July 15, 2006
Question: My doctor uses my TSH and thyroid hormone levels to change my dose of thyroid hormone. He measures them every couple of months and has me increase or decrease my dose, depending on these little changes in the hormone levels. He calls it "fine tuning" my dosage. Personally I don’t see any change in how I feel even when he increases my dose a little. I just keep feeling tired, achy, and depressed. He seems convinced that by measuring my levels and making these little dosage changes that he’ll some day get rid of my symptoms. From reading your website, I don’t believe he’s on the right track. What do you think I should tell him to get him to use another approach?

Dr. Lowe: First I suggest that you ask your doctor to question the scientific basis of the endocrinologists’ notion of "fine tuning" by TSH and thyroid hormone levels. If he does, he’ll learn that the changes he sees in your TSH and thyroid hormone levels are probably nothing more than natural variations in the levels. He would probably see the same variations if he always kept your thyroid hormone dose the same. I’ll briefly review some of the evidence that your doctor should read.

TSH levels don’t significantly correlate day-to-day[1] or week-to-week.[2] One research group measured the TSH and free T3 and free T4 levels of ten normal young men.[3] When they measured the levels every 30 minutes for 24 hours, they found that the hormone levels were lower during the day and higher at night. During the day, the free T3 was 15% lower, the free T4 was 7% lower, and the TSH was 140% lower. When the researchers measured the hormone levels every five minutes for six to seven hours (7 PM-to-11 PM), the levels varied every thirty minutes. The TSH level varied 13%, the free T3 15%, and the free T4 11%.

Other researchers measured the TSH levels of 31 healthy people. They found that women had significantly higher TSH level than men.[1] On different days, individuals had "a large" variation of TSH levels. The large variations were about equally extreme in both men and women. The researchers concluded, "The present study demonstrated a large variation of TSH levels in various conditions, even in the same individuals, indicating the necessity of strictly controlled conditions in the study of TSH secretion."

Another research group measured TSH and thyroid hormone levels in normal people every month for a year. They found that in individuals, the levels of thyroid hormone varied within narrow limits. But among the people as a group, the levels varied considerably. The researchers wrote, "This high degree of individuality implies that rigorous comparison of thyroid hormone results against a population-based 'normal range' can be potentially misleading." They also reported higher T3 and T4 levels in winter months. During these months, the pituitary gland’s secretion of TSH was more easily provoked.[6]

Other researchers woke people on two nights. They then let the people to go back to sleep so that they wouldn’t be totally deprived of sleep. From partially depriving the people of sleep, their TSH levels significantly increased and remained elevated throughout the following day."[4]

Many endocrinologists talk of using the TSH and thyroid hormone levels to "fine tune" hypothyroid patients’ thyroid hormone dosages. Considering how much the hormone levels vary, however, it’s obvious that the concept of fine tuning is mistaken. For the sake of their patients’ health, endocrinologists should promptly abandon the notion. This is unlikely, though, due to financial inducements the endocrinology specialty receives from corporations that profit from doctors endlessly ordering the hormone levels to "fine tune" their patients dosages. Hopefully, though, you can use the scientific evidence to persuade your doctor to use a safer and more effective approach with you. More on this topic

References

1. Sakaue, K.: Studies on the factors affecting serum thyrotropin levels in healthy controls and on the thyroid function in depressed patients using a highly sensitive immunoassay. Nippon Naibunpi GakkaiZasshi, 66(10):1094-1107, 1990.

2. Kraus, R.P., Phoenix, E., Edmonds, M.W., et al.: Exaggerated TSHresponses to TRH in depressed patients with 'normal' baselineTSH. J. Clin. Psychiatry, 58(6):266-270, 1997.

3. Weeke, J. and Gundersen, H.J.: Circadian and 30 minutes variations in serum TSH and thyroid hormones in normal subjects. Acta Endocrinol. (Copenh.), 89(4):659-672, 1978.

4. Baumgartner, A., Dietzel, M., Saletu, B., et al.: Influence of partial sleep deprivation on the secretion of thyrotropin, thyroid hormones, growth hormone, prolactin, luteinizing hormone, follicle stimulating hormone, and estradiol in healthy young women. PsychiatryRes., 48(2):153-178, 1993.

5. Ain, K.B., Pucino, F., Shiver, T.M., et al.: Thyroid hormone levels affected by time of blood sampling in thyroxine-treated patients. Thyroid, 3(2):81-85, 1993.

6. Harrop JS, Ashwell K, Hopton MR. Circannual and within-individual variation of thyroid function tests in normal subjects. Ann Clin Biochem., 22(Pt 4):371-537, 1985.

November 7, 2004
Question: Thank you for the best and the most informative website. I am 59-years-old and been hypothyroid since 1998. After reading your website, I switched from T4 alone to 90 mg of Thyrolar, which has both T4 and T3. After being sick all those years on T4, I now feel good. I exercise three times a week, and I’m on my feet all day running around taking care of responsibilities. But despite feeling well, my basal body temperature is always low. This morning, for example, it was 96.5EF under my tongue, and 95.5EF under my arm. Although I feel well now, I wonder why my temperature is still so low? What does it mean? Have you had other patients with low body temp?

Dr. Lowe: You may know that Dr. Broda Barnes championed the use of the basal body temperature. He advocated using it to identify people who are hypothyroid, and to adjust their dosages of thyroid hormone. I think it’s prudent to keep in mind Dr. Barnes’ tempered view of the basal body temperature. He believed that it is the best gauge of improvement available to hypothyroid patients, but he noted that the test isn't perfect. Based on my clinical experience, I agree. But then, no test is perfect.

At this time, we're conducting two studies in which we're measuring patients' resting metabolic rates and comparing them with their basal body temperatures. We’ve tested many patients, but so far, we don’t see a statistical correlation between the two measures. The important question is, why not? We suspect that the lack of correlation has resulted from the patients using different quality thermometers—some that give accurate temperature readings, others that don’t.

Unfortunately, patients cannot get glass mercury thermometers anymore. We have some of these, however, and we’ve compared temperature readings with them to readings by digital thermometers. We’ve found that digital thermometers often give readings that are almost a full degree higher or lower than readings given by the glass thermometers. So, the lack of correlation may be a result of poor reliability of digital thermometers. Obviously, before we can finish the studies in a meaningful way, we must work out this problem; otherwise, we could reach a false conclusion about the usefulness of the basal body temperature. Of course, we won’t allow that to happen.

Over the years, we've found that some patients’ low basal temperatures don't increase, or don't increase much, despite them fully recovering from their hypothyroid symptoms by using T3 or Armour Thyroid. Molecular and physiological principles lead me to a conjecture about the persisting low temperatures of these patients. We all have enzyme systems that maintain core body temperature by causing cellular energy to escape as heat. Thyroid hormone regulates the production of these heat-regulating enzymes. The enzymes decrease in  hypothyroidism, leaving most patients colder. When the patients undergo effective thyroid hormone therapy, the enzymes increase and, in turn, so does the patients’ body heat.

But the patient whose basal temperature doesn’t increase with effective thyroid hormone therapy is presumably different at the genetic level. The genes that code for the temperature-regulating enzymes in the patient are less responsive to thyroid hormone. As a result, her basal temperature remains low, as yours is, despite her recovering from all other indications of hypothyroidism.

Whatever the reason for persisting low temperatures in any individual, we know such patients exist. For them, the basal body temperature is not a useful gauge of improvement from a particular dose of thyroid hormone. Because of this, we prefer to measure the resting metabolic rate, based on the patient's oxygen consumption at rest. This test is more reliable when done properly. But, of course, it isn't as accessible to patients as basal body temperature test.

August 13, 2002
Question: I've been taking 3 grains of Armour Thyroid. I had my doctor draw my thyroid levels. Here are the results: TSH, 1.74; free T4, 0.6; total T3, 1.71. What do you think I should do regarding dosage?

Dr. Lowe: No doctor can intelligently decide what a patient should do with her thyroid hormone dosage solely by the results of thyroid lab tests. We can make informed decisions about dosage only when we know the patient's clinical status and have the results of physical exam procedures. Most endocrinologists and other conventional doctors would likely disagree with me about this. But their belief that they can determine correct dosages solely by lab test results is a major reason that millions of hypothyroid patients chronically suffer from hypothyroid symptoms despite taking thyroid hormone. I wish you success in your treatment.

July 12, 2002
Question: How long should I take Biothroid or the Armour Thyroid, which ever I decide on? Are they like Synthroid in that you take them forever? Or is there a certain time-frame involved? Thank you.

Dr. Lowe: The typical person who takes thyroid hormone for hypothyroidism or thyroid hormone resistance does so forever. As long as the person takes enough thyroid hormone for him as an individual and not too much, there's no harm in taking it for life. Keep in mind, of course, that T4 replacement therapy keeps few patients well; instead, it keeps many chronically ill and predisposed to premature death. (I encourage you to read our official denouncement of T4 replacement therapy.) So good health is likely only when a patient uses a thyroid hormone preparation that contains both T4 and T3, and when the dose is adjusted according to tissue responses and not TSH levels.

I believe that taking thyroid hormone on a lifetime basis may enable one to stay healthier and live longer than otherwise. I say this because with advancing age, the incidence of hypothyroidism (and probably thyroid hormone resistance) increases. Tragically, doctors fail to diagnose many of these cases. As a result, the health of the undiagnosed aging persons steadily deteriorates. Because of this failure of modern medicine, the argument has merit that aging people who want to remain healthy should take thyroid hormone prophylactically.

June 11, 2002
Question: My fibromyalgia improved a lot after my doctor prescribed Cytomel (T3). I developed a problem, however. I began having a fast heart beat a couple of hours after taking the Cytomel. When my doctor heard I was taking it on an empty stomach, he told me to take it with meals. Doing this has stopped the fast heart beats, but my fibromyalgia symptoms have come back, although they aren’t as bad as before. Am I doing something wrong that I can change?

Dr. Lowe: After most patients take T3, the level in the blood peaks after about two hours. T3 does directly affect the heart, and it’s likely that the high concentration of T3 that was reaching your heart briefly increased its rate of contraction. Clinical experience shows that few patients experience this after taking T3. It is of concern only in rare cases of patients with severely fragile cardiac status. Some patients, of course, find the increased heart rate annoying and prefer to avoid it. I don’t believe, however, that the proper solution is for the patient to take T3 with meals.

By taking T3 with meals, a patient reduces the amount of T3 that will enter her blood. Some food constituents, such as calcium, bind thyroid hormone in the GI tract. This effectively limits the amount of T3 that absorbs into the blood, the rise of the blood T3 level, and the brief exposure of the heart to higher concentrations of T3. But there is a problem with this approach.

The patient who takes T3 (or T4) with meals won’t have anywhere near an accurate idea of how much T3 enters her blood. Different meals will contain different amounts of T3-binding substances that will reduce the amount of T3 that enters the blood. One meal may contain a small amount of T3-binding substances; another may contain a large amount. As a result, the amount of T3 that enters the blood after meals is likely to vary a lot. Accordingly, the degree to which T3 drives the patient’s metabolism any day is also likely to vary widely.

Taking T3 with meals, then, blurs the relationship a patient and her doctor may look for between her dose of T3 and her metabolic status. The proper solution is simply to reduce the amount of T3 the patient takes on an empty stomach. With this approach, the relationship between a particular dose of T3 and metabolic status will be far clearer.

January 30, 2002
Question: I’m hypothyroid and take Armour Thyroid twice a day. My question is about the right time to take it in relation to when I eat. Should I take it two, three, or four hours after I eat? I've read all those times in different places. Thank you very much for your time—and your great website!

Dr. Lowe: As a rule, our patients take thyroid hormone only once per day. An advantage of this one-per-day schedule is that it’s easier to find a window for good intestinal absorption—when the stomach or small intestine doesn’t contain food.

Most of our patients wait at least one hour after taking thyroid hormone before they eat. Or they wait at least two hours after eating before they take thyroid hormone. The two hour wait is a rough estimate of the time it takes for food to pass through the stomach and small intestine. It’s worth noting, however, that several factors can increase the time a patient should wait before taking thyroid hormone.

One factor is being female. Researchers report that on average, the woman’s stomach empties more slowly than the man’s. In a 1998 study, for example, researchers tested how long it took for half of a solid meal to empty from the stomachs of healthy women and men. The average time for women was 86 minutes and for men was 52 minutes.[1] This result is consistent with those of other studies; it suggests that women may benefit by waiting a while longer than men after eating to take thyroid hormone.

Another factor is the slower movement of food and stool through the gastro-intestinal (GI) tract of many patients who have hypothyroidism or thyroid hormone resistance. Doctors often diagnose the sluggish GI function as "constipation-type irritable bowel syndrome."[2,pp.681-687] Until the patient finds a thyroid hormone dose that relieves her constipation, it may be prudent for her to allow more than two hours—maybe three—for food to clear from her stomach and small intestine before taking the hormone.

Still another factor is food-induced slow emptying of the stomach. If a meal contains much fat, oil, or protein, food will pass more slowly from the stomach to the small intestine. This may be helpful when a person has ingested refined sugar as part of the meal. Slower emptying of the stomach will slow sugar absorption from the small intestine into the blood. This may reduce the amount of insulin that’s secreted and avert an episode of low blood sugar. But at the same time, slowed emptying of the stomach may allow food to remain in the stomach or small intestine too long—so long that thyroid hormone taken two hours afterward may bind to food constituents. Binding of the hormone to food constituents, of course, will reduce the amount of the hormone that passes into the blood. In one study, when patients took T4 on an empty stomach, 79% was absorbed; when they took the hormone with food, 64% was absorbed.[3] It’s hard to say, however, how much of the hormone, when taken with food, will be bound in the intestine and how much will be absorbed into the blood. The determining factor will be the chemical composition of the food. Few of us ever know for sure the total composition of the food in a meal we eat. Because of this, we can better calculate how much thyroid hormone we’ll absorb from a given dose by taking it on an empty stomach.

Some patients avoid problems absorbing thyroid hormone by taking it in the middle of the night. They keep a bottle of thyroid hormone in the bathroom. With the bottle close at hand, they take their single 24-hour dose when they get up at night to urinate. That time of night, of course, should be long enough after they’ve eaten before going to bed—at least two hours later. It should also be long enough before they get up and eat breakfast—at least an hour before.

Unfortunately, this middle-of-the-night strategy doesn’t work for an occasional patient with a severe low blood sugar problem. To avert episodes of low blood sugar during the night, she must keep food near her bed and eat small amounts at intervals. Because of this, she may not have a time during the night when she can take the hormone on an empty stomach.

A variety of drugs can interfere with thyroid hormone absorption. If you’re taking other drugs, I suggest you discuss with your doctor whether any of them can impede absorption of the hormone. With his or her guidance, and consideration of the factors I mentioned above, you should be able to find a good window of absorption that works for you.

References

[1] Bennink, R., Peeters, M., Van den Maegdenbergh, V., et al.: Comparison of total and compartmental gastric emptying and antral motility between healthy men and women. Eur. J. Nucl. Med., 25(9):1293-1299, 1998.

[2] Lowe, J.C.: The Metabolic Treatment of Fibromyalgia. Boulder, McDowell Publishing Co., 2000.

[3] Wenzel, K.W. and Kirschsieper, H.E.: Aspects of the absorption of oral L-thyroxine in normal man. Metabolism, 26(1):1-8, 1977.

January 2, 2002
Question: In June of this year, I had a complete thyroidectomy. I’m currently taking 100 mcg of Synthroid. This dose of Synthroid has been effective in keeping my TSH level at 0.13. My endocrinologist advises me that this is exactly where he wants my TSH. He doesn't seem interested in the fact that I feel absolutely miserable. I have joint pain, mood swings, cry at the drop of a hat, feel short of breath at times, am losing hair, have interrupted sleep, and people who know me say I've changed since the thyroid surgery. I feel I've changed!! I just want my old self back! I’ve just changed endocrinologists. This new endo is listening and mentioned Cytomel. She says that before she’ll add Cytomel, she needs to check the T3 level in my blood, so she’s sending me for blood work. The new endo was surprised that my TSH could be so suppressed on such a low dose of Synthroid. Any thoughts? Thanks.

Dr Lowe: Different researchers have reported that different doses of T4 suppress the TSH level. Some researchers have reported that—on average—suppression occurs at 145 mcg (0.145 mg) of T4;[1] others have reported that—on average—suppression occurs at 171 mcg (0.171 mg).[2]

I’ve italicized the words "on average" to emphasize an important point: that patients fall into a bell curve regarding the amount of T4 (or T3) that suppresses their TSH levels. Patients also fall into a bell curve regarding how their thyroid glands respond to any particular blood level of TSH. In response to a TSH level that the typical conventional endocrinologist adores, the glands of some patients will release enough thyroid hormone to keep metabolism normal. In response to this same TSH level, the thyroid glands of other patients will release too little thyroid hormone to keep metabolism normal. These patients will remain ill with symptoms of slow metabolism—despite the same TSH level that keeps other patients well.

The same applies to T3 blood levels: Patients fall into a bell curve—some enjoying normal metabolism with a particular T3 level, others suffering from symptoms of slow metabolism with the same T3 level.

What’s most important to realize is this: The variation in how different patients respond to the same TSH or T3 level makes the reference ranges (formerly called the "ranges of normal") for the T3, TSH, or any other hormone totally without value in finding the dose of thyroid hormone that’s safe and effective for individual patients.[1,p.1217]

In my experience, most conventional endocrinologists, seemingly unaware of the bell-curve phenomenon, make a trouble-causing presumption: that researchers have scientifically established the safe and effective dose of thyroid hormone for all human beings. That dose, they presume, is one that keeps the TSH and thyroid hormone levels within their reference ranges. This, however, is a false and scientifically unjustified presumption.

Many patients know the presumption is false; they know it’s false because they, like you, become and remain ill when their doctors adjust their thyroid hormone dose according to the TSH level. I know the presumption is false for three reasons: (1) I've studied the research literature which shows that the presumption hasn't been established. (2) I've objectively assessed the tissue metabolic status of patients whose thyroid hormone doses were regulated by TSH levels and found the tissues understimulated. And (3), I've seen hundreds of such patients—formerly kept ill by TSH-adjusted thyroid hormone doses—fully recover their health when my cotreating doctors and I treated them in violation of the guidelines of the conventional endocrinology specialty.

I get the impression that a new breed of endocrinologist has recently appeared on the health care scene. From communications I’ve gotten, these practitioners only recently finished their specialty training and somehow avoided adopting the disease-causing and -sustaining practice guidelines that conventional endocrinology has promoted for the past thirty years. You may be able to find one of these younger endocrinologists who’ll treat you based on how your tissues—rather than your lab values—are responding to a dose of thyroid hormone. If not, I recommend that you consult a naturopathic physician (if N.D.s have prescribing privileges in your state) or a family physician or internist who’s holistically, nutritionally oriented. Many of these practitioners, when treating patients with thyroid hormone, completely ignore the guidelines of conventional endocrinology. Their unconventional approach to thyroid hormone therapy rescues many patients from the chronic illness that the guidelines have caused. With the help of one of these practitioners, you’ll stand a much better chance of getting your "old self back!"

References

[1] Korsic, M., Cvijetic, S., Dekanic-Ozegovic, D., Bolanca, S., and Kozic, B.: Bone mineral density in patients on long-term therapy with levothyroxine. Lijec Vjesn, 120(5):103-105, 1998.

[2] Fowler, P.B., McIvor, J., Sykes, L., and Macrae, K.D.: The effect of long-term thyroxine on bone mineral density and serum cholesterol. J. R. Coll. Physicians Lond., 30(6):527-532, 1996.

[3] Lowe, J.C.: The Metabolic Treatment of Fibromyalgia. Boulder, McDowell Publishing Company, 2000.

November 23, 2001
Question: Thank you so much for the information on your website! I've had untreated hypothyroidism for five years. I have most of the symptoms of hypothyroidism, but the worst is my muscle weakness and pain. My doctor says my TSH is "high-normal." Because of that, he says my symptoms can’t be caused by hypothyroidism and he refuses to prescribe thyroid hormone. Instead, he diagnosed me with "fibromyalgia" and referred me to a rheumatologist who confirmed that diagnosis. The rheumatologist gave me an antidepressant and ibuprofen. These haven’t helped at all. Both my doctor and the rheumatologist said my muscle symptoms can't be caused by hypothyroidism. I showed my doctor a list of hypothyroid symptoms from Mary Shomon’s website, and the list contains muscle problems. But he still won’t listen. Is there anything I can do to convince him, or should I just find another doctor who’ll listen?

Dr. Lowe: You’re right and your doctors are wrong: Muscle problems are common among patients with untreated hypothyroidism. (They're also common among patients with untreated thyroid hormone resistance.) The most common muscle problems are weakness and excess muscle tension. The muscle tension often activates trigger points that refer pain. In the most severe and rare form of muscle involvement, called "Hoffman’s Syndrome," muscles become enlarged and stiff.

According to what you say, you've long suffered from fibromyalgia symptoms that are also classic hypothyroid symptoms, and you’ve informed your doctor of this. Yet he refuses to permit you to undergo a trial of thyroid hormone therapy solely because your TSH level is within the reference range (formerly called the "range of normal"). In this respect, he practices as an extremist medical technocrat. Unless he revises his belief concerning who might and might not benefit from the use of thyroid hormone, you're likely to remain ill—that is, unless you find another doctor with a balanced approach to evaluating patients’ treatment needs. By "balanced," of course, I mean that the doctor uses both clinical (patient’s history, symptoms, and signs) and laboratory indicators of a patient’s need for treatment.

Judging from your e-mail, you're already aware of the need for a balanced assessment of patients’ needs—which you’re apparently not getting from your current doctor. I trust that if he remains uncooperative for long, you’ll cut your loses and find another doctor with a balance approach who will cooperate with you. It’s your life, and you deserve to live it in health and happiness. But your chances of achieving these under the care of an extremist medical technocrat are very slim indeed.