Matching Your Medication to Your Needs in Hypothyroidism & Hashimoto's
When you are told your thyroid is normal based on a lab test, but you still feel tired, teary, you’re losing hair and are gaining weight - it can be heartbreaking. Heartbreaking to suspect how you are feeling now is as good as life gets and heartbreaking to realise your doctor won’t prescribe any more medication.
I remember vividly being told my thyroid was normal and the fatigue and brain fog suffocating my life was therefore not related to my thyroid at all. I was barely able to get out of bed in the morning and I needed to sleep for 5 days to store up the energy to go to work at a job that should have been very easy 2 days a week. The only option I was given was psychological intervention and referral to a specialist for strong anti-depressants.
Oh, so what I am feeling is all in my head? I must be crazy…
It wasn’t until years later when I learnt I could order my own laboratory tests and paid the ridiculously cheap price of $40 AUD that I discovered the amount of active thyroid hormone (T3) circling in my body was severely deficient.
I had so little of this active thyroid hormone (T3) in my body it was likely I was not able to efficiently use the foods I was eating to fuel energy production in my brain cells, hair cells and fat cells. No f$%^g wonder I was exhausted and freezing cold on all but the hottest of hot summer days.
It wasn’t in my head, I wasn’t crazy - this was real.
So when I have clients now tell me they have been told their thyroid is normal I encourage them to:
1. Test a little more thoroughly
2. Depending on the results of their comprehensive standard pathology find a doctor that will engage in a conversation around supporting their health with medications that are available and that may be better suited to their own specific situation.
Then once their thyroid medication has been optimised:
3. Tidy up and resolve any remaining symptoms they continue to experience - medication does not solve all problems. I wished upon this star for years that medication would cure all my ills before I fully appreciated for me, living a life free of all symptoms meant, taking control of what I eat, how I move my body and the way I manage my stress levels.
4. Address the possible causes of the hypothyroidism to make sure they are not vulnerable to more autoimmune conditions developing. Autoimmune conditions like to entertain and party together. Once one of them appears it is common for more of them to cluster in and take up residence. Within 6 months of being diagnosed with Hashimoto’s, I had also been diagnosed with a total of 5 autoimmune diseases. Investigating and removing the possible triggers for autoimmunity may prevent the cascading effect of autoimmune clusters.
Get Your Medication To Match
When you are tired, teary and overweight and medicated it is vital to start here - making sure you are taking the type of medication that matches what your body needs.
In general, when you are on thyroid medication you will be taking levothyroxine which is synthetic thyroxine or synthetic T4. This medication has different names depending on brand names used by pharmaceutical companies. If you are not sure if your medication is T4 only here is a non-exhaustive list of brand names by country:
USA: Synthroid, Levoxyl, L Thyroxine, Levo T, Levothroid, Levothyroxine T4, Levoxine, Tirosint, and Unithroid
UK: Eltroxin Advanz, L-Thyroxin, Actavis, Almus, Northstar, Teva
Australia: Oroxine, Eutroxsig & Eltroxin.
Step 1. Test
For some with hypothyroidism and Hashimoto’s the traditional ‘gold standard’ of testing TSH and prescribing the medication synthetic T4 is not enough.
Before we talk about options let’s clear up some of the thyroid-specific language I’m going to use.
How thyroid hormone is made:
Your brain makes the thyroid-stimulating hormone (TSH). TSH is a messenger that talks to your thyroid gland.
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TSH travels to your thyroid, a small butterfly-shaped gland in your neck, and tells it how much thyroid hormone to make.
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Your thyroid makes T1, T2, T3 and T4 plus calcitonin. At this stage of medical knowledge we really only know what T3 and T4 do specific to thyroid and body functions so it is on these we focus. We’re not interested in calcitonin for this discussion.
T4 is only made by your thyroid gland and is the storage form of thyroid hormone. Think of T4 as the ingredients of a meal like a bag of dried lentils and a raw sweet potato. You cannot eat them as they are in their raw state but with a little effort, time spent cooking plus a few other additions, you can make a meal.
T3 is made both by your thyroid gland and from the conversion of T4. T3 is active thyroid hormone. Using the same food example, T3 is like the cooked meal of lentil and sweet potato soup you can eat immediately and provides you with energy.
T4 can also make another hormone called reverse T3 (rT3). RT3 is like someone stealing the food off your plate or someone putting their hand over your mouth as you are trying to eat your dinner. The end result of a high rT3 score is you are not able to access all of your active thyroid hormone T3.
Alrighty, let’s go back to talking about testing.
When testing your thyroid function in Australia, USA and the UK mostly the measure TSH is used. This is generally what is judged when you are told: “your thyroid is normal”.
For me and for many of my clients unfortunately whilst our TSH might be within reference range our T3, active thyroid hormone, is too low and/or our rT3 is too high. This means (for the reason which I’ll talk about elsewhere otherwise this post will be as long as War and Peace) our body is not efficiently cooking and converting our storage raw T4 into active cooked T3.
Just like eating hard lentils and uncooked sweet potato is not delicious neither can all of your cells use raw T4 for energy. When there is not enough of the cooked version of thyroid hormone, T3, your cells can go hungry not getting enough to fuel their activities. Leaving you with hair cells making less hair and hair poorer in quality. This can be happening to any part of your body from your eyelashes to your toenails.
In fact, scientists have found in recent animal experiments only the combination of T4 and T3 replacement, and not T4 alone, ensures normal functioning in all cells and tissues in the hypothyroid (Wiersinga, 2001).
This means if we are only taking T4 medication or synthetic thyroxine and our T3 is too low or not able to be used by our body seen with high rT3 we may continue to experience hypothyroid symptoms like fatigue, brain fog, weight gain, constipation, weak muscles, hair loss, dry skin, puffiness, heavy periods and infertility.
Step 1: What to test
TSH, Free T4, Free T3 and reverse T3 these are generally written on a pathology request form as TSH, FT4, FT3, rT3.
Increasingly this is being proven in scientific research as well. Let’s have a look at what has been claimed and to help you talk with your doctor or primary care physician here are a few peer-reviewed journal articles on studies to support your requests.
A review of all current studies on T4 + T3 medication published in The Journal of Clinical Endocrinology & Metabolism suggests:
- "TSH level within the reference range is not a sufficiently optimal marker of adequate thyroid hormone replacement therapy in hypothyroid patients".
- “Consider a personalized regimen of thyroid hormone replacement therapy in hypothyroid patients” using T3 + T4 as needed. (Biondi & Wartofsky,2012).
For those interested in natural thyroid medication, called desiccated thyroid extract (DTE) or natural desiccated thyroid (NDT), these medications typically include a combination of T3 and T4 sourced from animals. A study on hypothyroid people previously prescribed desiccated thyroid extract who were switched to levothyroxine (synthetic T4) reported they felt worse “despite adequate dosing based on serum TSH levels” (Hoang, et al., 2013).
Now that’s what I call the Buffy the Vampire Slayer roundhouse kick to the old, TSH is the best and only measure of thyroid function for the hypothyroid and Hashimoto’s, supporters. I’m hoping this belief goes up in dust one day!
Dosing T3
Often I am asked to provide advice on dosages of medication. I am not a doctor so I do not provide advice on dosing medications. Advice on medication must always be taken from a doctor and/or pharmacist. If you are listening to alternate advice on medication for yourself please always prioritise what a doctor or pharmacist has recommended.
However, when these questions are asked of me by doctors and pharmacist, I point to the following evidence for their research:
- When adding in T3, 50 µg of the patient’s T4 replacement dose may be replaced by 12.5 µg T3 (Wiersinga, 2001).
- Bearing in mind T3 medication may be most safely titrated up from minimum starting dose of 5mcg testing every 4 - 6 weeks and based on results and signs and symptoms.
- Additional doses of T3 may be most safely taken divided throughout the day rather than in one-morning dose. This is contrary to the method of dosing T4 once/day.
- Always caution if the pulse rate increases over 90 beats/minute, blood pressure increases, rapid breathing, sensation of a tight chest and/or anxiety appear or increase, T3 medication should be stopped immediately and medical advice and intervention sought urgently.
Does this mean I am advocating if you feel well, healthy, happy and are symptom free on T4 medications you need to swap? Nope.
One size does not fit all when it comes to thyroid medication.
If you don’t feel as good as you want to:
1. Request a thorough medical questioning on signs and symptoms you are experiencing and compare these with thyroid signs and symptoms. Check out my download on thyroid signs and symptoms for suggestions.
2. Comprehensive laboratory testing of thyroid:
a) Baseline standard pathology testing: TSH, Free T4, Free T3.
b) Additional judgement if T3 is not providing relief anticipated: Reverse T3 (rT3) which is best compared with T3 levels tested at the same time.
The bottom line:
• Testing TSH is not enough if you are still experiencing hypothyroidism symptoms.
• T4 medication alone may not be the best option for all hypothyroid and Hashimoto’s patients.
• It may be possible to match your thyroid medication to what you need to feel good.
In health and happy hormones,
Sonia x
References:
Biondi, B., & Wartofsky, L. (2012). Combination treatment with T4 and T3: toward personalized replacement therapy in hypothyroidism? The Journal of Clinical Endocrinology & Metabolism, 97(7), 2256-2271. https://pdfs.semanticscholar.org/1f05/33af337382745a8e57b1c58f21c9cc082ee3.pdf
Hoang, T. D., Olsen, C. H., Mai, V. Q., Clyde, P. W., & Shakir, M. K. (2013). Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study. The Journal of Clinical Endocrinology & Metabolism, 98(5), 1982-1990. https://pdfs.semanticscholar.org/8a02/5f13a5c7bd8992475c21e5ad93d802c8546f.pdf
Wiersinga, W. M. (2001). Thyroid hormone replacement therapy. Hormone Research in Paediatrics, 56(Suppl. 1), 74-81. https://www.ncbi.nlm.nih.gov/pubmed/11786691