Updated: Aug 16, 2020
It's common for thyroid patients to continue to experience symptoms of hypothyroidism on thyroid medications even while being told that their labs are normal. Patients are often dismissed by their providers and even told their symptoms are in their head. I have experienced this personally and hear about this often in my practice.
1) Your provider may not be ordering a complete thyroid panel
According to the standard of care released by the American Thyroid Association providers should rely mainly on TSH (your brain telling your thyroid to work harder) and T4 free (less active thyroid hormone) as primary markers for thyroid testing. If these are in the standard reference range then there is no need for further intervention. This method of thyroid treatment is highly outdated and leading to the under treatment of misdiagnosis of thyroid patients. TSH and T4 free can be important markers but they do not show the entire picture! Many functional and Integrative providers are more up to date on current research in this field and consider a complete thyroid panel to be:
TSH, T4 Free, T3 Free, Reverse T3, TPO and TGA antibodies
Request a full thyroid panel from your provider. If they are unwilling or unable to order then you can seek out a new provider.
In my experience, integrative, functional and open minded PCP's tend to be more willing to order a complete panel
How to find an open minded provider? Call a local pharmacy and request a list of providers that prescribe natural desiccated hormone. These providers tend to be more up to date in regards to thyroid treatment.
When searching for a new provider, contact the office and ask if the provider orders these labs.
If you cannot find a provider to order for you then you have the option to self order. I recommend using Blood Lab Testing System, they have the most affordable thyroid panels I've seen. I recommend the expanded thyroid panel for 75.00 https://www.mcssl.com/store/bltsystem/thyroid-function-tests
2) Your reverse T3 is elevated
Reverse T3 is an inhibitory hormone. It blocks T3 from entering the cell resulting in hypothyroid symptoms The standard reference range for Reverse T3 is (8-25 ng/dl) However, many individuals become symptomatic when their Reverse T3 is close to the top part of the standard reference range. For this reason, it's important that we look at the optimal range. Below is the most accurate way to calculate an optimal Reverse T3
(Free T3 in ng/dl divided by Reverse T3.)
if your T3 is not in ng/dl you can use this conversion calculator http://www.scymed.com/en/smnx
If your calculation is lower than 0.20 than that indicates that you could have too much Reverse T3
Causes of Reverse T3
If you are over medicated on your thyroid medications
Adrenal dysfunction: Adrenal glands work in tandem with your thyroid. When your thyroid is sluggish your adrenals can become distressed. T4 hormone replacement can also cause stress on the adrenal glands. The most accurate way to address adrenal function is through saliva or urine. I recommend the DUTCH test as it also tests for sex hormones.
If your cortisol levels are not optimal, I recommend asking your provider about supporting your adrenals with adaptogenic herbs, vitamin C or adrenal glandulars if needed. Avoiding caffeine can be helpful as it can cause further strain on our adrenal glads.
3) Your provider is following outdated reference ranges for interpretation
I find this extremely common. Many years ago when scientists first set out to identify the standard reference ranges for thyroid labs they inadvertently included those with thyroid disease and the elderly leading to a skewed reference range that is far too broad. Below is a column of standard reference ranges vs. optimal. Many patients feel better when their labs are in optimal range. Although labs are important it is best practice to thoroughly assess the patient for signs and symptoms of hyper or hypothyroidism. Below is a table of standard reference ranges vs. optimal.
Standard Reference Range Optimal Reference Range
TSH U/ml 0.5-5.0 0.5-2
T3 Free pg/ml 2.3- 4.2 ( top quarter of range) 3.7-4.2
T4 Free ng/dl 0.8-2.8 (top half of range) 1.3-2.8 ng/dl
Reverse T3 11-21ng/dl ratio of less than .20
(FreeT3 divided by Reverse T3)
TPO Antibodies less than 35 IU/ml Less than 2
4) Your thyroid medication is not right for you
There are many types of thyroid medication on the market today however the majority of hypothyroid patient's are only offered generic T4 levothyroxine and not educated about other options. Many of these patients continue to exhibit symptoms and are told by their providers that it's not their thyroid and their symptoms are in their head.
I find that many people do not respond well to solely synthetic T4 therapy especially levothyroxine. Levothyroxine contains multiple fillers and additives that some people with Hashimoto's tend to react to. I find that many people feel better when switching to brand name synthroid and even better yet tirosint. Tirosint is the purest form of T4 on the market, is available in gel capsule and easier to absorb.
Patients tend to have better outcomes on a combination of T4 and T3 therapy especially if they are on full replacement.
Below are thyroid medication options that you can ask your provider about
Combination of T4 and T3 therapy
NDT (natural desiccated thyroid hormone) this is available as WP thyroid (cleanest form) NP, Nature Thyroid and Armour
Adding in supplemental sustained release T3 (available at compounding pharmacies)
If you have been on T4 only therapy and start taking supplemental T3 or NDT your body can at first be very sensitive to T3. It's important to let your body slowly adjust to the T3. A common symptom can be chest pain.
Try splitting your dose of T3 in divided doses through out the day for the first few days.
5) You have a conversion disorder
Our thyroids naturally produce T4 (inactive) and T3 (active) hormone. Many patients with hypothyroidism have a conversion disorder where they are not properly converting T4 to the more bioactive T3. Clinically this can look like a TSH and T4 free in standard reference range and a free T3 that is below normal range or is in the lower level of the reference range. Patient's with a conversion disorder may experience significant signs of hypothyroidism such as fatigue, weight gain, hair loss, depression, mood swings just to name a few.
Causes of poor conversion include:
Vitamin and mineral deficiencies such as iron, zinc, selenium
Poor gut health which can impair conversion and also contribute to poor absorption of vitamins and minerals
Medications that can inhibit conversion include:
Glucocorticoids (anti- inflammatory immunosupressives)
Propranolol (anti-arrhythmic and antihypertensives)
Iodinated contrast agents (radiologic contrast media)
Amidodarone (Anti-anginal and anti-arrhythmic)
Clompramine (Tricyclic anti-depressant)
Test adrenal function
consider micro-nutrient testing
ask your provider about supplementing with high quality GMP verified thyroid supplement to help support T4 to T3 conversion
ask your provider about changing to a combo of T4 and T3 or NDT
6) You are not properly absorbing your thyroid medication
If a person is not properly absorbing their thyroid medications this will result in a continuation of symptoms. Inability to properly absorb thyroid medication is common among thyroid patients. Some causes of poor absorption include:
Poor gut health
Certain fillers in thyroid medications such as lactose can further inhibit the absorption of thyroid hormone. This is found in synthroid and levothyroxine. Some of the purest forms include Tirsosint and WP thyroid.
Taking magnesium, iron or calcium within 4 hours of thyroid hormone can inhibit absorption.
Consumption of coffee within 1 hour of thyroid medication administration as coffee can speed up the GI motility making it more difficult to absorb
There is recent evidence suggesting that night time dosing of thyroid medication on an empty stomach may increase absorption.
7) Your iron is low
Iron is crucial for thyroid function. Low iron also causes low free T3 (active thyroid hormone) and reduces your TSH response. When this level is low, patients often experience hypothyroid symptoms. Deficiency in iron can also impair your ability to properly convert T4 to T3. Unfortuntatley, iron deficiency is commonly undiagnosed. Hypothyroidism can cause low iron levels due to fluctuating thyroid hormones causing a decrease in stomach acidity which can impair the proper absorption of iron Signs of iron deficiency resemble the signs of hypothyroidism and include:
cravings for ice
inability to tolerate exercise (due to lack of oxygen to the cells)
shortness of breath
Labs to order: Optimal Levels
Ferritin - This is the total storage of iron in your body. 40-150
Serum Iron - Circulating iron in your blood. Middle of the reference range
TIBC (Total Iron Binding Capacity) - Body's ability to carry iron. Middle of the reference range
Percent Saturation - This is the ratio of serum iron to TIBC 35-38%
Do NOT supplement with iron unless you have a diagnosed deficiency. Too much iron is harmful to your body,
8) You have an autoimmune component that is not being addressed
An estimated 90% of thyroid disorders are caused by the autoimmune thyroid condition Hashimoto's Thyroiditis. It is a common misconception among conventional medicine that there is nothing the patient can do about the autoimmunity. Thankfully this is not true! The scientific literature supports that when root causes such as gut health, underlying infections, stress, food sensitivities, nutrition and stress are addressed that it's possible for the autoimmune attack to go into remission or as dormant as possible.
Look into finding an integrative or functional practitioner to work with you on finding the root cause and making lifestyle and dietary changes to best support your health
Decrease stress, I find incorporating mindfulness and meditation to be extremely helpful
Support gut health, there is a significant link between autoimmunity and leaky gut
Eat food as close as possible to its natural form, avoid processed foods as much as possible.
Avoid gluten, studies show that gluten causes leaky gut in anyone who consumes it. This is likely because of the hybridization of wheat over the years.
9) You are nutrient deficient
Nutrient deficiencies can result from poor gut health, infections and consumption of processed foods. Key nutrients involved in proper thyroid functioning include
Iodine (Be cautious with taking high amounts of iodine supplementation as it can make Hashimoto's worse. It's important to consume adequate amounts of iodine from natural sources such as kelp.)
Amino Acids (especially tyrosine)
10) Your symptoms are related to other health conditions
Many conditions mimic signs and symptoms of hypothyroidism. In fact, hypothyroidism can cause hormonal imbalances and adrenal dysfunction which have similar symptoms of hypothyroidism.
Imbalances of sex hormones especially estrogen and progesterone
Adrenal dysfunction (I highly recommend DUTCH testing to rule out adrenal dysfunction and imbalance of sex hormones)
Obstructive Sleep Apnea (There is also a link between hashimoto's and sleep apnea, this can be ruled out by doing a sleep study)
Fibromyalgia (Link between fibromyalgia and hashimotos)
Other autoimmune disorders (If you have one autoimmune disorder you are at a higher risk for developing another. ANA is a test that can be used to screen for other autoimmune disorders)
Vasquez, Alex. (2016).Textbook of Clinical Nutrition and Functional Medicine, Vol. 1 4th Edition.
Sodano, Wayne. (2018) Integrative Medicine Approach to Thyroid Disorders,
Wentz, Izabella (2017) Hashimoto's Protocol
Low T3 Syndrome and Chronic Fatigue Study