Why is Optimal Thyroid Health so Elusive?

This post comes to us from Dr. Tiffany Turner, a naturopathic medical doctor practicing in Scottsdale, Arizona with a focus on thyroid health and endocrinology. She is well versed in helping patients manage thyroid symptoms using diet and lifestyle interventions, as well as medication. We know thyroid issues can be some of the most confusing and frustrating to unravel, so we wanted Dr. Turner to help us better understand the steps involved in testing, monitoring and maintaining optimal thyroid health. 

Severe fatigue is the most common concern I hear from my new patients. This concern is followed closely by brain fog so pervasive that some of my patients worry they will lose their jobs. The list of thyroid symptoms continues, spanning a wide range of issues from weight gain and constipation to feeling cold all the time.

From those on the hyperthyroid side, I also hear about severe fatigue and this is sometimes coupled with anxiety, palpitations, loose stools, insomnia and in general, just plain feeling “awful”.

These patients are not “new” to their thyroid conditions. They didn’t wake up yesterday and start feeling ill. These are people who have been fighting for years to get their health back. People who have sought out every source of information they could arm themselves with and who have had multiple different care practitioners on their health team over the years. People like you, who are already well versed in lifestyle aspects of health, and who are taking the time to read this now and learn more about achieving optimal thyroid health.

With all this effort, why then does it seem so difficult to feel better?

You’ve worked hard to feel better, so let’s unwrap this enigma right now.

We’ll start with a discussion of thyroid lab testing and close with one of the most common questions I’m asked, “when can I stop taking my thyroid medication”.

• The best testing for assessing your thyroid function
• The importance of screening with thyroid ultrasounds
• Why the type of medication you take matters
• When dosing gets confusing and what to do about it
• Thyroid mimickers and thyroid troublemakers
• When can you stop taking thyroid medication

The best testing for assessing your thyroid health

As an initial look into the health of your thyroid, a comprehensive thyroid panel would include TSH, free T3, free T4 and thyroid antibodies.

The TSH remains an important indicator of thyroid function. The TSH is the signal that tells your thyroid to produce thyroid hormone. When your need for thyroid hormone goes up (such as in hypothyroidism), your TSH will go up as your body requests more thyroid hormone from your thyroid. When your need for thyroid hormone goes down (such as in hyperthyroidism where you have too much thyroid hormone), your TSH will go down as your body does not need more thyroid hormone.

Your TSH should be re-checked regularly to assess whether your thyroid medication is at an optimal dose for you and your need for thyroid hormone can change over time. For example, during pregnancy, periods of weight changes or on entering menopause your thyroid medication requirements may go up or down.

There are other more mundane factors that can influence your TSH test results as well. Have you ever had two TSH tests run within days of each other and received vastly different results? I’ve had patients bring me results like this, puzzled. However, there are several potential reasons for this and these are all about how you have those tests run.

A blood draw for a TSH test should always be drawn fasting, first thing in the morning and prior to taking your medication. Whether or not you have eaten actually does make a significant difference to your TSH level, so much so that it may affect clinical decision-making as to whether to increase or decrease your thyroid medication dose. Time of day also matters because your TSH has a circadian rhythm. You may be familiar with circadian rhythms in the context of cortisol, another important hormone. Taking your medication or not taking your medication prior to your blood draw is not so critical for TSH but it will affect your free hormone levels if those are being tested as well. Being consistent and letting your doctor know whether or not you took your medication prior to blood draw is helpful in knowing how to interpret those results.

Two additional factors that can affect your TSH testing is what time of month you have your labs drawn (if you are still menstruating) and the supplements you are taking. Fluctuating levels of female hormones create fluctuations in TSH levels, and because of this, it is recommended to check TSH between days one to ten or after day twenty of your cycle. You should also be aware of any supplements you are taking that may contain biotin, a popular supplement for hair health which is also contained in many multivitamins. Biotin-containing products consumed within 72 hours of your blood draw can falsely elevate your TSH levels.

Antibodies are helpful to see initially, as they indicate an autoimmune condition if present. However, if they are absent we still cannot rule out an autoimmune condition, as to do so we would have to do a complete histological examination of your thyroid (and it wouldn’t make sense to completely remove your thyroid just to do so!).

You may be wondering about testing for reverse T3, since I didn’t include it in the comprehensive panel I mentioned above. It turns out that reverse T3 is not that helpful for clinical decision making. Unless perhaps, you are in intensive care in a hospital. Outside of this context it does not carry a lot of utility. It is a helpful way for your thyroid to dispense with extra thyroid hormone, such as may occur in hyperthyroidism or in the event of overmedication. However, it does not block the ability of free thyroid hormones to do their work.

The importance of screening with thyroid ultrasounds

When’s the last time you had a thyroid ultrasound? This is an important annual screening for those with thyroid conditions. It helps us to see if you have any benign nodules or cysts and to keep an eye on the emergence of anything a little more suspicious. Occasionally, benign masses become large enough that there are structural issues and related symptoms, such as a hoarse voice. In these cases, and in cases where there is a malignancy, surgical consult may be warranted.

Why the type of medication you take for thyroid health matters

If you aren’t feeling your best on your current medication, it could be that you would benefit from switching to a different brand of medication. Some medications contain only T4 hormone, others contain only T3 hormone. Then there are medications that have both and are derived from natural sources. Within all these options, there are also differences from brand to brand in how tightly standardized the hormone content is.

When dosing gets confusing and what to do about it

Your thyroid medication should be dosed at a level that keeps your TSH within an optimal range. If not within this range, you may still experience symptoms or be increasing risks for complications long-term.

Now what if your thyroid medication dose is fairly high but you are still experiencing symptoms attributed to hypothyroidism, like weight gain and fatigue? There are a couple possibilities here. One possibility is that you are not absorbing the medication well (as discussed in the next section).

Another possibility is that your thyroid medication dose is too high. It seems counterintuitive, right? However, when you get too much medication your body is going to try to bail you out as best it can, and this can make you feel some of the symptoms of hypothyroidism. If you increase your medication further, you may feel an initial spurt of energy while your body tries to catch up and bail you out again and then symptoms start to return. Eventually, your body can’t bail you out anymore and you start experiencing symptoms of hyperthyroidism.

There are long-term risks associated with both hypothyroidism and hyperthyroidism and as a result, it is important to make sure your dosing is correct for you and your unique thyroid hormone requirements.

Thyroid mimickers and thyroid troublemakers

There are many symptoms that can fall into the category of “thyroid symptoms”. However, these symptoms aren’t very specific to thyroid disease. This means you could have another condition contributing to your symptoms and this may occur on its own or in conjunction with a thyroid condition.

This is why a comprehensive set of labs can be very useful because they give a snapshot of how your body is working as a whole, and can help elucidate any other potential causes for what you are experiencing. In addition, thyroid disease (both hypothyroidism and hyperthyroidism) can put you at an increased risk for certain other conditions such as diabetes, autoimmune gastritis and cardiovascular disease so choose a practitioner who is aware of how these diseases can cluster together and that is on the lookout for you.

Furthermore, there are some conditions which may interfere with your thyroid health (such as heavy metal burden or issues with nutrient absorption) or that may interfere with your ability to absorb your thyroid medication (such as gastrointestinal inflammation or dysbiosis). Certain substances, such as calcium and caffeine can also pose a problem to thyroid medication absorption. All these factors should be taken into account when assessing how to bring your thyroid hormones to optimal levels.

When you can stop taking thyroid medication

People often want to know “when can I stop taking thyroid medication?”, or in another variant, “will I have to take this medication for the rest of my life?”. The truth is there is no definitive way of knowing whether you specifically will need a thyroid medication long-term.

From what the research demonstrates, about 20% of people may experience an improvement of thyroid function over time. Will you be part of that 20% and will the improvement be enough to take you off thyroid medication completely? Nobody can promise that, because at this point in time there is no lab that will help us understand the answers to those questions.

However, what we can do is target any potential contributing factors (which can also be affecting your health as a whole), reduce your long-term risks by keeping an eye on your overall health and performing regular screenings, and improve how you feel by making sure your body has the thyroid hormones it needs.

Taking a medication for your thyroid does not mean you didn’t try hard enough, sleep deeply enough, eat clean enough, meditate often enough or exercise vigorously enough. It does not make you a failure. Quite the opposite, actually. It means that you are willing to take care of yourself and give your body the support it needs, whether that comes through lifestyle, supplements, medication or a combination of all three.

At the end of the day, your ability to live out your goals and dreams is what matters, and if it takes a small tablet of thyroid medication each day to have the health you need to live your dreams, embrace it for helping you.

References

1. Nair, R., Mahadevan, S., Muralidharan, R. S. & Madhavan, S. Does fasting or postprandial state affect thyroid function testing? Indian J. Endocrinol. Metab. (2014) doi:10.4103/2230-8210.139237.
2. Sviridonova, M. A., Fadeyev, V. V., Sych, Y. P. & Melnichenko, G. A. Clinical significance of TSH circadian variability in patients with hypothyroidism. Endocr. Res. (2013) doi:10.3109/07435800.2012.710696.
3. Benvenga, S., Di Bari, F., Granese, R. & Antonelli, A. Serum thyrotropin and phase of the menstrual cycle. Front. Endocrinol. (Lausanne). (2017) doi:10.3389/fendo.2017.00250.
4. Ardabilygazir, A., Afshariyamchlou, S., Mir, D. & Sachmechi, I. Effect of High-dose Biotin on Thyroid Function Tests: Case Report and Literature Review. Cureus (2018) doi:10.7759/cureus.2845.
5. Moura Neto, A. & Zantut-Wittmann, D. E. Abnormalities of Thyroid Hormone Metabolism during Systemic Illness: The Low T3 Syndrome in Different Clinical Settings. International Journal of Endocrinology (2016) doi:10.1155/2016/2157583.