Thyroid tired all the time

Tired? Always Cold? Think it’s hypothyroidism? Think again

With Mary Samuels, MD, James Hennessey, MD, and Deena Adimoolam, MD

Mixed messages persist regarding whether to treat subclinical hypothyroidism or not. You may be diagnosed with subclinical hypothyroidism if you have a thyroid function test indicating normal thyroxine (T4) concentration and mildly elevated serum thyroid stimulating hormone (TSH) level.

While symptoms like unexpected weight gain, depression and moodiness, sleeplessness, hair loss, and intolerance to cold temperatures are commonly associated with hypothyroidism, there are rarely any symptoms in individuals who have very mild subclinical hypothyroid disease so it is rarely detected. Then does it really matter?

Symptoms like feeling fatigued, always cold, gaining weight are possible signs of hypothyroidism but subclinical hypothyroid disease often has no symptoms and rarely requires treatment. photo; 123rf

No Apparent Benefit in Treating Subclinical Hypothyroidism

This is a question that has plagued doctors—to treat or not to treat for subclinical hypothyroidism? The answer remains controversial. Having subclinical hypothyroidism may increase a person’s risk of cardiovascular disease so you might say, “treat me.

However, guidelines from experts found no benefit in treating individuals whose TSH falls between 5-10 mlU/L,1,2 unless you are planning a pregnancy or are pregnant and have confirmed subclinical hypothyroidism.

Before you jump to the conclusion that everyone with subclinical hypothyroidism should be treated, findings from a pair of studies, published in the Journal of Clinical Endocrinology and Metabolism,3,4 may clarify the matter for you. Both studies were carried out by Mary Samuels, MD, professor of medicine, and her research team, at the Oregon Health Sciences University in Portland.

In the first study,3 the researchers wanted to know if changing the dose of levothyroxine has a noticeable effect on patients’ quality of life, mood, and cognitive reasoning. They used surveys to gather patient responses assessing their quality of life and mental health status, and a research assistant conducted tests to evaluate changes in memory, attention, and decision-making to develop a score for cognition.

According to Dr. Samuels, there was no improvement in participants’ test scores based on dosing levels, even though the dosages were increased to bring the patient into line with recommended TSH levels.3 Furthermore, patients reported feeling their best when they thought they were being treated with the highest dose of levothyroxine. If they thought their dose had been lowered, they reported feeling better at the beginning of the study, whether they had actually had a change in their medication or not.

The research team looked at changes in energy expenditure and body mass index (BMI), in the second study of these same individuals,4 to assess whether a change in these parameters had any effect on the dose of thyroid replacement therapy needed. Again, the authors reported no differences found; yet, patients believed that the dose they did best on was the highest dose.

“This means that even if you think you have a very mild form of hypothyroidism, you should not expect to gain any significant health advantages or benefits from thyroid replacement therapy,” Dr. Samuels tells EndocrineWeb.

Unless You Are Pregnant, Approach Treatment with Caution

James Hennessey, MD, an endocrinologist at Beth Israel Deaconess Medical Center in Boston, says patients often leap at the idea of hypothyroidism when they have certain symptoms because it is so easily treated; he reviewed the studies for EndocrineWeb but wasn’t involved in them.

“It’s important to realize there are many other conditions which can produce similar symptoms, including depression, poor kidney function, or an autoimmune disease like systemic lupus,” he says. So pushing for treatment may be premature or even counterproductive.

If you have symptoms that are causing you to worry, or that you’ve noticed recently, the best course of action is to make an appointment with your doctor to share these changes so your health can be assessed, and your thyroid status can be properly evaluated.

Dr. Hennessey offers another note of caution—you should know that the TSH levels that are listed on websites as normal or abnormal may refer only to specific age ranges. “There is a big difference between what is acceptable for a 30-year-old than for a 60-year-old. And, while 2.5 mlU/L is a great TSH level for a younger person, a thyroid function at 6.0 mlU/L is equally fine for a more senior patient.

“Receiving treatment can even be dangerous,” says Deena Adimoolam, MD, an endocrinologist and assistant professor of medicine at the Icahn School of Medicine at Mt. Sinai Hospital in New York City. It may be constructive to realize that there are symptoms of too much thyroid hormone; signs of overtreatment include anxiety, sweating, and insomnia but there are also “silent” effects that can result such as irregular heartbeats (arrhythmias) and even heart failure.

Even when one doctor has treated you for years, Dr. Adimoolam says, “if you change doctors for any reason, you should expect to be screened by your new provider who is likely to recommend that you taper off your thyroid replacement medication before checking your TSH levels.”

Seek Treatment Based on Thyroid Function Status, Not Perceptions

“Patients should also know that the TSH levels that are on listed on websites as normal or abnormal may refer only to specific age ranges. There is a wide difference between what is acceptable for a 30-year-old than for a 60-year-old. While 2.5 mlU/L is a great level for the former, 6 mIU/L is fine for the latter,” Dr. Hennessy adds.

“Age is only one of the factors that I rely on in evaluating whether or not a patient would benefit from thyroid replacement therapy,” says Deena Adimoolam, MD, assistant professor of medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York City.

“We need to assess the patient based on her overall clinical situation —history of symptoms, physical examination, comorbidities, other meds—and lab values, specifically thyroid function tests, keeping in mind that these tests, specifically the TSH, will change with age in making a determination to treat or not to treat.”

While you might feel certain that you have hypothyroidism and insist that your doctor give you levothyroxine (thyroid replacement therapy), according to Dr. Hennessey, physicians must resist these entreaties and instead should offer you alternatives to address your concerns.

Should you experience a change your health status, such as taking new or different medications or doses, experiencing new life circumstances, such as pregnancy, these may warrant a fresh evaluation of your thyroid function levels,” Dr. Adimoolam says.

Of course, if you have symptoms that worry you, or that have occurred recently, the best course of action is to make an appointment to mention these changes with your physician who can assess the need for testing and possible treatment.

Dr. Hennessey offered another note of caution—it’s important for patients to know that the TSH levels that are listed on websites as normal or abnormal may refer only to specific age ranges. “There is a big difference between what is acceptable for a 30-year-old than for a 60-year-old. And, while 2.5 mlU/L is a great TSH level for a younger person, a thyroid function at 6.0 mlU/L is equally fine for a more senior patient.

“Receiving treatment can even be dangerous,” says Deena Adimoolam, MD, an endocrinologist and assistant professor of medicine at the Icahn School of Medicine at Mt. Sinai Hospital in New York City. While lesser symptoms of overtreatment can include anxiety, sweating, and insomnia, “silent” effects can include irregular heartbeats (arrhythmias), and even heart failure.

More to Learn about Effects of Treating Hypothyroidism

Even when one doctor has treated you for years, Dr. Adimoolam says, “if you change doctors for any reason, you should expect to be screened by your new provider who is likely to recommend that you taper off your thyroid replacement medication before checking your TSH levels.”

“Remember—life is not static,” she says, “New medical issues, other medications, changes in life circumstances like an interest in pregnancy, even as you age, will warrant a reevaluation of your thyroid status, medications, and dosing.”

There is a lot more to study on the issue of who needs to be treated,” says Dr. Hennessey. “Patients who are diagnosed with subclinical hypothyroidism who are not treated as well as those who are receiving levothyroxine need to be more closely evaluated.” Dr.

“I would like to see longer term studies looking at the effect on quality of life as well as mortality rates,” says Dr. Adimolam. Until then, you can expect that there will be articles on the internet telling you that your hair is falling out not because you are aging, but because your thyroid is off. Chances are, your thyroid is not the problem, she says, so it’s best to bring any concerns to your doctor and have an open mind.

These studies were conducted with grants from the National Insitute of Diabetes and Digestive and Kidney Diseases, the National Center for Advancing Translational Sciences, and an OSHU Clinical and Translational Science Award.

Only Dr. Hennessey offered the following disclosure– he has been a consultant to Allergen Pharma, and AbbVie.

Last updated on 12/16/2019 Continue Reading Some Pregnant Women Should Be Treated for Subclinical Hypothyroidism View Sources

  1. Garber JR, Cobin RH, Gharib H, et the AACE/ATA Taskforce on Hypothyroidism in Adults. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
  2. De Groot L, Abalovich M, Alexander EK, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(8):2543-2565.
  3. Samuels MH, Kolobova I, Antos=ik M, Niederhausen M, Purnell JQ, Schuff KG. Thyroid Function Variation in the Normal Range, Energy Expenditure, and Body Composition in L-T4-Treated Subjects. J Clin Endocrinol Metab. 2017;102(7):2533-2542.
  4. Samuels MH, Kolobova I, Niederhausen M, Purnell JQ, Schuff KG. Effects of Altering Levothyroxine Dose on Energy Expenditure and Body Composition in Subjects Treated With LT4. J Clin Endocrinol Metab. 2018;103(11):4163-4175.

Sleep problems like insomnia can be caused by many different factors, including chronic pain, acid reflux, and depression. But did you know that your issue could also be triggered by a small gland called the thyroid? The thyroid is responsible for regulating an important hormone that keeps your body warm and help organs function properly. If your thyroid isn’t working correctly, it can cause a lot of problems, including getting in the way of your sleep. There are two types of thyroid conditions: overactive or underactive. How the gland impacts your sleep depends on which condition you have.


When your gland produces too much thyroid hormone, this is known as hyperthyroidism. The condition causes different bodily functions to speed up, leading you to feel wired and jittery. Symptoms may also include feeling anxious and experiencing a racing pulse, making it hard to get into a relaxed state. As a result, people who have hyperthyroidism may have trouble sleeping. When the condition first occurs, it might not seem like a problem since an overactive thyroid makes it seem as though you have endless energy, thanks to a revving metabolism. That sensation is short-lived, however, and as time goes on, you’ll start to feel really tired.


When the thyroid gland is underactive and not producing enough thyroid hormone, this is known as hypothyroidism. The lack of this important hormone causes processes throughout the body to slow down, making you feel tired more easily. For people with this condition, even a solid seven to nine hours of sleep at night doesn’t shake the constant sense of exhaustion. Some sufferers also report feeling like they are stuck in a fog or haze, without the ability to think sharply.

The good news is that for many people with a thyroid disorder, medication can help reduce negative symptoms and improve sleep issues. See your doctor if you’re concerned: A simple blood test can determine if you have the appropriate levels of thyroid hormones in your body.

Thinkstock In 2001, Kim Rhyne gained 20 pounds in six weeks. Normally an energetic women’s ministry leader in Cleveland, she was suddenly so exhausted that she could barely drag herself out of bed. “I wasn’t eating a lot more or doing anything any differently than I had been before,” says Kim. “I had no idea what was going on with my body.”

Knowing that an underactive thyroid often causes these symptoms, Kim’s doctor gave her a blood test to check her thyroid function. When the results came back within the normal range—though just barely—he diagnosed her with depression and started her on antidepressants.

Nine months later and not feeling any better, Kim had her thyroid levels rechecked. This time her levels were higher, so her doctor diagnosed her with hypothyroidism and started her on the medication Synthroid, which is commonly used to treat the condition. The drug pushed her test results back into the normal range, but Kim still didn’t feel well. She even struggled to muster up the energy to go grocery shopping or chat with the congregants who frequently stopped by her home. “I would end up in bed before guests even left the house,” she recalls. Meanwhile, she was more irritable than ever, snapping at her husband for the littlest things.

Kim told her doctor how bad she was feeling but he wouldn’t raise her medication dosage, citing her normal test numbers. Then, earlier this year—nine years after she was first diagnosed—Kim started chatting with a woman at church who happened to be an endocrinologist (a doctor trained in the treatment of hormone disorders). The woman suggested that Kim come see her for a workup. Her findings: Kim needed a slightly higher dose of Synthroid. A few weeks later, Kim started to feel like her old self again. “I couldn’t believe that I had spent years feeling tired and irritated when the solution was as simple as taking a little more medication,” says Kim, now 41.

Unfortunately, Kim’s struggle to get the right treatment is not that uncommon. Nearly 13 million people in the U.S. are not correctly diagnosed with hypothyroidism, and experts think that the number is probably climbing. “One in eight Americans is now age 65 or over, and you’re more likely to develop thyroid problems when you get older,” explains E. Chester Ridgway, MD, a professor of medicine at the University of Colorado School of Medicine. “That 13 million may just be the tip of the iceberg,” he says.

Why are thyroid disorders so hard to detect? For one thing, doctors don’t agree on how to interpret screening tests. There are also several tests that check thyroid function, but many doctors use just one. And in some cases, like when test results are borderline “normal,” symptoms should be given extra weight when deciding on treatment.

One Test, Many Interpretations

Your thyroid gland plays a crucial role in regulating just about everything, including your heart rate, metabolism, muscles and mood. If your thyroid is underactive (hypothyroidism), it’s not making enough thyroid hormone, so your body starts pumping out extra thyroid-stimulating hormone (TSH), which makes your TSH levels high. Insufficient amounts of thyroid hormone can cause symptoms like weight gain, fatigue, chills, and dry skin, hair and nails. On the other hand, when your thyroid is making too much thyroid hormone, you’ve got an overactive thyroid (hyperthyroidism), which causes weight loss, insomnia and anxiety.

Although most experts agree that measuring TSH levels with a simple blood test is the best way to detect a thyroid issue, they differ on what should be considered normal. Most primary care doctors use one standard range (0.5 mIU/L to 5.0 mIU/L), but many endocrinologists narrow that range (0.3 mIU/L to 3.0 IU/L), meaning that a larger group of people fall outside it. Kim’s internist considered her TSH levels normal, but her endocrinologist found them high.

It’s also worth noting that the TSH screening isn’t the only one. Doctors can also test for antibodies that show up in Hashimoto’s disease, an autoimmune condition that causes up to 95% of all hypothyroidism cases. It’s possible to have normal TSH levels but high levels of these antibodies, says Theodore C. Friedman, MD, PhD, chief of endocrinology at Charles R. Drew University and a professor of medicine at UCLA. But not all doctors order this additional blood test. Some doctors also believe in measuring two forms of thyroid hormone (T3 and T4).

When Symptoms Matter More

Grace White, 56, had all the classic signs of an underactive thyroid—fatigue, weight gain, hair loss and dry skin. But her TSH was normal, though borderline.

After seeing several doctors, who ruled out other conditions, Grace—who works for an airline manufacturing company in Billings, Montana—saw an endocrinologist. He quizzed her about her symptoms and decided to try her on medication. “Two weeks later I felt so much better,” she says. Today, 16 years later, her endocrinologist still doesn’t go strictly by her blood work. “He always asks how I feel, then decides whether my dose should be adjusted.”

But many doctors aren’t willing to do the same, because the symptoms of hypothyroidism can mimic issues like anemia, type 2 diabetes, sleep deprivation and depression. And no one wants to overtreat, since that can cause cardiovascular problems or osteoporosis.

The results of blood tests almost always determine whether or not you have an underactive or overactive thyroid, but sometimes it makes sense to give symptoms more weight than you would otherwise, says Jeffrey Garber, MD, president-elect of the American College of Endocrinology. In those cases, other health problems must be ruled out, a patient’s TSH must be borderline, and she should have symptoms as well as other signs that point to a thyroid disorder (an abnormal thyroid exam or a family history of the condition). “At that point, I’d consider putting a patient on a low dose of medication and watching her for 6 to 12 weeks,” says Dr. Garber. “If she really has hypothyroidism, she should feel much better.” If there’s no improvement, he’ll stop the treatment.

Getting To the Bottom of It

Since it can be so hard to get the right diagnosis and treatment, you may have to be your own advocate. Some tips that can help:

• Know your TSH number. Most primary care doctors say that a TSH level between 0.5 and 5.0 mIU/L is normal. But many endocrinologists use a narrower, lower range (between 0.3 and 3.0). Note: Endocrinologists are currently debating changing their range to between 0.4 and 4.0.

• See a good endocrinologist. Find one who treats people with a wide range of hormone conditions, including diabetes and adrenal gland problems. (Go to “Doctors who only see people with thyroid disorders often won’t look for other causes,” says Dr. Friedman.

• If your TSH is borderline, ask for a repeat test and an anti-TPO test. TSH levels can fluctuate from day to day. Wait 4 to 6 weeks for a follow-up test, says Leonard Wartofsky, MD, a former president of the Endocrine Society and professor of medicine at Georgetown University. The anti-TPO test will reveal whether you have Hashimoto’s disease.

• Rule out other health conditions. Make sure you also get a blood glucose test for diabetes, a ferritin test for anemia and a mental health screening for depression.

Beyond Medication

If you have hypothyroidism, taking a thyroid hormone replacement medication is a must. But there are things you can do to help those meds work better, says Dr. Friedman:

Eat foods rich in selenium.
This mineral helps convert thyroid hormone into a form that your cells can use. You’ll find it in Brazil nuts, seeds and grains, chicken, brown rice and eggs. But don’t overdo it if you’re at risk for diabetes—some studies show that selenium raises your risk.

Tell your doctor or pharmacist about any other drugs you take.
Some antidepressants, for example, can affect how much thyroid hormone you need. And blood thinners can become more potent if you’re taking thyroid medication.

Be careful with antacids that contain calcium or aluminum.
They can also block the absorption of thyroid hormone. Wait at least an hour after taking your thyroid meds before you reach for one. (Waiting 4 hours may be even safer, according to the National Institutes of Health.)

Don’t take your thyroid medication at the same time as calcium or iron supplements.
Both nutrients can prevent thyroid hormone from being properly absorbed, so take them at least 1 hour apart.

Winnie Yu is the coauthor (with Dr. Theodore Friedman) of The Everything Guide to Thyroid Disease.

“Every Afternoon At About Four I’m So Tired I Could Sleep At My Desk”

“Exhaustion is my reality. At four o’clock, I’m wiped, totally wiped.”

Patricia is 33, happily married as far as marriages go, one kid, steadily employed in the usual American less-­than-­satisfying corporate job, good eating habits, and, until recently, a health club goer a couple/three times a week. Now she’s too tired for that. Just looking at her, you can tell she’s dragging. Circles under her eyes and she needs to blink a couple of times to bring a thought to the surface.

One tuckered out woman.

Patricia brought in blood tests from her primary care doc and everything looked fine. Blood count, metabolic profile (checking for diabetes and kidney or liver disease), thyroid function, iron level. He even did screening tests for mono, autoimmune inflammation, and, because it’s the new hot topic, Lyme. At a sleep lab, she was told there was no evidence of a sleep disorder.

Nada. Nothing. She exhaustedly absorbed the mantra of contemporary medicine: “We can’t find anything wrong with you. All your tests are normal. Do you think you might be depressed?”

Patricia told me she didn’t think she was depressed, though contemplating feeling like this for the rest of her life could send her in that direction. Really, if she had the energy to call a babysitter she’d love to go out with her husband.

The 4 pm crash gives us a clue
Although Patricia had never been an energizer bunny in the morning, now she wakes up feeling like she hasn’t slept at all. To snap her brain into gear for work, these days she downs a couple of extra shot lattes. She knows she’ll function at two thirds capacity until 3 or 4 in the afternoon, when she becomes so tired she melts like a warm ball of Silly Putty. Then, a few hours later, at 8 or 9 (much to her annoyance, since it’s just before bedtime), she’ll get a strange burst of energy, just enough to interfere with sleep. Recently, though, even this energy burst is history.

My bet was on her adrenal glands, two walnut-sized structures that sit atop the kidneys. If you put your hands on your hips, your thumbs will be just about where your adrenals are located.

Your adrenals are actually two separate glands. The first, called the medulla, is within, surrounded by the second, the adrenal cortex. Envision a plum. The seed of the plum is the medulla, the fruit the cortex. Both the medulla and the cortex are your front-line responders to stress. However, the medulla, connected to your brain and nervous system, is your first responder and it works really fast.

Threatened by a mugger? Signals from your brain to your adrenal medulla trigger a burst of adrenalin that turns you into a temporary superwoman. (“Here’s a face full of pepper spray, punk!”)

The adrenal cortex, indirectly connected to your brain through the pituitary–the master gland that also controls your thyroid and ovaries (or testicles, depending)–is the slower, second responder.

The cortex deals with chronic stress, and its several hormones regulate metabolism (especially glucose for energy), reduce inflammation, and control blood pressure by balancing sodium.

Your adrenal cortex is good for a day’s work before it needs to be charged up at night. Think of it as a one-day battery you recharge during sleep. Its hormone, cortisol, starts the day at a high level and then dwindles out by evening. It trusts that you’ll sleep at night in order for it to be at the top of its game in the morning.

Since you don’t encounter many major stressors in a day, like a mugger or having to lift a car off someone, it’s the adrenal cortex that’s more involved in the daily stress you experience. But–and here’s the big but–when you’re beset by relentless low-grade stress your adrenals will poop out. Exhausted, tired, fatigued. And since adrenal function normally starts winding down in the late afternoon, if you’re experiencing adrenal fatigue it’s at this time with your especially low cortisol levels that you’ll first feel symptoms.

Your adrenals are fine—they’re just overworked
It’s important to understand there’s nothing actually wrong with your adrenal glands. They’re just running on empty. If they could talk, they’d plead, “Overworked! Give us a rest! Charge us up! We need a vacation!”

Typically, adrenal fatigue occurs as a consequence of unchecked physical or emotional stress. To return to Patricia, she’d had more than her share during the previous year. Her mother had died of ovarian cancer after a long illness, and with Patricia an only child her father had needed her help constantly. Patricia’s husband had been “a rock,” but her young daughter needed her, and then there were the work demands. She’d been stretched so thin she would have snapped, but instead sat numbly in front of the TV sipping pinot noir, waiting for bedtime.

Adrenal fatigue is not a difficult diagnosis if your doctor has it on her mental “check­-for-­this” list. The challenge patients face is that most conventionally trained endocrinologists don’t believe adrenal fatigue is real. My guess is they can’t tolerate a diagnosis that emerged from natural medicine practitioners. The best book on the subject, Adrenal Fatigue: The 21st Century Stress Syndrome, was written by a (heaven forfend!) chiropractor, James L. Wilson, DC.

The anti-­alternative website lists adrenal fatigue among its unproven “fad diagnoses,” joining candida overgrowth, Gulf War Syndrome, and multiple chemical sensitivity. The even more unsympathetic Endocrine Society (I inadvertently typed “Endocrime”) dismisses adrenal fatigue as a myth.

Their intellectual curiosity is a shameful less than zero.

Dr. Wilson created a questionnaire that you can take, but keep in mind that a lot of the symptoms listed are not specific for adrenal fatigue. The idea behind the quiz is for you (and your doctor) to at least consider adrenal fatigue as a diagnostic possibility and order further tests.

However, unless your doctor thinks of ordering the simple test that measures cortisol levels in your saliva you could go undiagnosed for years. The Endocrine Society actually advised insurance companies not to pay for this test, but, fortunately for you, the price has dropped considerably and it’s available for less than $100, the remainder covered by virtually any health insurance in its out­-of-­network benefit list.

When you look at the test results at these two links, you’ll wonder how endocrinologists could be so dense. Here’s a graph showing normal cortisol levels, taken from saliva specimens in the morning, at noon, and in the afternoon and evening.

And here’s the graph of a person with all the symptoms of adrenal fatigue.

Patricia’s adrenal stress profile was pretty much a flat line. Classic adrenal fatigue. Next week, I’ll outline my approach to help worn out Patricia get her life back.

Be well,
David Edelberg, MD

5 Things to Do If Your Thyroid Hormone Medication Isn’t Working

For about one in seven of the 10 to 12 million Americans with an underactive thyroid gland, conventional treatment with the synthetic thyroid hormone levothyroxine just isn’t enough.1 If you continue to feel sick, tired, depressed or have symptoms like stubborn weight gain, it’s worth talking with your doctor about the best solution for treating your hypothyroidism. But in the meantime, these tips might be just what you need to help you get the most out of your levothyroxine:

#1. Time levothyroxine for optimal absorption. For best absorption into your bloodstream, levothyroxine should be taken on an empty stomach—30 to 60 minutes before breakfast, or three or more hours after dinner. Taking levothyroxine with or too soon before or after a meal or snack could reduce absorption to 64%, from a high of 80% when you’re fasting, according to the American Thyroid Association (ATA). 3 Just changing your timing could bring your thyroid levels back into a normal range. In one older but often-cited Italian study 4 of four people whose thyroid numbers were not in control despite taking thyroid hormone, researchers found that they all took their medication just 15-20 minutes before breakfast. Changing their routine, so they took thyroid hormone 60 minutes before their morning meal, improved their numbers within a month. Take it with water. In another Italian study, coffee interfered with absorption. 5 And don’t take antacids or supplements containing calcium or iron with four hours of your levothyroxine. 6

#2. Practice patience and ask for tests. Some people start feeling more energetic and alert within a week or two of starting thyroid hormone – but not everyone. It could take a month or two to feel better. And you may have to see your doctor several times for tests of your blood levels of thyroid stimulating hormone (TSH) and adjustments to your levothyroxine dose to get it just right. 2

#3. Don’t switch back-and-forth between brand-name and generic levothyroxine. Switching from a brand-name to generic thyroid hormone, or vice-versa could affect your TSH levels—even if the dose is the same. 7 The US Food and Drug Administration requires that all levothyroxine preparations deliver 95-105% of the potency on the label. But, the ATA notes, even tiny variations could make a difference. That’s why the group’s guidelines recommend sticking with the drug type (generic or brand name) to keep your TSH levels steady. (Ask for it at every refill.) If you’ve made a switch and have concerns, have your doctor retest your TSH level, the ATA, American Association of Clinical Endocrinologists, and The Endocrine Society have recommended in a joint statement. 8

#4. Consider adding T3, but know that it might not help. Stories about the purported wonders of synthetic triiodothyronine (T3) for hypothyroid symptoms are all over the internet—but don’t believe everything you read. Some endocrinologists recommend that people whose hypothyroidism symptoms persist despite normal TSH levels try adding T3 to their levothyroxine therapy. T3 is the body’s active form of the thyroid hormone thyroxine. Enzymes in organs like the liver, brain, and heart convert thyroxine (T4) into T3 and the thyroid gland produces some as well. For most people with hypothyroidism, the body converts levothyroxine into T3. But there’s evidence this doesn’t always happen.

Early research from Chicago’s Rush University suggests that a genetic mutation could be responsible, preventing enzymes from making the conversion. But more studies are needed.9

Meanwhile, many experts maintain this unproven combo therapy isn’t ready for prime time. The ATA’s 2014 guidelines say it shouldn’t be used routinely because long-term studies have yet to prove it has benefits, while the European Thyroid Association (ETA) since 2012 has considered it an “experimental treatment modality” for people whose fatigue, depression, weight gain and other hypothyroidism symptoms haven’t waned even though taking levothyroxine alone has moved their TSH levels into the normal range. 10

Testing T3 levels in people with lingering symptoms is also controversial. In one new study, published in April 2017 in the European Thyroid Journal, researchers found that combination therapy helped 24 out of 37 people in this situation. But it didn’t seem to matter whether they had low T3 levels beforehand or if their levels rose during treatment. 11

If you’re curious about T3, talk it over with your doctor. It’s also wise to check that your health insurance covers testing and treatment.

#5. Skip “natural” thyroid medications and supplements. Many supplements claim to “support” thyroid health—but some are laced with thyroid hormones not listed on the label. Adding them to your medication could mean you’re getting too much. In a 2013 study of 10 top-selling thyroid-support products sold on the internet, researchers from Germany’s Landstuhl Regional Medical Center and from the Walter Reed Army National Military Medical Center in Bethesda, MD, found that nine were laced with T3, T4 or both in a variety of amounts. Ingredient labels listed animal thyroid tissue for some while others only listed herbs such as ashwagandha, guggul, and Coleus forskohlii. The researchers concluded that drugs were added to the supplements. 12 Supplements, including types containing a seaweed called kelp, may also contain dangerously high levels of iodine. And natural thyroid supplements may contain gland tissue from the thyroid, liver, heart, pancreas and other animal organs—raising a small but serious risk for exposure to prions, which are agents that could transmit the brain disease Creutzfeldt–Jakob. 13

Updated on: 11/17/17 Continue Reading 6 Thyroid Medication Mistakes You Don’t Want to Make View Sources

“Guidelines for the Treatment of Hypothyroidism.” Jonklas J et al. THYROID.

Volume 24, Number 12, 2014. URL:

“Guidelines for the Treatment of Hypothyroidism.” Jonklas J et al. THYROID.

Volume 24, Number 12, 2014. URL:

“Guidelines for the Treatment of Hypothyroidism.” Jonklas J et al. THYROID.

Volume 24, Number 12, 2014. URL:

AACE, TES, and ATA: Joint Position Statement on the Use and Interchangeability of

Thyroxine Products. American Association of Clinical Endocrinologists, The Endorine Society and the American Thyroid Association.

“Prevalent polymorphism in thyroid hormone-activating enzyme leaves a genetic fingerprint that underlies associated clinical syndromes.” EA McAnnich et al. J Clin Endocrinol Metab. 2015 Mar;100(3):920-33


“Neither Baseline nor Changes in Serum Triiodothyronine during Levothyroxine/Liothyronine Combination Therapy Predict a Positive Response to This Treatment Modality in Hypothyroid Patients with Persistent Symptoms.” Medici BB et al. Eur Thyroid J. 2017 Apr;6(2):89-93. URL:

If You’re Tired By Mid-Afternoon, It’s Time To Troubleshoot Your Sleeping Habits

(Photo: CHRISTOF STACHE/AFP/Getty Images)

I’m always feeling drowsy and sometimes I fall asleep in the middle of the day. What’s wrong with me? originally appeared on Quora: the knowledge sharing network where compelling questions are answered by people with unique insights.

Answer by Emily Altman, MD, board-certified dermatologist, on Quora:

Fatigue should be distinguished from sleepiness, difficulty breathing, and muscle weakness, although these symptoms may also be associated with fatigue.

To determine the cause of sleepiness or drowsiness, a few things need to be considered. It could be the result of sleep deprivation. Some things that may cause sleep deprivation are:

  • Too few hours devoted to sleep (obvious but true, since our lives tend to be very busy and we often sacrifice sleep for the sake of accomplishing more in our work, our family life, etc.) Adequate sleep is crucial to normal brain function. Lack of sleep can also contribute to the development of chronic illnesses like diabetes and hypertension, both of which impact brain function.
  • Alcohol consumption too close to bedtime results in uneven, interrupted sleep patterns.
  • Stress and sleep work both ways. Stress results in release of hormones that contribute to sleeplessness and to less deep sleep. Lack of sleep contributes to more stress.
  • Sleep apnea, a disorder of interrupted breathing when muscles are relaxed. Interruptions of breathing may last ten seconds to a minute. When the brain oxygen levels drop, the brain wakes the person up to start breathing again. There may be hundreds of such cycles every night. Sleep apnea can contribute to fatigue, drowsiness, personality changes, depression, physical health changes and other medical issues. Sleep apnea is frequently associated with snoring. A sleep study done in a sleep lab can help determine if sleep apnea is present.
  • The relationship between depression and sleep goes both ways. Depression may cause sleep problems, and sleep problems may cause depressive symptoms.

According to Sriram Yennurajalingam, MD, and Eduardo Bruera, MD, (1) clinical fatigue includes three major components:

1. Generalized weakness, resulting in inability to initiate certain activities.

2. Easy fatigability and reduced capacity to maintain performance.

3. Mental fatigue resulting in impaired concentration, loss of memory, and emotional lability.

Sleep deprivation can cause fatigue. There are other medical causes of fatigue. Fatigue, especially if it is of acute onset, needs a workup. Some medical issues that can contribute to fatigue are:

  • Thyroid problems. The thyroid gland, considered one of the master glands, regulates energy metabolism in the body, in addition to many other functions. If thyroid function is low, fatigue is a frequent symptom.
  • Diabetes is another metabolic problem that can present with fatigue.
  • Iron deficiency, more common in women due to cyclical blood loss, but found in both genders if there is insufficient intake of iron or chronic iron loss, as in bleeding intestinal ulcers and others.
  • Certain infections, like infectious mononucleosis, Lyme disease, pneumonia, the flu, etc. can result in fatigue.
  • Autoimmune diseases, like lupus, rheumatoid arthritis or multiple sclerosis.
  • Heart disease.
  • Certain medications.
  • Other medical conditions such as malignancies can present with fatigue.

A work-up of fatigue should include a thorough medical history and physical examination, an electrocardiogram, a chest xray, and blood work that includes a complete blood count (CBC), a comprehensive metabolic panel, sedimentation rate, iron studies, thyroid function studies, ANA (antinuclear antibodies) and fasting blood sugar.

The lists I provided are not exhaustive, just a starting point for investigation of fatigue. If there is sudden onset fatigue, an evaluation by your primary care physician should be done as soon as possible.

1. Yennurajalingam S, Bruera E. Palliative management of fatigue at the close of life: “it feels like my body is just worn out.” JAMA. 2007;297(3):295-304

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10 ways to overcome fatigue with a low thyroid

There is NO tired like THYROID tired.

Written by Cammi Balleck, CTN, ANCB Board Certified Naturopath

Are you tired all the time? Don’t worry. Revitalizing your energy is accomplishable. Fatigue and exhaustion are very common symptoms of hypothyroidism. When your hormones are balanced you are energetic and ready to take on the day. When stress comes you have the strength to deal with it without feeling like you need a glass of wine and a nap.

Above all it is critical that your hypothyroidism is optimally treated. ‘Normal’ doesn’t necessarily mean your thyroid lab tests are “optimal”.

If you still need an energy boost, here are a few ways you can overcome your fatigue naturally. Supplement needs vary on an individual basis so consult with your doctor to be sure the suggested supplements are right for you and that the dosage is optimal for your body. Your medical history is unique. Your path to health will be unique too.

1. Take Whole Food Supplements

A balanced diet is best, but even the best of diets are lacking in many nutrients. I suggest you get a whole food multivitamin like this one by NutriGold. Additional supplements may be necessary based on your eating patterns and nutritional need. Testing is necessary to determine if you are deficient in a certain vitamin or mineral before adding them to your dietary regime. Also, adding an omega-3 supplement is always a good idea.

2. Do You Have Adrenal Fatigue?

The body relies on the adrenal glands located on top of each kidney to manage stressful situations. If our bodies are working picture perfect, our adrenal glands release, in perfect balance and harmony, the stress hormones cortisol, adrenaline, and DHEA, in order to help us cope with the day-to-day stresses and demands of life. They also have plenty of sleep time to recover, rejuvenate, and replenish themselves in order to come to our aid when called upon. Given our busy stressful lives it’s not surprising that many of us suffer from issues of adrenal dysfunction.

Our adrenal glands can become so overwhelmed and exhausted that they are unable to meet the body’s demand for adrenaline, cortisol, and DHEA. Instead of being in adaption phase where we are able to adapt to everything, we are in a low phase where we cannot adapt at all.

How would you know if you have adrenal fatigue?

Do you have chronic fatigue?

Does your energy plummet half way through the day?

Do you struggle with insomnia?

Do bright lights bother you more than they should?

Do you startle easily due to noise?

When standing up from sitting or lying down, do you feel lightheaded or dizzy?

Do you struggle with chronic pain or fibromyalgia?

Do you have chronic headaches or migraines?

Do you have depression, anxiety, or mood swings?

Do you struggle with weight gain?

Do you have low sex drive?

Do you feel wired and tired?

If you answer yes to many of these, speak to your doctor about an adrenal function saliva test.

Adaptogenic herbs are awesome helpers when it comes to boosting your energy. Rhodiola Rosea is an adaptogen herb with tremendous energy enhancing and brain boosting power (it also helps burn fat!). By combining these two adaptogenic champions together you can help balance stress hormones, boost energy, and even burn fat. Adaptogenic herbs are awesome because they work with your body to bring you back into balance whether your levels are high or low. Be sure to ask your doctor about adding herbs in particular if you are on medications or if you are pregnant or nursing. Not all herbs are right for every person. We’re all different in terms of how our bodies react to various supplements so be sure to always start slow and watch your body.

3. Seize Enough Sleep

No one can function when they are deficient in sleep. Aim for 8-9 hours every evening. Try to establish a regular sleep schedule. Avoid staying up too late too often. Make sleep a regular priority and allow yourself to sleep. If you need a nap and you have the time take one. Your body needs the sleep to heal itself. If you are having trouble sleeping see 18 things thyroid patients can do to beat insomnia.

4. Keep Your Blood Sugar Balanced

Healthy thyroid function depends on keeping your blood sugar in a normal range and keeping your blood sugar in a normal range depends on healthy thyroid function. If you eat too many high glycemic carbohydrates, the pancreas secretes insulin to move excess glucose from the blood into the cells where glucose is used to produce energy. But over time, the cells lose the ability to respond to insulin. It’s as if insulin is knocking on the door, but the cells can’t hear it. The pancreas responds by pumping out even more insulin (knocking louder) in an effort to get glucose into the cells, and this eventually causes insulin resistance from too many high glycemic carbs.

Studies have shown that the repeated insulin surges common in insulin resistance increase the inflammation of the thyroid gland, and as the thyroid gland becomes hypo, thyroid hormone production falls. Low blood sugar is just as dangerous as high, so it is important to keep your blood sugar in balance.

Together, hyperglycemia (high) and hypoglycemia (low) are referred to as dysglycemia. Dysglycemia weakens and inflames the gut, lungs, and brain. It imbalances hormone levels, exhausts the adrenal glands, disrupts detoxification pathways, and impairs overall metabolism. Each of these effects significantly WEAKEN the thyroid function. As long as you have any blood sugar imbalance, whatever you do to fix your thyroid isn’t going to work and you are still going to have fatigue.

I highly recommend you pick up a blood glucose meter, like this starter kit, if you have a thyroid and/or blood sugar problem. It’s a simple and cost-effective tool for good health. I define the normal range for fasting blood glucose as 75 – 95 mg/dL.

The second, and much more important, target is post-prandial blood glucose. This is a measure of your blood sugar one to two hours after a meal. Several studies show that post-prandial blood glucose is the most accurate predictor of future diabetic complications, and is the first marker (before fasting blood glucose and Hb1Ac) to indicate dysglycemia. Normal post-prandial blood sugar one to two hours after a meal is considered 120 mg/dL.

5. Anabolic Not Catabolic

I recommend if you are fatigued that you do yoga, qigong, and/or tai chi because they are not stressful on the body and they do not break down tissue. Of course, you have been told that exercise gives you energy, however, with hypothyroidism you may find that exercise exhausts you. This is because most cardio and weight training exercise is catabolic by nature, meaning that the stress of it causes your body to break down its own tissue. Anabolic is the opposite of catabolic, it helps energy, healing and growth. After catabolic exercise your body’s natural repair processes start up and your body recovers from the stress with the goal of rebuilding itself stronger than before. But when you are hypothyroid, your body cannot properly recover from stressful exercise. We are all different in terms of what degree of physical activity our bodies find ‘exhausting’ so listen to your body.

6. Add Vitamin B12

B12 is an “energy nutrient” that our body needs to carry out essential functions. Auto-immune diseases such as Hashimoto’s have been associated with a B12 deficiency. If you’re feeling weak and easily tired, you could have a Vitamin B12 deficiency. This vitamin is what your body requires for energy production, blood formation, and DNA synthesis. Gastrointestinal absorption depends on many co-factors, so it is quite possible to take adequate amounts of B12 in the diet yet have a B12 deficiency from not absorbing. Remember you are not what you eat. You are what you absorb.

If you’ve got insufficient B12 levels in your blood, your health will become vulnerable and defenseless against disease. Daily life gets harder for you to endure as you experience debilitating symptoms such as muscle weakness, fatigue, tingling in your arms or legs, mental fogginess, memory problems, mood swings, and feelings of apathy and lack of motivation.

What’s more unfortunate is that you may already have B12 deficiency without you knowing about it! Symptoms of this condition may only manifest after a number of years as influenced by your diet and your body’s absorption of B12. Look for a sublingual methylcobalamin Methyl B12 like this one from Jarrow Formulas.

7. Shed Your Shades

Your eyes may be more sensitive to the sun, but try taking off your sunglasses and get out in the midday sun. Sunlight on the eyes is a natural way to boost your endocrine system. When I do my daily errands, I try to leave my sunglasses in the car and walk in and out of the buildings so that my eyes get a good dose of unobstructed sunlight. I also put my sunglasses on my head as I walk my dog and let my eyes soak in the sun. I have noticed not only do I have more energy but I sleep better too.

8. In Need of Iron?

Iron is critical for producing a protein that helps red blood cells deliver oxygen throughout your body. So without it, everything suffers. Iron deficiency causes less oxygen to reach your tissues, so your body is deprived of the energy it needs. If your fatigue is coupled with feeling weak, irritable or unable to focus, iron deficiency might have something to do with it. After all, there’s a reason people who have iron deficiency are often said to have “tired blood.”

Iron deficiency is the most common nutritional deficiency in the United States and women are among those at greatest risk. If you notice low energy levels, weight gain, or even a lower body temperature, talk to your doctor about iron testing.

While most of the attention is on iron deficiency, there is a concern as well for iron overload. I recommend having your doctor test your iron levels before using iron supplements. Most women only need 8 milligrams per day, so try adding a serving of lentils, spinach, red meat, liver, nuts, chicken or chickpeas to your diet. More isn’t necessarily better. When it comes to iron supplements, I like ferrofood from Standard Process or I also like Carlson Labs Buffalo Liver which are widely available.

9. Don’t Forget Vitamin D

Vitamin D is unlike any other vitamin because it is a “pre-hormone” produced in the skin with sunlight exposure. The sun is the main source of Vitamin D3, a type of vitamin D that increases levels of “feel-good” chemicals in the brain called dopamine and serotonin. Deficient levels of either of these neurochemicals can be an underlying cause of fatigue and depression. A deficiency in vitamin D has now been linked to numerous health problems including hypothyroidism, depression, and even cancer. In fact, a recent study conducted by Boston University researchers revealed vitamin D affects genes that have a wide variety of biologic functions of more than 160 pathways linked to autoimmune disorders and cardiovascular disease. I recommend you have your vitamin D tested, add a whole food vitamin D3 supplement (Standard Process has a supplement I like called Cataplex D), get 15 minutes of sunshine on your skin, and add foods such as cod oil, salmon, mackerel, eggs yolks, and beef liver.

10. X out Xenoestrogens

Xenoestrogens are invisible but they are big endocrine disruptors (hormone imbalancers). They can steal your natural hormone balance, cause fatigue, and in addition have reproductive (weight gain, estrogen dominance, cancers, PMS, PCOS, hypothyroid) and developmental consequences. Experts say that in a typical day, sadly, we are exposed to more than 700 xenoestrogens in chemically made toothpaste, deodorant, sunscreen, food preservatives, the lining of cans that hold food, and many kinds of plastic. They are foreign estrogen which pass into our cells from plastic water bottles, pesticides, herbicides, fungicides, plastics, fuels, car exhausts, dry cleaning chemicals, industrial waste, meat from animals (which have been fattened with estrogenic drugs), and countless other household cleaning and personal products which many of us use every day, probably even the makeup you have on right now. I suggest you cut these out as best you can. Always remember we absorb 60% of what we apply to our skin. If you wouldn’t eat it – don’t put it on your skin. Buy food and cosmetic items that are natural, BPA and phthalate free for you and your household.

I hope these tips help you to find your way to a more energetic and less lethargic you for the holiday season and next year! Remember without enough vitamins and micro-nutrients your body’s ability to perform its job crumbles and you won’t have enough physical, emotional, physical or mental energy to survive the day.

About Cammi Balleck, CTN, ANCB Board Certified Naturopath

Cammi Balleck, author of the book Happy the NEW Sexy, has been a featured guest on TBN NETWORKS, VERIA, HALLMARK, FOX NEWS NATIONALLY, and the CW stations in Denver. Cammi has a doctorate of naturopathy, and she is Board Certified by the American Naturopathic Certification Board (ANCB). Cammi has over 13 years experience, specializing in all aspects of health from weight loss to happiness and stress to hormone balance. She has been a health expert for FIRST MAGAZINE FOR WOMEN,O, Prevention, Fit Pregnancy, Women’s Health, Woman’s World, Women’s Day, Fitness, Shape.

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