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.
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.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