Friend, or Foe?
"I feel tired all the time"
"I can't lose weight."
"I'm anxious and my heart races."
"I don't feel like I can think."
"I'm losing my hair."
Patients with symptoms like these come to Eureka for treatment all the time.
When you're dealing with thyroid conditions like hypothyroidism, or Hashimoto's, it can feel like there's a delicate balance between feeling great, and feeling terrible. Rather than struggling to find this balance on your own, thyroid doctors work with patients (like you) to help you find your balance.
One common request we see from patients is to change, or alter their thyroid medications. You're not weird, crazy, or alone when you make these requests.
It's not uncommon to see patients who have symptoms because they're either over-medicated, or under-medicated. When you take too much medication, you'll have too much thyroid hormone, and you'll feel hyperthyroid symptoms. When you take too little medication, you'll have too little thyroid hormone, and you'll feel hypothyroid symptoms.
It's a complex topic, so we interview two experts, Dr. Marco De Santis (DO) and Dr. Vineeth Mohan (MD), to share what' they've learned from their 35+ years working with thyroid patients.
If you have a diagnosed thyroid condition, you're taking medication, and you feel less than great, then this guide is for you. We'll explore over-medication and under-medication symptoms, as well as the common drugs used to treat thyroid conditions.
The Thyroid Experts
Dr. Vineeth Mohan, M.D, is a board-certified endocrinologist with over 20 years experience. He completed his medical degree at the University of Texas, then served as Chief of Endocrinology at Andrews Air Force Base. Dr Vineeth’s work has been listed in "America's Top Docs'' by Castle Connolly Medical.
Dr. Marco De Santis, DO, is an endocrinology, diabetes, and metabolism specialist in Newark, Ohio. Dr. Marco graduated from Lake Erie College of Osteopathic Medicine in 2008, and has over 15 years experience in medicine and has extensive experience in thyroid conditions, diabetes, and osteoporosis.
Important Symptoms and Tell-Tale Signs
“One big symptom that patients mention is fatigue, that's a huge one; and it can happen with too much, or too little medication.” says Dr. Vineeth.
When there’s not enough thyroid hormone, your metabolism and energy production decrease. When there’s too much thyroid hormone, your metabolism uses energy in your body faster than it can produce. In both cases patients often feel fatigue.
This also means that when there’s too little thyroid hormone it can be harder to lose weight, and when there’s too much thyroid hormone, it can be harder to gain weight. While it sounds glamorous to have a hard time gaining weight, too much thyroid hormone (hyperthyroidism) comes with its own serious problems, which can include cancer, muscle loss, osteoporosis, and more.
Weight gain is the second most common symptom we see at Eureka, and weight gain can be a symptom that there’s under-medication. People who don’t have enough thyroid hormone (hypothyroid) will often complain that they’re gaining weight. When we discuss weight gain, it’s important to mention that for almost everyone on earth, weight gain is easier than weight loss. So when weight gain is due to under-medication (e.g not enough thyroid hormone), it tends to appear with other symptoms too, so it’s rarely the only symptom you’ll experience.
As a general rule, when your thyroid hormones aren’t balanced well, these are the most common symptoms you’ll notice.
Most Common Symptom
- Fatigue: appears when there’s too much, or too little thyroid hormone causing energy balance problems.
Other Common Symptoms
- Weight Changes: when there’s too much, or too little thyroid hormone, you’ll notice weight changes become much easier and more common.
- Brain Fog: challenges engaging, staying engaged, or remembering things also known as brain fog are common when there’s energy balance problems.
- Mood : since too little thyroid hormone decreases energy levels, and too much causes too much to be spent, it’s not uncommon for people to feel anxious, or depressed.
- Hair Loss: when you start to lose hair, or your hair starts to break that can also be a sign that there’s too little, or too much thyroid hormone.
In some rare cases, thyroid medications can also cause heart palpitations. When patients have had hypothyroidism for a while, organs like the heart can become more sensitive to thyroid hormones. When this happens, it’s your body’s way to try and find balance, even though there’s not enough thyroid hormone being produced. Palpitations (e.g. a rapid heartbeat) can be a symptom that there’s too much medication based on enhanced sensitivities. However, when medication is slowly and gradually introduced, palpitations disappear, and the these problems go away.
Sometimes weight loss also leads to over-medication symptoms. Say you’ve lost 50 lbs because you’ve been on a successful diet. Suddenly you’re anxious, you can't sleep, and you’re tired all the time. Since you now weigh less, your previous medication dose is now a little too high for you. When you lose weight without a thyroid condition, your body naturally regulates your thyroid hormones to make sure your metabolism is inline with your energy expenditure. In the case where you’re taking thyroid medications and you weigh less, your metabolism doesn't need to work as hard to maintain your current weight, however your medication dose now gives your body signals similar to someone who produces too much thyroid hormone. When this happens you can experience hyperthyroid symptoms and end up with the symptoms we’ve described above.
It’s also important to note that sleep, stressors, and mood can affect energy levels and lead to fatigue, too. Symptoms tend to suggest there’s a root cause, and any great thyroid doctor will focus on treating the root cause, rather than treating the symptoms—at least, that’s our approach to personalized thyroid care.
How to Make Things Better vs. Worse.
When thinking about over-medication or under-medication symptoms, a concept most doctors use is TSH (from laboratory tests) to determine what to do next.
TSH (thyroid stimulating hormone) is a hormone which sends signals to your thyroid how hard to work. When your thyroid no longer works as expected, the brain continues to send these signals to the thyroid. So when you’re over-medicated (e.g. too much thyroid hormone) less TSH is produced, and when you’re under-medicated (e.g. too little thyroid hormone) more TSH is produced. That’s why TSH is a useful value for thyroid treatment, because it shows how your body is responding to current hormone levels.
“I’ve had many patients over the years that say, ‘I feel better when my TSH is less than one, or when it's between one and two’. Most people don't feel better when it's above two or three. There's a rare person where, for whatever reason, they feel better when their TSH is higher…but almost everybody feels better when it's lower normal.” says Dr. Marco De Santis.
When patients have normal TSH, T3, and T4 values but have persistent symptoms, it’s best to look into other issues (to make sure there’s nothing more serious) before adjusting medications. When fatigue is persistent, labs are perfectly normal, and the medications have been adjusted multiple times, it’s likely the issue isn’t thyroid-related. Fatigue can be a common symptom for everything from lifestyle challenges, to other more serious conditions. Sometimes the thyroid is the culprit, and sometimes, it’s important to explore other paths.
“Suppose I have a patient who has Hashimoto's, and they either have very mild hypothyroid, or maybe their thyroid function is actually normal. What am I going to talk about? Diet.” says Dr. Vineeth. Data suggests that as societies become more modern, we tend to see more autoimmune diseases. Diets that are less processed, less refined, contain less animal products, and include more whole-foods, fruits, vegetables, legumes, and beans seem to lead toward more favorable health outcomes.
Stress also plays a role in autoimmune conditions like Hashimoto’s or Grave’s disease, and while it’s easier said than done, stress reduction, good quality sleep, and mindfulness practices will lead to benefits. Exercise is another pillar which can be added to the mix to improve outcomes for anyone dealing with thyroid challenges. If exercise was a pill, everyone would take it.
If you’re already doing everything else right, some preliminary data suggests gluten-free diets can help improve autoimmune responses. Some short-term studies show improvements in thyroid antibodies on a gluten-free diet, and some research suggests this will help preserve thyroid function. Gluten intolerances can also lead to absorption issues with some medications, so when people avoid gluten sometimes their symptoms can improve. Removing gluten isn’t going to cause any harm, and there might be real benefits.
Sometimes managing over-medication and under-medication can become very complex.
“If patients have a ton of fluctuation, I might want to check Grave’s disease antibodies. I've had some patients over the years where their TSH levels fluctuate like crazy, and when you check they have both Grave’s and Hashimoto’s antibodies.” says Dr. Marco De Santis, “they have the Grave’s antibodies which cause hyperthyroidism, and they have the Hashimoto's which causes hypothyroidism. So their body vacillates between the two. For a doctor, that's really crazy because we think about these thyroid diseases as separate. In my experience, when people have both antibodies, it's the Grave’s disease that is usually more powerful.”
Have symptoms and want to change or adjust your medication?
Levothyroxine (T4): Sides and Warning Signs
“Although it's improved over the years, there also seems to be differences in the medications” says Dr. Marco. Generics are not regulated as well as brand name drugs, so it’s not uncommon to see some discrepancies between dosages. People and their symptoms can be very sensitive to these fluctuations. In some instances, the medication may say 100 mcg, and one time it's actually 90mcg, then another it's 110 mcg, which can lead to a big difference in symptoms and how people feel.
Dr. Vineeth says “side-effects from too much levothyroxine are most obvious when a person takes too much medication. If someone has palpitations, hair loss, anxiety, poor sleep, and their thyroid levels show that they're on too much thyroid hormone, it's a no-brainer to reduce the dose.”
For symptoms like hair loss, there’s a lag-effect between the time to make changes and the results. When a person takes too little levothyroxine, it's going to take time for the body to adjust, and a few weeks before new hair growth to settle in once thyroid levels are normal again. It’s common for people to feel better before their hair gets better. When there’s too much thyroid hormone from too much medication, hair loss can be more dramatic. Sometimes severe shedding can take as long as six months before it’s back to where it was before.
Some patients might notice muscle pain, joint pain, and muscle cramps when they first start thyroid replacement hormones. It's usually only in severe replacement cases and almost always when the patient starts on thyroid hormone replacement. It tends to resolve on its own, or with supplementation like magnesium and electrolytes.
Both doctors agree as long as you're on a therapeutic dose (not too little, or too much) symptoms will resolve. Common side-effects from thyroid medications tend to be common symptoms for having too much, or too little thyroid hormone. In that sense, it’s more a problem with dosages than with the medication.
It’s also worth a mention that these medications also contain dyes and lactose. For some patients sensitive to these, even small of these amounts can lead to persistent symptoms, or side-effects.
Combination Therapies (T4 +T3): Sides and Warning Signs
When your body produces levothyroxine, there’s a buffering approach to make sure your body converts any excess T4 to T3 (another more active thyroid hormone). Levothyroxine tends to be prescribed alone (T4) because in initial studies, T3 and T4 combinations didn’t suggest favorable outcomes. However, some patients do well on combination therapies where they receive levothyroxine (T4), alongside a T3 medication like Cytomel, or Liothyronine.
T4 to T3 conversion processes work better in some patients than others, and so for some patients, combination therapies make a big difference to their symptoms. There’s even evidence which suggests that patients with depression do better on therapies which include T3 for mood elevation. Dr. Marco says “there was a patient who came to me on a high T3 replacement dose, and she mentioned it was prescribed by her psychiatrist for depression, and she’s never been better. I’ve never checked the literature, however she’s an example where this works.”
Since T3 appears to be a more active hormone than T4, it does tend to drive hyperthyroidism symptoms unless it’s managed well, which means we can expect to see hair loss, anxiety, heart palpitations, and tremors when there’s over-medication.
In general, it’s a little less common to see these symptoms on T4 alone vs. combination (T4 + T3) therapies. In general, more research is needed on combination therapies, but there is a resurgence in the idea that the original studies on thyroid replacement are lacking sufficient long-term data.
Synthroid, Armour Thyroid, And Other Alternatives
Dr. Marco says “for patients that want to take something more natural, desiccated thyroid medications (made from pig’s thyroid) like Armor Thyroid or NP Thyroid are common alternatives. While these medications contain both T3 and T4, it’s difficult to know the exact amount in each dose. At times that means patients could be getting more or less than they need, which can lead to TSH fluctuations and common symptoms.”
Many patients want to take Armor Thyroid because they want something more natural. But, both doctors question whether it’s more natural to consume a pig’s thyroid gland, rather than a bio-identical human hormone (like levothyroxine).
Some research suggests that natural alternatives can be problematic for some patients, and this can induce an immune reaction. While it’s not clear why the immune reaction occurs, it does seem to be more common in people who also have an allergy to iodine.
Medications like these can be controversial, but some patients can function well with these alternatives, even under difficult circumstances. “I had a patient a few months ago who was pregnant. When she became pregnant, she was on Armor Thyroid. I explained, Armor Thyroid is not recommended, as T3 doesn't cross the placental barrier, and the T4 in the product may not be enough to guarantee proper neurological development for the baby.” says Dr. Marco. “She was insistent on taking it, so I kept her dose towards the upper-end, I documented that she understands the risks involved, and wishes to take this. Her pregnancy was fine and the baby was fine too. How someone feels and reacts can be very individualized.”
While it’s not a replacement for thyroid medications, there are studies which suggest black seed oil is helpful for immune support, and for inflammation as well. Some minerals like iron, selenium, vitamin D, and B12 can also improve patient outcomes, at least as far as the symptom we’ve discussed.
Overcoming the Struggle And Winning the War
Thyroid health requires a good thyroid doctor and a personal insight into what over-medication and under-medication symptoms look like. Since over-medication symptoms are just as bad as under-medication symptoms, finding the right balance matters.
Our hope is that the insights from Dr. Vineeth and Dr. Marco will help you live symptom-free.
Achieving optimal health is a journey and a collaboration, which is why It’s important to find the right partner, as much as it is to find the right path.
If you’re looking for the right partner, with Eureka, you can skip the wait and get personalized thyroid care in minutes. Don’t have health insurance? We can still give you recommendations for free.
