When Your Thyroid Medication Isn’t Working

Two thyroid facts worth knowing:

1. The diagnosis of mild (also called “subclinical”) hypothyroidism (low levels of thyroid hormone) is overlooked by many physicians.
2. When you actually are diagnosed with hypothyroidism, you might be prescribed the medicine that won’t work best for you.

You’ve shown up for your usual ten minute, quick glance billed to your insurer as an in-depth primary care office visit. You’re allowed to talk about one problem only, and so you present the symptoms of hypothyroidism every doctor and nurse practitioner should be able to recite in their sleep. She listens, sometimes attentively, and orders the insurance approved blood test, a TSH (Thyroid Stimulating Hormone).

Be aware this is not measuring anything produced by your thyroid but rather a second hormone from a different gland a few inches away, the pituitary gland. It’s an indirect measurement, sort of like determining how fast your car is moving by looking at your fuel gauge rather than at the speedometer.

Does the TSH give you an accurate picture of your thyroid status? Sometimes, sometimes not. But if the lab reports your TSH as between 1.0 and 5.0, you’re told your thyroid is ‘normal’, and that, as they say, is that. Oh, by the way, a high TSH means your pituitary is encouraging your thyroid to make more hormone. High TSH = under-active thyroid (get it?).

So, if your TSH is between 1.0 and 5.0, you’re sent on your (less than) merry way, tired, cold, sluggish and depressed, thinking “I thought it was my thyroid”.

Well, it still can be your thyroid. You need more in depth testing. So it’s time to be a pro-active patient!

Just like you watch your speedometer, and not your fuel gauge, if you want to avoid a speeding ticket, your doctor should be measuring your actual hormones (T3 and T4) and testing you for the common thyroid autoimmune disease called Hashimoto’s thyroiditis. She also should know that a lot of endocrinologists now believe any TSH above 2.5 should be treated as hypothyroid. Probably 20%-30% of adults drag around with their TSH above 2.5.

You do need to be realistic and not blame everything on your thyroid.

You may be surprised to learn that eating too much, or eating unhealthful foods, or being chronically inactive can also put weight on, poundage not curable by taking thyroid medication. And as for ‘tiredness’, it shouldn’t surprise you that ‘fatigue’ is one of the top complaints physicians hear from patients. Thyroid issues are responsible for some fatigue issues but certainly just a small percent.

If you suspect underactive thyroid (hypothyroid) is responsible for some of your symptoms, you can do a quick screening test on yourself invented by Broda Barnes, M.D., a Rush Medical College trained physician and professor at U. of IL College of Medicine. We use it often here at WholeHealth Chicago to initiate thyroid treatment. Low body temperatures (below 97.6) frequently accompany hypothyroidism. Barnes standardized the measurement and gave “cold” patients a trial of thyroid hormone treatment which was usually successful. However, the TSH test was invented at about this time and seemed more ‘scientific’.

But uh-oh! What happens when you’re taking the prescribed thyroid replacement and nothing happens. That’s right. Your hopes…dashed; you’re still cold, tired and worse than anything, you haven’t lost an ounce. What went wrong?

Don’t give up! Any of several possibilities:

1. Your dose isn’t high enough. A definite possibility, but don’t increase it on your own. Dose adjustment is not DIY healthcare. Let your doctor adjust your dose by listening to your symptoms and tracking results of a full thyroid panel (TSH, T3, T4). Some patients feel best being a scoatch below hyperthyroidism (a scoatch is slightly less than a smidgen), but going around in a self induced hyperthyroid state (called ‘factitious hyperthyroidism’) is simply unhealthy.
2. The thyroid product isn’t right for you. Conventional physicians have been brainwashed to prescribe Synthroid, a/k/a Levoxyl, a synthetic T4 which replaced dried (‘desiccated’) pig (‘porcine’) thyroid in the 1960’s (Armour <which older Chicagoans remember as the meat packing plant>). Why ‘pig’? Because the pig’s thyroid blend of T4 and T3 is actually closest to the human thyroid. The current brands of pig thyroid (called ‘porcine’) covered by insurance are Armour and NPThyroid.
3. Alternatively, your doctor might add pure T3 (liothyronine, Cytomel) to your T4 as a separate prescription. Since T3 is much more potent than T4, your initial dose will like be quite small, on the order of 5 mcg (mcg stands for micrograms, one millionth of a gram, one thousandth of a milligram). If you’re prescribed Cytomel, never ever self-treat (“Oh, I’m feeling so fat today, I’ll just take a few extra Cytomel”). Yikes! Too much Cytomel can trigger very unpleasant side effects and possibly dangerous heart arrhythmias.
4. If you are using Cytomel (T3) you might feel an afternoon crash. This is because T3 has a short half life and disappears quickly from the body. You might feel better if you spread your dose throughout the day, e.g., 5 mcg three times a day. There are also capsules of slow release T3 available but you’d need to get this from a compounding pharmacist. It is expensive and rarely covered by insurance.
5. Don’t neglect your adrenal glands. Your thyroid and adrenals are both pituitary controlled, stress responding glands and when under chronic stress, both can get fatigued. If you start treating your thyroid, your increasing metabolism may place an extra burden on your adrenals. Symptoms of adrenal fatigue can mimic hypothyroidism. Take an adrenal support formula when starting thyroid. If you still feel thyroid symptoms, and your lab tests are good, have your doctor order an adrenal test measuring salivary cortisol taken throughout a single day.

• You may have overlooked selenium. It’s only recently been shown that diets low in selenium can induce hypothyroidism.

• Familiarize yourself with Janie Bowthorpe’s website. The more I read Janie, the more I’m convinced the woman knows more about thyroid than 99% of physicians practicing in the U.S.
• Don’t increase your thyroid dose without professional supervision.
• And finally, again, please, don’t forget that “fatigue” is one of the commonest complaints a primary care physician hears each day. There are dozens of causes of fatigue. If your pursuit of hypothyroidism turns up zip, don’t let either of you give up.

Be well,

David Edelberg, MD