Dr. Lily Conrad's Integrative Approach to Thyroid / Hormone Imbalances

An Interview with Elizabeth "Lily" Conrad, MD

Lily Conrad, MD
Lily Conrad, MD has an integrative approach to diagnosing and treating hormone imbalances. Lily Conrad, MD

Elizabeth Conrad, MD – known to her patients as "Dr. Lily" -- is an integrative physician in practice in McLean, Virginia. Dr. Lily has a devoted following of patients who are seeing her for thyroid and hormonal imbalances. She agreed to share her thoughts about her approach to diagnosing and treating patients in this Q & A interview.

Mary Shomon: Did you start out with the intent to be in conventional/traditional medicine and switch to integrative/holistic, or did you always intend to be an integrative MD? What motivated or inspired you?

Dr. Lily: I have always known that I would be an integrative physician. We are so much more than what we can see, touch or measure in a lab test. Our potential for improving our happiness and health expands dramatically when we nurture mind, body, and spirit. I was very fortunate that the pediatric surgeon who conducted my interview for the Columbia University College of Physicians & Surgeons was very open-minded and interested in hearing about the practice and benefits of meditation. We spent much of the interview discussing breathing and the similarities between meditation and physical exercise.

Hormonal Issues

Mary Shomon: Your practice, Well Being-Being Well, works with many patients who have hormonal imbalances. What are the most common hormonal issues you see in your female patients?

Dr. Lily: We do see many women who have concerns relating to Premenstrual Syndrome (PMS), Polycystic Ovarian Syndrome (PCOS), hypothyroidism, perimenopause, and menopause. We also see patients who are thinking about pregnancy, women with insulin resistance, metabolic syndrome, and pre-diabetes.

Mary Shomon: Why do you think it's so difficult for many patients who see conventional physicians to get properly diagnosed with thyroid, adrenal, or other hormonal imbalance issues?

Dr. Lily: It takes time, which can be very limited in practices seeing 20 or more patients a day. Also, many of these imbalances are subtle and are not easily detected using standard tests. People can have real-life health issues and lab values may be within normal limits. For example, the normal range for cortisol is very wide, in addition, what is normal on a lab is not necessarily what is optimal. It is important to address the whole person, in a partnership, and to look at many factors: nutrition, stress management, environmental exposures etc. to help support optimum health.

Our training in conventional medicine is mostly hospital-based and excellent as far as diagnosing and treating severe disorders. Heart attack, stroke, and appendicitis are all best served with a conventional approach. Conventionally trained physicians do recognize that each of the systems affect the others. For example, heavy and irregular periods often improve when the thyroid is optimized. However, on its own, a conventional approach can be less helpful for subtle chronic diseases and imbalances.

Medicine is always changing and improving. As physicians, we want the best for our patients. Integrative physicians are uniquely positioned with additional tools to address subtle imbalances; such as herbs, nutrition, and acupuncture to provide customized care for each patient. Eastern medicine incorporates the value of balance, and this adds much to our healing view. The body is more like a garden to be tended, promoting harmony and vitality. The conventional perspective has been to look at disease as something we are fighting or suppressing with drugs.

As medical students, we don't often have much exposure to herbs, nutrition and supplements, acupuncture and mind-body techniques. Fortunately, this is changing and schools are beginning to incorporate Complementary/Alternative Medicine (CAM). It is encouraging to see pioneers like Dr. Jim Gordon, of the Center for Mind-Body Medicine and Georgetown University in Washington, DC, promote this transformation of health care, as we move away from a central focus on drugs and surgery at the core with self-care and CAM techniques at the periphery to a central focus on self-care, with prevention and wellness as a focus and thus less need for drugs and surgery. It makes so much sense.

Thyroid Issues

Mary Shomon: What tests and issues do you take into consideration when evaluating a woman for a potential thyroid problem?

Dr. Lily: I am interested in her history and what she is experiencing, if there is a history of thyroid issues in her family. I will review other symptoms and do a physical exam. Testing often includes TSH, Free T3, Free T4, Reverse T3, Thyroid Antibodies, anti-thyroglobulin and thyroid peroxidase antibody. Often an adrenal test is done as well and any other tests that may be needed.

Mary Shomon: The American Thyroid Association's 2014 Hypothyroidism Guidelines claim that hypothyroid patients should only be prescribed levothyroxine, and that to prescribe T3 and/or natural desiccated thyroid drugs is unethical for physicians. What are you thoughts on the ATA's position?

Some patients respond beautifully to T4 and can convert the T4 to T3 without any problems. However, not all patients can do this well. I find the Free T3 and Reverse T3 to be invaluable in understanding the lack of efficacy of T4 in some patients. Many studies have shown that patient satisfaction is greater with a T4/T3 combination therapy. Fortunately, the ATA recognizes the need for continuing research in this area. I am happy that currently studies on Slow Release T3 are being conducted. Slow release preparations are often better tolerated than immediate release T3.

Mary Shomon: The American Thyroid Association's 2014 Hypothyroidism Guidelines claim that hypothyroid patients who don't feel well when given levothyroxine and restored to "euthyroid" levels should be referred for a psychiatric evaluation. What are you thoughts on the ATA's position?

Dr. Lily: There are data that suggest that patient's T4 levels may be adequate but the T3 levels often fall when given T4 alone. Mood and a sense of wellbeing can be affected by the T3—serotonin connection.

I think it is better to have them see their family doctor or internist to be sure everything has been checked. Patients who have continuing symptoms deserve a thorough evaluation, maybe something else is going on…like Lyme Disease or Lupus. Many diseases can present with fatigue. If there is depression they could benefit from seeing an integrative psychiatrist.

Mary Shomon: What is your experience with hypothyroid patients? What do you prefer prescribing for your patients: levothyroxine, synthetic T4/T3, T3 only, natural desiccated thyroid, compounded meds?

Dr. Lily: I prescribe these on a case by case basis. Patients do seem happiest with the combination therapy and the natural desiccated thyroid works well. It is also available through most pharmacies.

Adrenal Imbalances

Mary Shomon: There is a great deal of controversy over the very existence of "adrenal fatigue" or adrenal insufficiency. The conventional medical world says that we have Cushing's Disease or Addison's Disease, and otherwise, there are no shades of gray in adrenal function. What are you thoughts on why conventional medicine views it in such a black-and-white way?

Dr. Lily: Cushing's Disease and Addisons disease are severe forms of cortisol excess and insufficiency. I believe that the recognition of relative adrenal insufficiency (RAI) is rising. For example, it is fairly common in chronic liver disease. A very nice study was published recently on RAI in patients with liver disease, (Ailment Pharmacol, Ther, 2014 Oct; 40(7) 819-26.)

One factor that makes adrenal dysfunction so hard to recognize is that the normal values have such a wide range, for instance, a morning cortisol has a normal range of 2-20. This one "snapshot" in the morning might not be enough. I prefer to get multiple readings throughout the day as in the cutting edge, Genova Adrenal profile test.

Mary Shomon: What is your approach to identifying and treating adrenal imbalances in your patients?.

Dr. Lily: We perform a thorough history and physical exam which is adapted as needed. Many patients may have low blood pressure, and we will check their pulse and blood pressure in different positions. Often I will order a saliva test for cortisol that gives us multiple readings throughout the day, DHEA-S is included in this test as well.   Standard bloodwork is done including a comprehensive chemistry profile. We look at key nutrients such as Vitamin D and minerals like magnesium. Depending on the patient, I may look for other causes of their symptoms.  We then begin to formulate a plan to address the underlying causes of the symptoms when possible. Gentle tools to address these issues are available,such as mind-body techniques and the use of adaptogenic herbs like Ashwagandha. 

Weight Loss

Mary Shomon: Many women in middle-age, and of perimenopausal and menopausal age struggle with weight gain, or difficulty losing weight. What sorts of advice do you have for women who are eating well and exercising, but having little weight loss success?

Dr. Lily: First, I want to say, good for you. Exercise and healthful eating will help you to feel your best and maintain health much better than being sedentary, and not eating enough vegetables and fruits. Next, I want to make sure she is eating enough, drinking enough pure water and getting enough rest. Often weight loss stalls because of inadequate intake of protein and calories or inadequate rest. If you are still having trouble see someone who can partner with you to help identify where you are,and make a plan to support you to where you would like to go. Some women are raising cortisol by over exercising, while others may have elevated insulin. Your program should be tailored to you.

Mind-Body Medicine

Mary Shomon: We are starting to truly recognize the importance of reducing stress, incorporating relaxation, and putting the power of the mind-body connection to work as part of wellness. Do you have some thoughts on some of the best ways women can do this, given our busy lives?

Dr. Lily: One of my favorite techniques is to work in moments of mindfulness every day. When you step outside, feel your feet on the ground, take a breath and look up. Notice the sky, do you feel the sun on your face? Are there clouds, is there wind? Are there birds or other animals? When you arrive home take a breath and notice how you are feeling in that moment. When you eat, take a moment to think of something you are grateful for and give thanks. Then notice the appearance of the food, its color then its scent its texture and flavor. As women, we are often the center of our family and we can nourish ourselves in this way and also teach our children to tune into the moment. My children will remind me if I have forgotten our grace, which is most often like this: each person briefly says one thing they are grateful for as we go around the table. Taking the moment to pause and be grateful can change our mindset and help us be ready to receive.

Another easy tool is to list three things you are grateful for on a daily basis, perhaps on a little pad on your bedside table. It is a great way to start or end the day.

Find a practice that you like, that feels natural to you. Yoga, pilates, Tai Chi, Qi Gong, massage, walking outside, mindful meditation and guided imagery all can help us strengthen the mind-body connection.

Find something you like and try to do it regularly. There are some nice apps available that have short but effective meditations that you can do in under 10 minutes.

If you like your yoga class, great! Pick a place in your home where you can roll out your mat and spend 5-10 minutes a day doing postures and breathing. If you can stretch that to 20 minutes, even better!

One Thing Every Patient Should Do

Mary Shomon: If there was one thing you could ensure that every one of your patients would do to improve wellness, what would it be?

Dr. Lily: Be kind to yourself, take time for self-care, treat yourself as you would a treasured friend!

Elizabeth (Lily) Conrad, MD, graduated from the College of Physicians and Surgeons of Columbia University in 1991. She completed her residency in family practice at The Montgomery Family Practice Residency Program in Norristown, PA. Dr. Lily, as she is known to her patients, has been board certified in Family Medicine since 1994. Her career has been devoted to healing the whole patient in a committed, working partnership that supports health and well-being. In addition to her traditional family practice background, Dr. Lily has been studying meditation since her introduction to the martial arts in 1985. She has studied many traditional mind/body approaches to healing including Mindfulness-Based Stress Reduction with Jon Kabat-Zinn and Saki Santorelli at the University of Massachusetts. Her studies have also included yoga, Ayurvedic medicine, and homeopathy. Dr. Lily studied acupuncture at UCLA, recognized as the country's top school of acupuncture for physicians. She became board certified in Medical Acupuncture in 2004. She has continued to study acupuncture and Chinese herbal medicine as well as western herbal medicine and nutrition. She practices integrative medicine in McLean, Virginia, at Well Being-Being Well, where she also focuses on conventional and natural treatment, customized plans to support hormonal balance and empowering patients with education and strategies to lead healthier, more balanced lives.

Elizabeth Conrad, MD
Well Being-Being Well, 6862 Elm Street #720, McLean, Virginia 22101, Ph: 703-635-2158