I am often asked by patients with hypothyroidism (low thyroid hormone levels), “What is the right thyroid hormone dose for me”. Of course, a physician wants to find the appropriate dose of medication to treat each condition a patient has. When it comes to thyroid disease however, this can be a complex question. Not only is there an issue of whether T4 alone or combination T3 and T4 will be required to treat a particular individual but the therapeutic window of these hormones must also be considered. Continue reading
Our member, Ella, has analyzed her own T4 plus T3 thyroid replacement needs and offers a terrific explanation of how she arrived at her conclusions. Follow her thinking in her message to metabolism.com
The 2013 guidelines issued by the American Association of Clinical Endocrinologists and the American Thyroid Association reiterated their long standing opinion that only a single hormone, T4 (Synthroid, levothyroxine) is advised for treatment of hypothyroidism. These key organizations
Mainstream endocrinologists seem to be moving grudgingly toward acceptance of combination T4 plus T3 therapy for hypothyroidism. A great example of the mixed feelings harbored by endocrinologists in this regard is the title of a recent editorial, “ Combo (treatment) a Last Resort for Hypothyroidism” . Although the author, Dr. Bruce Jancin of the University of Colorado, recognized the value of combination T4 plus T3 therapy, he did so with the least possible enthusiasm. In his article the doctor acknowledged the weakness of scientific studies showing negative results with combination therapy and pointed out the findings of the Watts Study which provides a genetic rationale for why some people need to have T3 added to T4 to return to proper thyroid hormone balance. Continue reading
A long time member of metabolism.com, Eric Pritchard, has been a determined critic of “T4 only” treatment of hypothyroidism. In his latest comment Eric shows that scientists were aware of the inadequacy of “T4 only” treatment since 1947! I wanted to give everyone a chance to read his comment so I am posting to the main blog. Thanks again for your insight Eric.
Submitted on 2012/03/25 at 6:11 pm
Endocrinologists have a hard time with the symptoms of hypothyroidism in the same sort of way that New York City folks believing that there is anything worthwhile west of the Hudson River. However, there are very relevant functions to the thyroid hormone effectiveness that exist beyond the boundaries of the classical endocrine system. This potential was given initial credence by Drs. Kirk and Kvroning in 1947 when they published a note saying that not all patients’ symptoms were managed by thyroxine (T4). This was collaborated in 1954 by Dr. Means. Drs. Gross and Pitt-Rivers discovered triiodothyronine (T3) and found it far more active than T4, which is now called a pro-hormone. The concept of euthyroid (your thyroid is OK) hypometabolism (but you are dragging anyway) was demonstrated by Dr. Goldberg in 1960. Drs. Refetoff and Braverman, circa 1970, discovered the connections between the thyroid gland and symptom producing cells, namely the cellular reception of hormones and the conversion of T4 to T3 outside of the endocrine system, which produces 80% of the body’s requirement for the active hormone, T3.
Another issue that is dismissed is the necessity of supporting chemistry to function properly. For example, every thyroid hormone replacement counter-indicates is use if the adrenals are insufficient.
So there is far more going on than endocrinology is willing to promote. That is why there are 1.7 million patients suffering in spite of T4 therapy. That is why there are still more patients suffering from false negative diagnoses for the symptoms of hypothyroidism.
During 2 decades of practicing endocrinology I had not encountered an instance of an over the counter product containing enough active thyroid hormone to make a difference in thyroid levels. In the last month I consulted on two new patients who appear to have developed toxic thyroid levels due to non-prescription products. The first involved a “Metabolic Complex” obtained from New Zealand. This seemed like a fairly random event in which a non-prescribing health practitioner was able to obtain an unregulated product which was passed on to the patient. Not likely to become a common issue. This second instance is more worrisome since it involves a product purchased directly by the patient from the internet, and supposedly “vegetarian” in nature.
Here is the story. A woman with a history of hypothyroidism for about one year taking synthetic prescription thyroid hormone decided to find a more natural solution to thyroid hormone replacement. She stopped the thyroid hormone replacement prescribed by her local physician and purchased a product via the internet advertised to improve thyroid gland “health”. Prior to starting the OTC product her thyroid blood tests indicated low thyroid levels, as expected. About a month after starting the thyroid supplement her thyroid levels were clearly above normal, entering the thyrotoxic range. Fortunately she returned to her physician who alerted her to the problem and asked her to stop the thyroid supplement and one month later she was back to being hypothyroid again. It was at this time I first consulted with her and found her to have the expected symptoms of fatigue, weight gain, poor memory, dry skin and water retention (edema). I restarted her on prescription thyroid hormone replacement.
I wanted to see the product bottle myself but was unable to obtain it. Instead I went on-line and tried to track down the product’s manufacturer and list of ingredients. It was a frustrating exercise since the names of the products and the manufacturers and distributors changed from one website to another. I narrowed my search to one product manufactured in California and another in Canada. Perhaps I will be able to get the original pill container and nail this product down but for now it remains a bit mysterious.
Members of metabolism.com have asked me to pass on the name of these products. Now come on…do you think I want to make this situation worse by giving the information away to juvenile delinquents? I am hoping government regulators will become more vigilante to what appears to be a growing problem. In the mean time I advise everyone to be on the alert to similar products being marketed to an unsuspecting public.
Gary Pepper, M.D.
Some of the details of this report have been changed to protect the identity of my patient. This information is for educational purposes only and is not intended as medical advice or therapy.
A few weeks ago a new patient arrived at my office to discuss treatment for her thyroid disease. She was diagnosed with an under active thyroid several years prior but treatment with Synthroid was unsuccessful. She stopped using the medication on her own, at least a year ago. Blood tests obtained by another doctor a month before her visit with me, were diagnostic of hypothyroidism (low thyroid levels with elevated TSH) . During our session she described typical symptoms of hypothyroidism including fatigue, feeling unusually cold, dryness of the skin, brittle nails and puffiness around the eyes. On exam her thyroid was enlarged and had a gritty texture typical of Hashimoto’s Thyroiditis. Her sister and mother also had thyroid disease, increasing the likelihood of the diagnosis of Hashimoto’s. Since her latest thyroid blood tests were only a few weeks old I felt comfortable beginning her on thyroid hormone replacement, in this case, Armour Thyroid, which I prefer due to its excellent clinical effectiveness.
My new patient was also on a number of supplements and vitamins including a non-prescription “metabolic complex” given to her recently by her chiropractor. By law in the U.S. supplements like these do not possess thyroid hormone and, in my experience, have no impact on thyroid hormone levels, either to increase or decrease them. As a precaution, we obtained a new set of thyroid hormone levels along with the test for Hashimoto’s Thyroiditis (anti-thyroid antibody panel).
Several days later, the patient called complaining she was “allergic” to the Armour Thyroid, developing jitteriness, anxiety, feeling flushed and a rapid heart rate. My first thought was she received the wrong dose of medication but a quick check of her records indicated this was not the issue. I called the lab and was surprised to learn the TSH at the time of her visit was already low, indicating excess thyroid levels or hyperthyroidism. What could have caused the sudden switch from hypo to hyper thyroidism? Rarely, patients with Hashimoto’s Thyroiditis can convert to hyperthyroidism, an event I call the Zombie Thyroid because the thyroid comes back from the dead. More likely was that one of her supplements contained actual thyroid hormone, so I asked the patient to get me the labels from these products. In the meantime, I instructed her to stop the Armour Thyroid and the supplements until I could figure out what was happening. Her allergic symptoms resolved in a few days.
Examination of the supplements’ labels indicated that one manufactured in New Zealand did in fact have thyroid extract in it. It had so much thyroid hormone in it that the patient was already becoming hyperthyroid at the time she first came to the office. Signs and symptoms of hyperthyroidism didn’t develop until she started taking Armour Thyroid along with the supplement. The mystery was solved but I am left feeling much less secure that my patients will not injure themselves with products obtained from outside the country either via the internet or from practitioners who provide it, perhaps unwittingly.
As I have in the past, I urge everyone to avoid medications and supplements produced outside the country which can contain active ingredients with potential health hazards. Always check with a physician before beginning a supplement which is obtained from the internet or mail order.
Gary Pepper, M.D.
This information is for educational purposes only and is not intended as medical advice or treatment. Some details of this case have been altered to protect the patient’s identity.
Every so often I like to bring attention to someone who has struggled to get properly treated for hypothyroidism. Not everyone shares the same dilemma regarding treatment of hypothyroidism because T4 by itself may be sufficient in many instances. But for those who continue to experience symptoms of hypothyroidism despite T4 treatment, adding T3 can be a life changing experience.
Here is Sarah’s story:
I was diagnosed with hypothyroidism in my early twenties and Synthroid did not help. I did not know at the time that many of my symptoms were due to hypothyroidism. After changing to my long time physician, I told her of my original diagnosis some years back. She did only the TSH and told me I was no longer hypothyroid! So for some 15 years after being in her care and continuing to feel crummy, then for the last 8 steadily gaining weight and feeling worse, I was not on any medication. I begged her for Cytomel several years back and was denied…she said she didn’t treat with that. When I finally was deemed hypo by her, she put me on the smallest dose of levothyroxine. It did not help. I finally went to see a shrink and he put me on 25 mcg of Cytomel. For the first time in my post pubescent life, I feel like living. My dose was upped to 50, and I felt even better but my thyroid levels were off, so we are now working on that and I am back to 25 mcg per day. If you can’t get Cytomel from your regular physician, you might get a psychiatrist to prescribe it. It changed my life and I finally feel alive. I’ve since switched primary physician because she wouldn’t listen to me, and she didn’t like that I was on Cytomel. I don’t know what it is about this medication that regular physicians don’t like and make them refuse to treat with it, especially when so many can benefit from it. I’ve lost only 12 lbs since being on it, but I gained nearly 35 unnecessarily while not being properly treated and was told to eat less and exercise more…I only ate about 1500 calories a day and walked my dog 2 miles each day, so I don’t feel it had anything to do with my diet!
The HCG diet has created a great deal of controversy among experts and the people who have tried it. Cami posts these words of warning about the HCG diet based on her own and her husband’s experience.
What Dr. Simeons book does not tell you is that there is a good chance your hair will fall out aproximately three months after completing the 500 calorie phase of the diet. He also doesn’t mention that the shock to your system can cause adrenal fatigue, and hypothyroidism if you were already prone to these conditions.
My husband and I both went on the hCG diet and both lost the weight we had been hanging onto for years. I followed the diet perfectly, but as soon as the hCG stopped, the weight began coming back on, FAST! I had to do a steak day every other day, my blood sugar plummeted and I began to feel awful! I suffered fatigue, dry skin, dry mouth, no energy, no libido, and my muscles and joints began to hurt. The carb and sugar cravings were so intense I felt like a drug addict. I gained all the weight back plus 13 lbs. in three months, then the hair began to fall. My doctor was shocked and completely surprised. His only theory is that the usual dose wasn’t enough for me and I triggered a starvation response which affected my thyroid and adrenals. Together we are going to support adrenal health, then begin t3 therapy in an effort to repair my thyroid. My husband on the other hand, feel great! He has been able to keep off the weight, add some muscle and is happy and energetic every day. hCG does work, but if you have any health problems related in any way to the hypothalmus, I would consider taking the weight off very slowly to avoid starvation response.