Some of the most common questions I receive via phone, email, Facebook, and yelled across the street concern thyroid replacement hormone.
The question usually goes something like, “Hey, what’s the best thyroid hormone?”
And like most things with Hashimoto’s, this is a super difficult, complicated question disguised as a simple one.
All I can do is mumble, “It depends”
In addition, the problem is that, in reality, many, many people don’t feel better after taking thyroid replacement hormone.
Or they feel better for a while, then they feel worse again.
And a lot of Hashimoto’s patients get fixated on this drug.
Some have to change to natural desiccated. Some are told they have to get on a synthetic. Others have to add T3 or only be on T3. Or they have to raise the dosage, then lower it, then change to something else.
And doctors also share this fixation because thyroid hormone is really important physiologically and for most, thyroid replacement hormone is the only tool in their tool box. And many refuse to budge from the myth that synthetic T4 is the only safe option.
So we wind up with dueling and intractable obsessions resulting in people being pissed off at their doctors, doctors refusing to prescribe anything except Synthroid or the generic equivalent and, unfortunately for the patient, little or no improvement in their hypothyroid symptoms.
There has got to be a better way.
In this post, we will look past this obsession and help break down and demystify thyroid replacement hormone.
The first question, and one that is controversial, is do you really need to be on thyroid replacement hormone?
This is an important question and, of course, the answer is….(wait for it)…it depends.
Really, it depends on how much thyroid function you have left.
Hashimoto’s is an autoimmune disease in which your immune system slowly destroys your thyroid.
If enough of your thyroid gets destroyed and it stops producing sufficient amounts of thyroid hormone, you can not be without replacement hormone. End of conversation.
On the other hand, if you do have enough thyroid function (and a lot of people do), then the problem may lie elsewhere.
Often the problem is an out of control immune system impacting thyroid function or problems with breakdowns in thyroid pathways that are causing the hypothyroidism.
It’s not the lack of thyroid replacement hormone.
If you focus on properly managing the autoimmune disease part of the equation and on properly evaluating and improving the pathways that make thyroid hormone work, then you may not need extra thyroid hormone at all.
(To complicate matters, once you start taking replacement hormone it impacts the amount of thyroid hormone your body is producing.
So if you have been on it for many years, chances are you may have compromised the thyroid’s ability to produce it alone.)
Even when thyroid hormone replacement is used, it is still very important to manage the autoimmune condition.
This will make the medication work better, slow the destruction of the thyroid gland, and prevent the progression of the autoimmune condition into attacks on other parts of the body like the brain, which comes in really handy, at times.
This is where we should really be fixated. Slowing or stopping the progression of the autoimmune part of this disease should be our obsession. (Ok, I admit it, it’s mine.)
Let’s Look At The Options
That being said, let’s take a look at what the options are and how you can make the best decision for you and your unique set of circumstances.
First there are 2 important factors to consider:
* Bio-identical versus Synthetic
Bio-identical Versus Synthetic
Bio-identical, as the name suggests, is more like what your body actually produces. The most popular of these are Armour or Nature-throid. The advantage to these is that we can actually test their levels in your system using laboratory testing other than TSH.
The disadvantage is that some people with Hashimoto’s will feel worse on these because their immune system can attack T3 and T4 because they actually have antibodies against them.
Unfortunately, we do not yet have laboratory tests available to test these antibodies.
The advantage of synthetic drugs like Synthroid and levothyroxine is that they are synthetic and the immune system will not attack them.
The disadvantage is that TSH is the only test to measure levels of these drugs and there are many reasons why TSH is an unreliable marker of thyroid hormone levels.
The criticism by doctors leveled against bio-identical hormones is that the dosage varies from batch to batch. A frequently perpetuated myth (from the marketers of Synthroid) is that the dosages and ratio of T4:T3 in Armour aren’t consistent.
That’s just not true, studies have shown otherwise. Armour contains a consistent dose of 38 mcg T4 and 9 mcg T3 in a ratio of 4.22:1. As does Nature-throid.
T3 to the Rescue
Many patient advocates and thyroid support groups sing the praises of T3. And for some, there is no question, T3 is the answer. For others, it’s a nightmare.
T3 is the active form of thyroid hormone, this is what has the greatest impact on our bodies. This is what gives you energy, gets the bowels moving, makes you feel happier and helps you think more clearly. For some this is what helps their hair grow better and their skin get that blood flow back into it.
These people may have trouble converting T4 to T3 because their cells develop thyroid hormone resistance.
On the other side of this are the people who get hyperthyroid with the addition of T3. Think anxiety, insomnia, palpitations, weirdness, a strong desire to vacation at the funny farm.
This is also the case with people who are not managing the autoimmune part of this disease. The attacks against the thyroid causes more thyroid hormone to be released into the bloodstream.
For these people, synthetic T4 might be the better choice along with a concerted focus on managing the causes of these inflammatory incidents (like eliminating gluten, dairy, soy, stress and environmental toxins).
2 Common Things Make You Feel Worse
There are also 2 important factors that can make you feel much worse on thyroid replacement hormone:
Fillers and Adrenal Issues.
Fillers: These are extra things added to the drugs by the manufacturers. Many popular thyroid medications contain common allergens such as cornstarch, lactose and, in some cases, even gluten.
Most Hashimoto’s patients have issues with gluten, and many of them also react to corn and dairy (which contains lactose).
Synthroid has both cornstarch and lactose as a filler. Cytomel, which is a popular synthetic T3 hormone, has modified food starch – which contains gluten – as a filler.
Even the natural porcine products like Armour use fillers. In 2008, the manufacturers of Armour reformulated the product, reducing the amount of dextrose & increasing the amount of methylcellulose in the filler.
This was great for some patients who were sensitive to dextrose and a disaster for others who were sensitive to the methylcellulose.
Nature-throid is considered the most hypo-allergenic of the bio-identicals.
The best choice may be to ask your doctor to have a compounding pharmacy fill the prescription using fillers you aren’t sensitive to. This can be more expensive and unfortunately, some insurance companies refuse to cover it.
Adrenal Issues: If you take Synthroid or even a bio-identical and feel so horrible on the drug that you just can’t continue taking it, one thing to check right away is your adrenals.
The warning label of Synthroid states explicity “Patients with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation of treatment with levothyroxine sodium.”
This can cause an acute adrenal crisis in the most extreme cases.
But even in less extreme cases, like those people who have adrenal fatigue and/or exhaustion, taking this drug can result in the patient feeling really lousy.
The adrenals should always be evaluated whenever a patient is prescribed thyroid replacement hormone. (Ideally, this should happen before it is prescribed. Good luck with that.)
Let’s take a look at some other common clinical situations and look at why these things happen.
Normal TSH, But Still Feel Like Crap
This is by far the most common scenario for people with Hashimoto’s. Chronic inflammation can prevent thyroid hormone from getting absorbed in to the cells of the body. This the root of autoimmune disease, but can also come from other things (like infections, surgery, obesity, overtraining, poor diet, etc.).
*Inhibit thyroid receptors on cells from responding to thyroid hormone.
*Prevent T4 from converting to T3.
*Interfere with the communication between the pituitary and the thyroid (and the adrenals).
Felt Better With Bio-Identical
Some people truly do feel better with bio-identicals. It’s not true of everyone but the addition of T3 can sometimes be the answer because these people:
*May need T3 due to problems with the thyroid hormone receptors on cells
* Were unable to convert T4 to T3 when using T4-only medication
*Had sensitivities to dyes or fillers in synthetic compounds that are not in bio-identical compounds
*Have receptor sites on cells that simply respond better to bio-identical than synthetic hormones
Did Better With T3 Only
As we have seen, some people improve with the addition of T3, while others do their best with T3 only. And these can be synthetic or bio-identical.
This can happen for a couple of reasons:
* Their receptor sites are resistant to thyroid hormone because of high cortisol, high homocysteine, inflammation, low progesterone, vitamin A deficiency and more.
* Difficulty in converting T4 to T3
Didn’t Feel Better With T3 or Bio-identical Hormones
In both cases, more T3 is introduced. These people often don’t have too little T3, they have an active and uncontrolled autoimmune process causing the release of thyroid hormone.
These are also the people who often vacillate from hyper to hypo. They have an immune flare up, more hormone is released and then they crash, it calms done and they are hypo again.
In some cases, these people can have excess adrenal hormones caused by too much nicotine, caffeine, stress or exercising too much.
Feel Better on Synthetic Hormones
Some people actually feel better on synthetic hormones. These can be people who are converting well, have an overactive metabolism and just don’t need more T3.
These are people who also really benefit from an approach that will calm the autoimmune attacks that cause their thyroid to be revved up in the first place.
In every single case described above addressing the underlying autoimmune process first will result in a better clinical outcome (you will feel better) because by reducing the inflammation which is the root of this problem you can:
Improve thyroid receptor site sensitivity
Prevent further destruction of the thyroid
Slow the progression of the autoimmune disease so it doesn’t spread to other parts of the body.
Once again, there are so many variables with Hashimoto’s. The best approach involves a full thyroid work-up and exam, followed by trial and error of different types of replacement medications.
Such a work-up includes more than just TSH, it also has a more complete thyroid panel (including antibodies), other important blood markers (glucose, lipids, CBC with diff, electrolytes, iron, etc.) and additional inflammatory markers like homocysteine, vitamin D, CRP, ferritin, etc.
A history must be taken with attention paid to the patient’s past responses to replacement hormones. With Hashimoto’s patients what a patient feels is clinically relevant and diagnostically important.
Unfortunately, this rarely happens in the conventional model, where the standard of care is to test only for TSH and, if you’re lucky T4.
If TSH is elevated, the patient will get whatever hormone that particular doctor or practitioner is fond of prescribing and that’s the end of it.
Then they are told, “Come back in 6 months to a year and get your TSH tested again. Buh bye.”
And all too often, as many of you know, this approach is doomed to failure. But there is a better way and we are practicing it here at Hashimoto’s Healing.
We offer a complete work up and we focus…, ok, I’ll say it…rather obsessively on reducing the inflammation at the root of this disease and at doing other things to calm, slow and prevent the advancement of autoimmunity to other parts of your body.
This is not just a thyroid problem and there is a lot at stake here. If we’re going to be obsessive, let’s obsess about the things that are at the root of the problem.
I set aside time every week to talk to people with Hashimoto’s about what’s going on with them. In the last year, I have had over 500 of these conversations.
I offer a free 30 minute Hashimoto’s Healing Discovery Session.
In it you can share where you are and where you want to be, I can give you some advice that will help right away and we can discuss how else I may be able to get you feeling better.
If you want to talk with someone who gets it, someone who has been there and who has devoted his life to help people with Hashimoto’s, then I suggest you schedule a time to chat with me.
You might just learn something. Here’s the link to schedule.
http://www.ncbi.nlm.nih.gov/pubmed/23072197 T3 to T4 ratios
http://www.womensinternational.com/pdf/thyroid_hormone_therapy_options.pdf T3 to T4 ratios
http://www.medscape.com/viewarticle/722086_1 Full on medical discussion
http://www.ncbi.nlm.nih.gov/pubmed/15767619 Interesting study on the difference additional T3 therapy makes
http://tpauk.com/main/?page_id=1054 Argument against marketing propaganda
The Thyroid, A Fundamental and Clinical Text, Braverman and Utiger, 9th Edition, 2005
Why Do I Still Have Thyroid Symptoms When My Lab Tests Are Normal? Dr. Datis Kharrzian, Elephant Printing 2010
Wow, it’s been a year since I launched my website and Facebook support group. SO MUCH HAS HAPPENED!
I am a big proponent of looking back at the data and the experiences and analyzing what we learned. And, hopefully, we can build from that and improve what we are trying to do.
And that is to help and educate people to heal their Hashimoto’s.
Over the course of this year, I have had over 500 consultations with people with this disease.
I’ve listened as people described their symptoms and their health histories and I’ve also taken a number of surveys and polls at our Facebook support group which has now reached 10,000 Likes.
I want to thank everyone who has joined us for their continued love and support! This is something we could not have achieved without you.
In this blog post I’m going to summarize the top 5 things that I think are really important (from a clinical and practical point of view) and I’ll share a few odds and ends that are just really interesting to me.
Here are my top 5 clinical pearls and a little discussion on each and why I believe it matters to you.
By far, the most common thing I have seen is that many, many people taking thyroid replacement hormone are functionally hypothyroid.
What does that mean?
Well, they are taking thyroid replacement hormone (and it doesn’t seem to matter whether it’s Synthroid, Armour, or Synthroid and Cytomel, or Naturethroid, etc.), their lab test results (usually this means TSH and if we’re lucky TSH and T4) are normal.
However, they have all the common hypothyroid symptoms: they are tired all the time, they are frequently depressed and/or they have anxiety, they have trouble losing weight, their hair is falling out, they have brain fog and memory issues, etc.
Since there is such a consistency of symptoms despite the thyroid replacement hormone, then you have to look at the possibility that the solution can be found in something other than thyroid replacement hormone.
Many people really focus on switching hormones or switching back or switching dosage up and down and for a few, the change works, for others it works for a little while and stops working and for the majority it doesn’t matter because it doesn’t work at all.
For some the addition of T3 can help tremendously, for others it helps for a little while and then stops working. And for others it doesn’t seem to help very much either.
So, if it’s not the thyroid replacement hormone, then what’s the problem?
The problem that I have seen repeatedly is that they are not converting and/or absorbing the replacement hormone.
One reason for this is that TSH is produced by the pituitary which absorbs thyroid hormone differently than the rest of cells in the body.
The pituitary can register thyroid hormone levels when the rest of the body is resistant or just not absorbing it.
There are lots of other reasons why this can happen, but the most important thing to understand is that it’s not always the choice of thyroid hormone, it’s a problem somewhere along the process of getting that hormone into the cells of your body.
What this means is that this becomes a systemic problem and trying to solve that kind of problem by just adding more thyroid hormone is like trying to fix global warming by driving a hybrid.
It might help a little, but there’s a whole lot more that needs to be done.
For example, I worked with one woman who as taking both Levothyroxine and Cytomel. She had the exact symptoms described above. Normal TSH and T4 and all the hypothyroid symptoms I described.
After doing a compete panel we discovered that she had high cholesterol, LDL and triglycerides (because she was functionally hypothyroid) and she wasn’t converting or absorbing well.
We focused on cleaning up her diet, giving her targeted nutrition to help her liver and we worked on improving conversion. She contacted me a month later in total disbelief because her cholesterol had dropped by a little more than 50 points and she noticed that she had a lot more energy.
No cholesterol medication, no changes in thyroid replacement hormone. We just made everything work better and this caused her liver to convert more efficiently. In addition, the changes to her diet help reduce the systemic inflammation and this allowed her cells to better absorb thyroid hormone.
Check out this post on T4 that goes into detail about what is happening here.
This is really a “no brainer”, but I am continually surprised at how many people refuse to accept this or want to negotiate a kinder, gentler half way approach that doesn’t involve them changing their diet and, of course, their lives.
Hashimoto’s is an autoimmune disease and that means that your immune system is attacking your your own tissue. Tissue attack and destruction is induced by immune system stimulation.
Where is your immune system? An estimated 70% lives in your digestive tract. So everything that passes through there interacts with your immune system.
Also, there is a lot of research evidence that shows a clear link between “leaky gut” or intestinal permeability and autoimmune disease.
The breakdown of your intestines is a breakdown in the barrier to your immune system and this clearly is a factor in the initiation of autoimmune disease, but it is also an important factor in people’s symptoms because if this is not addressed you have constant immune stimulation and constant tissue attack.
My advice is always get off of gluten, dairy and soy 100% and for many, because of the state of their intestines, this is not enough. They need to do more. For them we recommend a version of the Paleo diet designed for autoimmune disease and Hashimoto’s, in particular.
I have gotten messages on Facebook and emails from at least a dozen different women who have credited this change alone with completely transforming their lives.
If you’re on the fence about your diet, you’re just prolonging your misery needlessly. It’s such a simple part of the solution.
This is another common area of dysfunction that is often overlooked. However, in my experience and in the experience of many of my colleagues (including my teacher and mentor, Dr. Datis Kharrazian,) this is one of the first steps that needs to be taken.
There are a couple of different types of blood sugar dysfunction. Hypoglycemia, which means your fasting glucose is generally too low and Insulin Resistance, which can be a whole combination of symptoms but is generally brought on by too much sugar in the diet.
And, in reality, lots of people have a mix of both.
The reason this can wreck the whole show is because of the impact of sugar fluctuations on the entire endocrine system.
Blood sugar and insulin spikes impacts cortisol and thyroid hormone levels. This creates a vicious cycle that impacts the pancreas and the pituitary and winds up driving you down.
And to add insult to injury, many people use sugar to get energy to overcome their fatigue.
This is like smoking cigarettes to help your asthma, it does way more harm than good.
For example, I worked with a woman who really had supplement fatigue. She had been put on so many different things that she had spent what amounted to a small fortune on supplements.
She sent me two full pages of things she had been prescribed. This was giving her very expensive urine, but wasn’t helping her feel a whole lot better.
The one thing that no one had told her was that she needed to balance her blood sugar. She had what amounted to a pretty serious case of insulin resistance. She had really bad fatigue, brain fog and memory issues and depression. She just felt like she had lost her life.
One of the main reasons that she had developed this was that her fatigue was so oppressive that sugar was the thing she relied on to get her through the day. Well, what she didn’t realize was that this was intensifying the fatigue and actually making her feel worse and worse.
So we focused on normalizing her blood sugar by getting her to stop the sugar habit and start using protein and good fats and by giving her targeted nutrition that helped to improve insulin receptor sensitivity.
And lo and behold, she felt like a new person. That was the one missing link for her. It restored her energy, it improved her brain fog and memory issues, it helped her to start feeling like her old self again.
Check out this post to get an in depth look at what happens with blood sugar issues.
The next area that is really crucial to evaluate and treat, if necessary, is the adrenals.
There are various stages of adrenal issues from adrenal fatigue to exhaustion and if your adrenals are compromised it can dramatically impact the way you feel when you take thyroid replacement hormone.
In fact, the warning label for Synthroid reads:
“Patients with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation of treatment with levothyroxine sodium.
Failure to do so may precipitate an acute adrenal crisis when thyroid hormone therapy is initiated, due to increased metabolic clearance of glucocorticoids by thyroid hormone.”
What this means, in plain English, is that in cases of hypothyroidism, the adrenals need to be evaluated before putting patients on thyroid replacement hormone.
How many people with Hashimoto’s and hypothyroidism do you think have adrenal insufficiency?
I put this question to my Facebook support group and 100% of the 85 respondents with Hashimoto’s said they had most of the symptoms of adrenal insufficiency such as:
* Fatigue, also a thyroid symptom
* Headaches, splitting headaches especially
* Decreased immunity
* Sleep issues. Difficulty falling asleep, staying asleep and waking up feeling exhausted even after you had enough sleep.
* Mood swings
* Sugar and caffeine cravings, (have a hankering for a Red Bull? It could be your adrenals)
* Irritability or lightheadedness between meals, a blood sugar and adrenal problem
* Eating to relieve fatigue, another blood sugar problem
* Dizziness when moving from sitting or lying to standing, it affects your blood pressure
* Gastric ulcers, ulcers in the stomach can be caused by the adrenals
Granted, that’s not a scientific study, but it certainly is emblematic of this problem.
Unfortunately, many doctors dismiss adrenal insufficiency as one of those make believe disorders. It’s not make believe at all, it’s very real.
For example, I had a patient who had developed Hashimoto’s after having a baby. She was diagnosed after lab tests revealed antibodies above the normal range and elevated TSH. Her doctor immediately put her on Synthroid.
She had a terrible reaction and felt so sick that she literally could not continue with the drug. The doctor dismissed this reaction and insisted that she get back on the drug.
She dismissed her doctor and eventually found me. We did a number of different things including getting her on the autoimmune diet, cleaning up her liver and we worked on restoring her adrenals and helping her body adapt to stress.
After three moths of following this protocol she went back to her doctor and asked him to reorder the tests. He grudgingly did saying there wouldn’t be any change he was sure of it.
The lab test all came back normal, TSH was within normal range and the antibodies were undetectable. Naturally, she felt vindicated and was overjoyed.
This doesn’t happen with everyone, but this was a perfect example of a case that illustrates this point.
Here’s a post I wrote that goes into the adrenal thyroid connection in much greater detail.
I think my last important observation is one that I had to learn myself the hard way. I struggled for years before I was diagnosed with Hashimoto’s.
Largely because I didn’t really know what was happening, I kept making excuses for not fully committing to what I have now come to call the Hashimoto’s lifestyle.
Once I got diagnosed and got obsessed with learning about this disease and seeing the damage it can cause in people’s bodies, I started to realize what was at stake and went all in.
After that, things really started to turn around for me in a big way. And I have seen the exact same thing in many, many people I have worked with.
Those that aren’t successful in getting this under control are usually the ones who are unwilling to give up certain things in their lives in order to save their health.
These include stressful jobs and relationships that are repeatedly causing flare ups of their condition. Foods like gluten, dairy and soy that are in virtually every processed and fast food. (You can’t eat like the average American if you have Hashimoto’s, you just can’t).
In addition, you really need to understand that this becomes a systemic problem over time. It progresses into other systems of the body and these can include the liver, the stomach, the gall bladder, the intestines, the cardiovascular system, the brain and nervous system, the muscles and joints and more.
And sometimes you need to go through every system and evaluate it and fix what’s not working.
So you have to go all in. You have adopt a lifestyle that includes diet, includes eliminating triggers like stress and toxic (chemical and emotional) situations.
You know, I was the co-owner of large and lucrative medical practice which it took me 2 years to close. I was so stressed out running that place that it totally fired up my autoimmunity.
I am now a couple of years into an entirely new life and this life is richer, happier and it has far less stress in it.
Plus, I really love what I do. Honestly, I believe that my higher power has a plan for me and that is to help people with Hashimoto’s.
That’s why I’ve gone all in and have devoted both my personal and professional life to bringing hope, help and healing to people who suffer from Hashimoto’s.
These were some interesting observations I have made:
1. More than 80% of the people I worked with had Mono and were exposed to the Epstein Barr Virus.
Clearly this virus is somehow involved in Hashimoto’s. How? The research is far from definitive. Theories include activation of NF Kappa Beta, activation of rouge B cells and proteins like IL-8.
This is an area I intend to explore in much greater depth this year.
2. The most common symptom is fatigue.
Of all the many potential symptoms of Hashimoto’s fatigue is by far Public Enemy #1. And fatigue is often brain based which means it is the result of neurodegeneration caused by hypothyroidism and autoimmunity in the brain. Read more about this here.
3. The disease is progressive. My teacher and mentor, Dr. Datis Kharrazian and others have identified 3 stages. Read this post to learn more about this.
4. Many people have more than one autoimmune disease or at the very least antibodies to other tissues.
One of the most common places for these additional antibodies is to brain tissue, especially cerebellar tissue.
A lot of people don’t understand this and they just dismiss cognitive issues as “aging”. Well, with Hashimoto’s your brain is at serious risk of degenerating rapidly. This is something that really needs to be taken seriously.
Well, that’s all for now. I can’t wait to see what this next year will bring!
And if you’re not aware of it, I offer a free 30 minute Hashimoto’s Healing Discovery Session. In it you can share your story with me. Tell me where you are and where you want to be.
I’ll make some recommendations that I think will help right away and we can discuss how else I might be able to help.
I set aside time every week to talk with people who have Hashimoto’s and I’d love to talk to you.
You can schedule a free session by clicking here.