Dealing with Hypothyroidism

So you have been diagnosed with hypothyroidism and you're taking thyroid medication but you still have hypothyroid symptoms: fatigue, weight issues, hair loss, constipation, brain fog, joint pain etc.

Now what?

First make sure that your physician is ordering more than just the TSH test to monitor your thyroid function. TSH is a good screening test to find out if a person is hypothyroid, but it’s not so good at monitoring thyroid function.

The best tests for monitoring are the TSH plus a free T4 AND a free T3. Some physicians will order a TSH with a free T4 for monitoring. This is a little better but it only indicates how much inactive thyroid hormone a person has and we need to have good amounts of our active thyroid hormone available for use and this is what the free T3 tells us.

The thyroid makes the inactive free T4 which then gets converted to the active free T3—but mostly outside of the thyroid, like in the liver and the gut. Some people convert better from T4 to T3 than others but the only way to know how much T3 there is, is to test for it. It is entirely possible to have a TSH and free T4 within normal limits but a low free T3. This means having hypothyroid symptoms even with a normal TSH and free T4.

Also, many people diagnosed with hypothyroidism are treated with Synthroid aka levothyroxine aka T4 only. So if someone on T4-only thyroid medications in not good at converting T4 to T3, s/he will have good T4 levels but not good T3 levels, and so will still feel hypothyroid.

Also, if you are on Synthroid/levothyroxine/T4-only, you are at a higher risk for making reverse T3, which as you recall is like anti-T3. With elevated reverse T3, you are making less active T3 even though your free T4 and free T3 levels may look normal on the lab results. An elevation in reverse T3 can happen more to women on T4 only who are peri-menopausal and/or under stress, since estrogen and cortisol levels can increase reverse T3, but just being on long term T4-only can elevate reverse T3.

Also, if you are hypothyroid and have never had your thyroid antibodies tested for, ask to be tested, since if you do have thyroid antibodies your thyroid hormone levels, and how you feel, will be affected.

Should you be treated by an endocrinologist (hormone specialist) instead of a primary care physician? It depends: if you are not satisfied with your care, you should certainly consider looking for a different provider. But surprisingly many endocrinologists only use the TSH test to monitor and only use Synthroid/levothyroxine/T4 to treat, so switching to an endocrinologist for treatment might not be the answer.

If you are on Synthroid/levothyroxine/T4-only, you might notice some improvements in your symptoms if you take it at bedtime. Studies show that due to lower metabolism while sleeping and being in a horizontal position, the breakdown and excretion of T4 is slowed, allowing it to have more effect on the body. If you choose to try this, start on a night before a morning when you can sleep in because a few of my patients have had some difficulty initiating sleep taking T4 at bedtime. If that’s the case, go back to taking it in the morning. Also, you do have to wait at least 2 hours after you’ve eaten it take the T4, but optimally we should finish eating 3-4 hours before bedtime to help our sleep quality, help maintain a healthy weight and even help prevent dementia.

Just a reminder: if you take thyroid medications in the morning, be sure to wait at least 1 hour before eating, or drinking caffeinated beverages, or even decaf coffee which can still contain an appreciable amount of caffeine, in order to get the best results from your thyroid medication.