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Three Reasons Why Your Thyroid Medication Isn’t Working

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Reviewed by Jessica Montalvo, MD

This article is part of a special report on Thyroid Disorders. To see the other articles in this series, click here.

In the last post I explained that, for the vast majority of patients, hypothyroidism is an autoimmune disease. This isn’t just an academic distinction. It’s the reason both conventional and alternative treatments are so often ineffective.

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In this post I’m going to show you why taking replacement thyroid hormones without addressing the underlying immune imbalance is doomed to fail.

The ultimate effect of hypothyroidism, whether it’s caused by iodine deficiency or autoimmunity, is to decrease the amount of thyroid hormone available to the body. The conventional approach is to simply replace these hormones with either synthetic or bio-identical forms.

On the surface it seems like a reasonable approach. Patient doesn’t have enough hormones? Give more hormones. Simple, right?

Not so much.

Once again the conventional approach falls short because it ignores the underlying cause of the problem. It’s like taking Advil when you’ve got a pebble stuck in your shoe. It might work for a little while, and might even be necessary to dull the pain. But you’d be a lot better off if you took the pebble out of your shoe. Right?

Let’s take a closer look at why thyroid hormones often don’t work, or stop working over time. The following diagram illustrates how autoimmunity affects thyroid metabolism (please note, “HPT” stands for “hypothalamus-pituitary-thyroid axis”):

hashimotos

Immune dysregulation is another term for autoimmune disease. We still don’t know exactly what causes it, but most researchers agree it’s a mixture of genetic susceptibility and environmental factors such as iodine (excess), infection, pregnancy, diet and intestinal permeability.

In autoimmune disease the body attacks itself. It does this the same way it attacks foreign invaders like bacteria and viruses: with T-cells, B-cells, natural killer cells, and cytotoxic T cells. The immune response also involves proteins called cytokines, chemical messengers that pass messages between cells.

This self-attack by the immune system increases inflammation. And inflammation has a profound effect on all aspects of thyroid metabolism and physiology.

First, inflammation suppresses the HPT axis. (1) One study showed a single injection of the inflammatory cytokine TNF-alpha reduced blood levels of TSH, T3, free T4, free T3 and TRH for 5 days. (2) This shows inflammation disrupts the production and regulatory mechanisms of thyroid hormones. Thyroid medication will increase the levels of T4 (and possibly T3), but it doesn’t address the other effects of HPT axis suppression.

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Second, inflammation decreases both the number and sensitivity of thyroid hormone receptors. (3) If there aren’t enough receptors, or they aren’t sensitive enough, it doesn’t matter how much thyroid medication we take. The cells won’t be able to use it. It’s like when my grandpa used to turn down his hearing aids while he was watching the football game. It didn’t matter how much my grandma yelled at him – he couldn’t hear a word she said.

Third, inflammation decreases the conversion of T4 to T3. (4) T4 is the inactive form of thyroid hormone. The body has to convert it to the active T3 form before it can be used. Most synthetic hormone medications on the market are T4. If you give a T4 medication (like Synthroid, Levoxyl, Unithroid, etc.) to someone with inflammation, it’s not going to work because they can’t convert the T4 to T3.

Patients who don’t convert T4 to T3 well do better on bio-identical hormones like Armour, because it contains both T4 and T3 (in a 4.22:1 ratio).

Inflammation disrupts thyroid metabolism in several other ways, but I think these three examples make the point.

Now let’s review.

Inflammation causes HPT axis disruption, decreased receptor function, and decreased conversion of T4 to T3. Thyroid medication only increases the levels of thyroid hormone (usually T4) in the blood. No matter how much we take, it’s not going to restore HPT axis coordination, improve receptor function, or increase conversion of T4 to T3.

The only way to do that is to address the problem at its root by regulating the immune system and decreasing inflammation. (For more on how to address underlying inflammation, check out this episode of Revolution Health Radio with Izabella Wentz.) Unfortunately, this is rarely done in either conventional or alternative treatment of thyroid disorders.

Before I sign off, I just want to make one thing clear. I’m not saying thyroid medication isn’t necessary or useful. In fact, I think it’s an important part of treating Hashimoto’s—especially when TSH is consistently elevated and T4 and T3 are consistently low. My point is thyroid medication is only one piece of the puzzle, and it won’t be effective on its own unless the autoimmunity and inflammation are addressed.

If thyroid medication is the fantasy magic bullet of conventional medicine, iodine is the equivalent in alternative medicine. In the next post I’m going to explain why supplemental iodine may cause more harm than good in Hashimoto’s patients.

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641 Comments

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  1. Hi Kris,
    My name is Emily and at 16 i was treated with synthroid after having a high tsh. After having a high TSH my doctor gave me synthroid, however, i felt no better on it. She did not give me any other tests , only free t4 , that is it.. Should she have tested my free t3 , or thyroid antibodies? I am very under educated with the thyroid but all i know is synthroid gave me anxiety and did not make me feel any better… What should I do, and what tests should I ask my doctor for. Could my thyroid condition be due to adrenal fatigue and therefore, I should not be on thyroid medication?
    I appriciate your feedback,
    Emily

  2. Hello
    I have , yet another question , as i dive into more info regarding Graves which i was diagnosed with about 6-7 years ago , and reading what you writ i understand that the autoimmune diseases /condition of Graves doesn’t go away , in fact it can attack , now , since my thyroid was destroyed , other organs ? my question is do all autoimmune diseases are like that , from what i know not all …
    if my thyroid was still alive would that have change anything for the better , like centering the Graves on it ?
    last question if the ” Graves ” starts again can the body recall it’s symptoms from the thyroid ( higher hart bit , loss of appetite , anxiety etc. ) and actually make thaws symptoms again even thow the thyroid is no more ? or are thaws symptoms part of Graves no mater what ?

    Thank you for reading
    regards
    Nili

  3. Hi Chris,

    I am curious about what you think regarding people who no longer have a thyroid. I was diagnosed with Hashimoto’s Disease when I was fourteen, and by the time I was nineteen, I had metathesized thyroid cancer. Doctors removed my thyroid, two parathyroid glands and a few dozen lymph nodes. I’m 28 now – a yoga teacher, and vegan and gluten-free. (The health change came as a result of the cancer; previous to this I was an unhealthy Midwesterner.) I do find that whenever I eat gluten (if I slip when out to eat with friends or what not), I will come down with a cold within a week. Anyway, I can never get a straight answer from doctors about what the Hashimoto’s diagnosis means without a thyroid.

    Also, I have taken nascent iodine in the past, but I then read that after having had the cancer and thyroidectomy, this was a mistake. Thoughts on this?

    I would LOVE if you could write an article for people without thyroids. The Western medical approach does not seem enough for me personally.

    And on a note of interest: surgeons removed 2/4 parathyroid glands, though I was told that one was possibly damaged in the surgery (again, this is when I was nineteen). At twenty-five, a few years after a move to the United Kingdom, I started to experience memory loss, peripheral vision loss and hand tremors. For months before these symptoms started, I kept going to the GP saying I felt shockingly lethargic and weak. My GP kept saying it was because I was a vegan. I was adamant that it wasn’t, but he kept recommending dietary changes that completely misaligned with my world views.

    Anyway, come the serious symptoms, I went back to the GP and the one I saw was brand new–on her GP rotation–so she actually seemed to take me seriously. I saw her on a Wednesday and she ran a battery of blood tests. Come Friday night at 10pm, I got an emergency phone call asking me to come to A&E (ER) right away. Apparently my blood calcium had dropped so low that they thought I would seize at any moment (and didn’t know how I was alive and functioning).

    The doctor in A&E prescribed me Rx calcium tabs and also blamed my vegan diet. (WTF, right?) They told me to come back on Monday, at which point my calcium dropped even lower. At this point, they realized the remaining parathyroid function had likely gradually stopped over the years–accustoming my body to lower and lower levels of calcium. The body is amazing!

    I ran into that GP in a non-medical setting about six months later and I couldn’t place her at first and I asked her how I knew her. She said, “Well, your calcium-girl to me,” and she told me it was one of those cases she would never forget in her career. I’m sure I’m in a medical journal somewhere. Ha! So now I’m on calcitriol as well, to manage my ability to uptake calcium. *sigh*

    Anyway – thanks for reading, Chris! I’m sure many out there would love your views on health for the thyroid-less as well!

    Blessings,
    Julie

    • Hi Julie,
      Oh my goodness, I am in the same boat as you are in. My thyroid was removed 4 years ago 80%. My surgeon tried to save my parathyroids, but they did not survive. I would greatly appreciate information on the best meds and supplements to take. I was put on T4 only, which I do not understand. I still cannot believe my old endocrinologist thought that is all I needed!. For Heaven sake I do not have any thyroid or Para’s at all. I have changed doctors and will ask for a change in medication to Natural Desiccated Thyroid meds. I am a calcium crasher too, having spend a few times in the ER on a calcium drip…Naughty me. So, in closing I would love to see more information for us “no-thyroid” patients. Good Luck Julie!

  4. Can you give us an idea of what you mean by “regulating the immune system and decrease inflammation”? I have tried every kind of natural healing and I am finally getting good results with taking dessicated thyroid (Thyroid-S). Thanks.

  5. Hello Chris,
    My name is Danny, i am fixing to join the marines. I have a thyroid problem, and it is a over active thyroid. i would have to stop taking my meds, and it would have to be for six months. I was concerned bout if it would cause heart problems. thank you for

  6. Hello
    I had Graves then my thyroid was destroyed , i am taking now Synthroid , now that was some years ago about 3 months ago on my regular blood test , i was feeling good , it showed that i had both hyper and hypo at the same time ?!? ( they double checked it and came out the same ) is that at all possible ?

  7. really enjoyed your site, I had hyperthroid for 28 years, no real problem, slept well no tremors, good bowels, i was tested for graves which was neg. about a year ago I went into a thyroid storm, prier to it I had eaten alot of seaweed wraps, didn’t think about the iodine in them, could this have pushed me over the hill? well that was scary, I drank alot of carrot juice during that time, and it calmed the effects. well long story short, i went thru the rai, doc gave me enough to destroy my thyroid, but it didn’t, she said its still functioning, but I’m on 50mcg of levoxyl I was just wondering is there a way to get my thryroid back to working healthy again, if so how, and by taking the levoxyl is this keeping my thyroid from thriving, thanks for your time, debbie

  8. Chris I have hashimotos for about 8 years my only symptom I have ever had has been A cloudy or foggy head every single day nothing I do seems to help it any ideas

  9. I have hypothyroid and feel terrible.. I have no energy and I have slot of problems constantly with my eyes. I am on medication and just went to have a recheckt7. Why the eyes?

  10. I appreciate all your information,have hashimotos and many other problems, went to a naturlist
    and was put on Black Walnut for parasite,now I find it is very high in iodine which you say is very bad for hashimoto,should I discontinue the use. Have also been taking LDN ,so many problems treat one and it make another area worse. Thanks for your help.

    • I have lechin planus on body and very badly in my mouth,could you offer any help. Thank you so much.

  11. Wondering about Hypothyroid cause by removal of 3/4 of thyroid. (tumor, 10+ years ago). What needs to be considered if the cause is not iodine, adrenal, etc…
    My sister has hypothyroid (iodine def) and now takes Armour (her quality of life has increased tremendously). My new client wants me to cook meals for her and I want to lead her in the right direction nutritionally, and to mention your articles, and my sisters relief from synthroid, and other plant based hormone replacements that people say work… like therapeutic grade essential oils, so she can determine if synthetic is the way to go for her. She deals with weight gain and lack of energy. Thoughts?

  12. Hi Chris,

    I have a question. I stopped breastfeed my baby when he was 13months old and on the next week i got some problem with my thyroid. The doctor couldn’t recognize it, but i was complaining at my throat but no other symptoms (i kept my weight since the delivery, no hair loss, no depression, etc.). I asked him and he make a scan and the blood test. I was right, the TSH was 12,8 but T3 and T4 were normal. The interesting thing that i went to this clinic 2 and 2,5 years ago with the same problem and the doctors said something was just in my mind when i told them I felt something strange in my throat and it wasnt a cold. 2 years ago I got pregnant and my little one (thanks God) is very healthy and i had a very very easy pregnancy with sport activities until the last week.
    I took 25mg/day on the first week, and from the second week i m taking 50mg Euthyroy/day. It s time to go back to the clinic to have a blood test after 6 weeks of this pills. To be honest, I feel better but i dont feel that recovery what i expected. The doctor didnt give me any advices, only this pill. How can i figure out if i should have avoid certain food. I drink coconut milk instead of milk, i make low carb diet, i try to eat meat and fishes, fruits like green apple, no gluten.
    Could you give some advices,please? I would love to get back to normal:-)

  13. Hello!
    One question – can hypothyroidism be accompanied by tinnitus? (ringing in the ears) Labwork consistently indicates thyroid levels on the rise and doctor says take more thyroid medication to bring it down. Levothyroxine increase in 2/2012 with tinnitus onset. Any connection?

    Thank you for any information you might provide.

    • Hi Candace

      I am apart of a large online thyroid support group. There are many people who talk about ranging in the ears on the forum. . People have switched meds, lowered and raised levels, I even know a guy who had his thyroid removed to stop the ringing but they all still have the ringing.

      • What is the support group that you belong to? I have been looking for a good one. I was hyper and did the Radio active iodine 8 years ago and still have trouble with my levels going up and down. They did a ultrasound to see if it grew back and they found that I don’t have any left. Had my Pituitary checked and it was fine. Please Help.

  14. Dr. Kresser,

    I have been experiencing symptoms of hypothyroidism for the past 2 years now. My doctor has said my levels were on the lower end, but then started treating my adrenals as well. I have been taking “Nature-Throid 1.5g” for almost a year now and I feel absolutely no different I even bumped it to taking 2 pills in the am, but hasn’t made a difference. I still cannot lose my fat even though I work out everyday and eat healthy. I am always tired, can’t sleep, have headaches, severe chronic constipation, and always bloated and swollen face and eyes (especially in the am). My doctor said he ruled out Hasimoto’s or celiac disease. I can’t find an answer and I am miserable. It’s taking over my life and ruining my spirit. Do you have any input or idea? I have been taking Oxy Elite Pro (fat thermogenic) because that makes me feel great! It burns my fat and boosts my metabolism, gives me energy. The only problem is I can’t sleep on that either.

    Thank you so much! I hope you are able to reply, I know how extremely busy you must be.

    • I have been Dx’d w hypothyroidism, fibromyalgia, adrenal insufficiency, among other things. Still trying to balance my body chemistry with bio identical hormones, herbs, supplements, and candida diet thus far. Please be careful with Oxy Elite Pro. I read your post, and looked it up because I wanted to try it. Evidently it is known to cause liver failure among other problems.
      http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm374742.htm
      I have appreciated reading people’s posts here!

  15. Hi,
    I have recently been diagnosed with hypothyroidism this past August 2012. My tsh level was 5.3 and my doctor put me on 25 mcg of Synthroid and told me to take that for three months and then come back to recheck my tsh level. Well, during the three month period I went from feeling much more energetic and back to my “normal” self to feeling very lethargic and irritable. So, at my recheck visit my tsh level jumped to 14. So, my doctor told me to take 75 mcg of Synthroid and to recheck in 6 weeks. Also, at that visit she plans to check other thyroid hormone levels. I started taking my new dose and The first two days on the higher dose I felt great and then the days following I feel like i went back to feeling lethargic and irritable. I am not wanting to wait the full six weeks before I see my doctor. I want to be referred to an endocrinologist because I can just tell this medicine isn’t working properly. I need help. I can just tell I have not been myself.

    • Hey – Amy, I have been going through something similiar? Did you ever level out? I seem to get better initially on a dose increase, then feel as fatigued as ever but havent come across many others in the same boat. Would love to hear about your experience. Thanks!

      • Hey. Yes I did level out finally. I feel a lot mods like myself nowadays. My dose has been raised once in the past three months. And at first I felt lethargic then by the six week lab I felt energetic and more like myself. My tsh level has been at 2.4. And my free t3 and t4 have been within normal limits. I started seeing an endocrinologist too which I felt helped. It’s given me more peace of mind too talking to a specialist.

      • Nuttmegs17, I have been having similar issues with starting something (Synthroid, supplements, Naturethroid, higher dose NT) and feeling great for a couple of days or a week at the most and then feeling like crap again! I have also been trying to figure out why I can’t find anyone else with this issue. Some information I have found points to my sleep apnea, low adrenal function or low iron.

  16. I want to hear about your thoughts on iodine – I am on Nature Thyroid and feel MUCH better, but for the belching and gas side affects. Iodine has been recommended. How can I be notified of your post(s)?

  17. What about someone who had to have their thryroid removed due to cancer and has no choice but to take medication. What are your suggestions for maintaining optimal health in this scenario? Thanks!