immediately if you become pregnant

Additional autoimmune diseases

While it’s not a stage of Hashimoto’s per se, at any point along the way, you’re at risk of developing another autoimmune disease.

Approximately 25% of patients with an autoimmune disease are at risk of developing an additional autoimmune disease. This phenomenon, known as multiple autoimmune syndrome (MAS), can involve the co-occurrence of two or more autoimmune diseases within the same individual. The combination of two autoimmune diseases is termed polyautoimmunity while having three or more autoimmune diseases is classified as MAS. The prevalence of MAS is increasing due to improved diagnostic methods, and it often involves a skin disease as one of the conditions. Women are more likely to acquire additional autoimmune diseases as they age, with Hashimoto’s hypothyroidism being a common co-occurrence in individuals with type 1 diabetes. Various factors, including environmental triggers, genetic factors, and immunological or psychological factors, may contribute to the development of multiple autoimmune diseases.

One of the most common autoimmune conditions that Hashimoto’s patients frequently develop is celiac disease. Celiac disease is an autoimmune disorder in which the immune system attacks the small intestine in response to gluten consumption. Studies have shown a strong association between celiac disease and Hashimoto’s, with some estimates suggesting that Approximately 4% to 6% of individuals with Hashimoto’s Thyroiditis also have celiac disease.

Another autoimmune condition that is often seen in conjunction with Hashimoto’s is type 1 diabetes. Type 1 diabetes is an autoimmune disorder in which the immune system attacks the insulin-producing cells in the pancreas. Like Hashimoto’s, type 1 diabetes is believed to have a genetic predisposition, making individuals with one autoimmune condition more likely to develop others.

Rheumatoid arthritis is another autoimmune disorder commonly seen in patients with Hashimoto’s thyroiditis. Rheumatoid arthritis causes joint inflammation, leading to pain, stiffness, and swelling. Studies have shown an increased prevalence of rheumatoid arthritis in individuals with Hashimoto’s, suggesting a shared underlying mechanism in these autoimmune conditions.

Other autoimmune conditions that Hashimoto’s patients may develop include lupus, multiple sclerosis, and psoriasis. These conditions, like Hashimoto’s, involve the immune system attacking healthy tissues in the body, leading to various symptoms and complications.

What to do?

If you have Hashimoto’s thyroiditis, you must be aware of the risk of developing other autoimmune conditions and work closely with your healthcare providers to monitor for any signs or symptoms.

This is where lifestyle changes become significant, including avoiding toxic exposures, incorporating a healthy anti-inflammatory and/or AIP diet, managing stress, and getting sufficient sleep.  

A note from Paloma

Understanding the various stages of Hashimoto’s thyroiditis is crucial for you and your healthcare providers in effectively managing this autoimmune condition. From the initial silent phase to the symptomatic hypothyroidism stage, each phase presents unique challenges and opportunities for intervention. By recognizing the progression of Hashimoto’s and implementing appropriate treatment strategies tailored to each stage, you can better navigate your health journey and strive for optimal thyroid function and well-being. Through ongoing education, monitoring, and collaboration with your healthcare providers, you can empower yourself to take control of your health and lead a fulfilling life despite the challenges posed by this complex autoimmune disorder.

Paloma Health can help you at every stage of the process. From convenient home testing kits to virtual visits with top providers, to productive sessions with specialized thyroid nutritionists and health coaches, to the Daily Thyroid Care supplement, Paloma offers a comprehensive approach to managing your Hashimoto’s. By leveraging cutting-edge technology and a patient-centered approach, Paloma Health empowers you to access expert care, education, and resources from the comfort of your own home. With Paloma Health by your side, you can feel confident that you have a dedicated partner committed to helping you thrive at every stage of your Hashimoto’s experience.

Vedrana Högqvist Tabor, Ph.D., contributed to this article.


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Mary Shomon

Patient Advocate

Mary Shomon is an internationally-recognized writer, award-winning patient advocate, health coach, and activist, and the New York Times bestselling author of 15 books on health and wellness, including the Thyroid Diet Revolution and Living Well With Hypothyroidism. On social media, Mary empowers and informs a community of more than a quarter million patients who have thyroid and hormonal health challenges.

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