Are You Hypothyroid and Your Treatment Isn't Working?

Your Next Steps if Your Hypothyroid Treatment Isn't Working

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After being diagnosed with hypothyroidism and beginning treatment, many people continue to have symptoms. This may be true even if you have been hypothyroid for a long time and if your TSH is normal.

If you just aren't feeling right after receiving treatment for your hypothyroidism, you are not alone. While this is common and can be incredibly frustrating, there is a number of things that might make a difference in how you feel both physically and emotionally.

Let's take a look at what you may be experiencing, and list some of the steps to consider in your quest to feel fully well.

Persistent Symptoms Of Treatment of Hypothyroidism

Even after you've been diagnosed and prescribed thyroid replacement drugs for hypothyroidism, and even after your lab tests appear "normal," you may continue to have persistent symptoms. You may have noted:

  • Continued weight gain
  • Difficulty losing weight
  • "Brain fog"
  • Difficulty concentrating
  • Hair loss
  • Hand, foot, or facial swelling
  • Intolerance to heat and/or cold
  • Muscle aches
  • Joint pains
  • Constipation
  • Carpal tunnel syndrome or tendinitis
  • High cholesterol levels
  • Difficult getting pregnant

Steps for Managing Persistent Symptoms Associated With Hypothyroidism

If you have any of the symptoms listed above, what can you do? Let's take a look at a number of steps you can take to feel better. As you take these steps it's important to have a doctor who can walk beside you in determining what you should do amidst the current treatment controversies.

1. Look at Your TSH Level

The first step to take in getting well is to know your TSH level (thyroid stimulating hormone level.) Understanding your TSH level, however, requires more than just knowing if your number falls within the "normal range."

Depending on your lab, as well as the particular organization making recommendations, a "normal" range is often considered between 0.5 and 5.0 mU/l.

In recent years, however, there has been considerable differences in recommendations concerning the ideal TSH level.

More innovative doctors are beginning to believe that a TSH of between 1 and 2, in other words, on the low end of the normal range, is optimal for people to feel well and avoid having hypothyroid symptoms. (Some also believe this decision should be made by including free T4 and free T3, which we will discuss next.)

In contrast, other recommendations have been to avoid routine treatment even in people with TSH levels which fall between 5 and 10 mU/l.

Since there is controversy over the optimal TSH level for people with hypothyroidism, it's important to talk to your doctor about what she feels your goal numbers should be within the normal range.

An analogy to make this a little clearer is that of optimal vitamin D levels. Some labs note that the "normal range" for vitamin D is 30 to 90. At the same time, some studies have found that levels between 50 and 70 are preferred for reducing the risk of some medical conditions such as cancer. In this case, if a person had a level of 31, their doctor might recommend a supplement even though their number falls within the "normal range.'

(Note: TSH levels should be kept at less than 1 for survivors of thyroid cancer in order to prevent a recurrence.)

Learn more about whether your hypothyroidism may be undertreated.

2. Look at Your Free T4 and Free T3 Levels

The next step is to be familiar with your free T4 and free T3 levels. It's important to note that thyroid replacement drugs such as Synthroid are T4 alone, whereas both T4 and T3 are normally present in the body.

Beginning with a study in the New England Journal of Medicine in 1999, which found that people with hypothyroidism often felt better with a combination of T4 and T3 replacement, practitioners began to consider whether adding T3 therapy to T4 therapy might be helpful for some people who continue to feel hypothyroid despite a normal TSH.

Ordinarily, T4 is converted to T3 in the body, and providing T4 via replacement should, in theory, be enough. But that may not always be the case.

Why might some people have a better quality of life with supplemental T3 in addition to their thyroid replacement therapy? There are a number of theories. It's thought that some people with a normal TSH may still be hypothyroid at a cellular level. This could be due to inadequate conversion of T4 to T3.

For people who may have low free T3 levels, treatment options may include supplemental T3 drugs (such as Cytomel) or switching to a product which replaces both T4 and T3 such as prescription natural desiccated thyroid (such as Armour.) Studies have been mixed on this practice, with credible studies finding both a significant improvement in some and a lack of a significant effect in others. Due to this, it's important to talk to your doctor about the latest findings and to understand the T4/T3 thyroid drug controversy. It's also important to recognize that each person is different, and you and your doctor should work together to treat your symptoms rather than any particular numbers.

Keep in mind that T3 supplementation may help with some of your symptoms but not others. For example, a 2013 study found that taking a T4/T3 compound did not improve quality of life relative to levothyroxine alone, but did help with weight loss.

If you think that T3 may be your problem, learn more about whether you may need T3 or natural desiccated thyroid.

3. Putting TSH, Free T4, and Free T3 Together

Rather than looking at specific numbers of TSH, free T4, or free T3 alone, the combination of these numbers may help you and your doctor decide if any changes need to be made in your medication dose, or if you need to consider using a T3 drug in addition to your thyroid replacement therapy (or switch to a T4/T3 compound.

Some practitioners feel that optimal hypothyroid treatment includes not only aiming for a TSH level between 1 and 2 but a free T4 in the top half of the normal range and a free T3 in the top 25th percentile of the normal range.

Looking at all of this together can be confusing. You might wish to take a moment to review the types of thyroid replacement therapy drugs that are available, including not just T4 drugs, but T3 and T4/T3 compounds as well.

4. Other Approaches to Feeling Well With Hypothyroidism

Finding the best medication or medications and the correct dose to manage your symptoms is just part of living well with hypothyroidism. There are a number of other things you can do to feel as good as possible.

First, if you don't have a doctor who seems experienced in managing the nuances of thyroid diseases, learn about how to find the best doctors to manage thyroid care. Yet, it's not only your doctor who can help you understand the latest research on hypothyroidism. Finding a good online thyroid support group may not only help you emotionally, but can be a great way to hear stories from other people facing the challenges you are, and become more informed about your disease.

As with most medical conditions, the importance of getting enough exercise and eating a healthy diet can't be understated. There are many things to know about hypothyroidism and your diet, such as the role of soy in thyroid health.

Finally, think of ways to reduce stress in your life. If you are coming up short, you can begin by checking out these 70 ways to reduce stress where you're likely to find at least a few that work for you.


Eligar, V., Taylor, P., Okosieme, O., Leese, G., and C. Dayan. Thyroxine Replacement: A Clinical Endocrinologist’s Viewpoint. Annals of Clinical Biochemistry. 2016. 53(Pt 4):421-33.

Kasper, Dennis L.., Anthony S. Fauci, and Stephen L.. Hauser. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill education, 2015. Print.

Schmidt, Y., Nygaard, B., Jensen, E., Kventny, J., Jarlov, A., and J. Faber. Peipheral Markers of Thyroid Function: The Effect of T4 Monotherapy vs T4/T3 Combination Therapy in Hypothyroid Subjects in a Randomized Crossover Study. Endocrine Connections. 2013. 2(1):55-60.