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Problems with T4 Therapy

[Q&As are placed in reverse chronological order. In other words, the latest Q&As come first. Earlier ones are further down the page.]

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Q&As

August 15, 2010
Question: I had my thyroid removed on January 19, 2010. No problem with my recovery. There was no Cancer. I am taking my RX for Synthroid. My question for you is this: Have you found that over a period of time, some patients have a problem losing weight, or their weight goes up a tinge after recovering from the surgery? I am having a horrible time getting my weight down (eating well most of the time and keeping busy. Thank you for your time.

Dr. Lowe: I regret that you’re having trouble with weight gain. You're like countless other patients across the world who, after having their thyroid glands removed, gain weight they can't lose.

Most of the patients’ doctors put them on “T4 replacement” after surgery to remover the thyroid gland. T4 replacement means the patient takes a T4 product, such as Synthroid, and the doctor adjusts the patient's daily dose to keep his or her TSH level up within the current reference range. Within only a few months, most patients on T4 replacement gain weight they can’t lose. They can't lose it despite dieting and regular exercise. Many post-thyroidectomy patients have consulted me who who were vegetarians and taught aerobic exercise classes several times each week. They were on T4 replacement, and despite their exemplary health sustaining lifestyles, still gained weight they couldn't lose—not as long as they were on T4 replacement.

I’ve described in many places this post-surgery problems that troubles so many patients. Here, I’ll quote a typical passage from a paper I wrote that is published in the open-access journal Thyroid Science:

“. . . in a study of patients made hypothyroid by therapeutic destruction of the thyroid gland, some used TSH-suppressive doses of thyroid hormone and others used T4-replacement. Those on TSH-suppressive dosages did not gain excess weight; those on T4-replacement did. The researchers concluded that T4-replacement was the cause of the excess weight gain.[55]”

[This quote is from a paper that is free to print or download: From page 5, Lowe, J.C.: Four 2003 T4/T3 vs T4 replacement studies. Thyroid Science, 1(1):C1-C21, 2006.]


I will also refer you to a short paper I wrote in which I cited several studies. The authors of the studies report that patients gained when they were restricted to T4 replacement: www.thyroidscience.com/editorials/lowe/wt.gain.tsh.lowe.11.08.pdff

Unfortunately, even when many patients take a dose of T4 alone that's high enough to suppress their TSH levels, the treatment is not effective for some 50% of patients. It's well worth noting, though, that most patients lose their excess weight and recover their health when they switch to thyroid hormone products that contain both T4 and T3 or T3 alone and take doses high enough to lower their TSH levels. Many can't find doctors who'll cooperate by prescribing these superior products. But most lose their excess weight and recover their health by using dietary desiccated thyroid products such as Thyro-Gold that don't require a prescription. I sincerely hope this is reply is helpful to you.

February 17, 2008
Question: My doctor refuses to prescribe any thyroid hormone product for me other than Synthroid. He said that Armour's potency isn't reliable and you never know what you're getting with Armour. Is this true?

Dr. Lowe: I began working with patients who were hypothyroid in the late 1980s. To learn about the treatment of hypothyroid patients, I spent a lot of time talking with other doctors about thyroid hormone therapy. I soon learned that most doctors tenaciously held two beliefs that had been shrewdly planted in their minds by the corporation that marketed Synthroid. The beliefs were: (1) the potency of Synthroid tablets was perfectly reliable, and (2) the potency of the tablets or capsules of other products—especially Armour Thyroid—was highly unreliable.

Based on these two beliefs, the doctors dogmatically pronounced that all hypothyroid patients should be treated with Synthroid. The doctors’ pronouncement was thoughtless parroting of a sound bite from the corporation’s marketing campaign—a campaign so effective that Synthroid eventually became the third most-prescribed drug in the U.S.

In my view, the doctors who parroted the Synthroid marketing hype should feel shame; they allowed themselves to be duped by a sales campaign for a product that was—and still is!—no more reliable than any other thyroid hormone product. In previous publications, I have cited the FDA evidence for Synthroid’s lack of reliability.

Of course, Synthroid isn’t the only thyroid hormone product with reliability problems. In my experience, no brand of thyroid hormone is especially reliable. By this, I mean that fairly often, patients find that the potency of the thyroid hormone products they’re taking is lower than the label states.

In my experience, the reliability problem has been worse with products from compounding pharmacies, but the problem is also common for the products of large pharmaceutical companies. It appears to me, then, that all thyroid hormone products are highly vulnerable to influences that reduce their potency. Accordingly, no claim that a product has superior reliability is legitimate.

If you’re new to the use of thyroid hormone, and you’re up to a dose that should be working for you, but you’re not benefiting from it, be sure to let your doctor and your pharmacist know. The dosage range that’s safe and effective for most patients is between 2-to-4 grains (120-to-240 mg) of desiccated thyroid. The equivalent dosage range for T4 is 200-to-400 mcg (0.2-to-0.4 mg). If you’re not improving within this dosage range, you may have thyroid hormone resistance, or the potency of the tablets or capsules you’re using may be lower than what’s stated on the label.

If your thyroid hormone product was prescribed, the bottle containing the pills or capsules will have a batch number. Your pharmacist will probably replace your thyroid hormone tablets or capsules with others from another batch. If you’re using an over-the-counter product such as Nutri-Meds desiccated thyroid, the bottle won’t have a batch number, but you can ask the company to replace the capsules or tablets your currently using.

If thyroid hormone has effectively relieved your hypothyroid or thyroid hormone resistance symptoms, but some of your symptoms have reappeared, you should consider whether the capsules or tablets your presently using have a lower-than-stated potency. You should let your doctor and pharmacist know the symptoms that have recurred. It will also help to have objective evidence, such as a decreased basal body temperature. Your doctor may find that your Achilles reflex that had become normal with thyroid hormone therapy has become slow again. And you may find that your basal temperature is decreased. If your TSH level was within the reference range, it may now be much higher now. Also, if your free T3 level was within the reference range, it may be much lower now. (This is a rare time during treatment when thyroid function testing can actually be of help.)

Clearly, all thyroid hormone products occasionally have potency problems. Because of this, it’s important for patients to stay vigilant for signs that the potency of the capsules or tablets they’re taking isn’t consistent.

April 22, 2007
Question: My doctor recently diagnosed me as having hypothyroidism. She prescribed Synthroid. She started me on 50 mcg and then increased it to 75 mcg. Before starting the drug, I’d become a little foggy headed and was tired, which was unusual for me. But after starting it, I became outright miserable. I was depressed for the first time in my life, and I was so tired that I could hardly get out bed. I became constipated, and I could hardly think at all. My thinking was so bad that I was afraid I was going to lose my job. Because the drug made me so miserable and dysfunctional, I stopped it. That was three weeks ago, and I’m starting to feel better now. My doctor is convinced that I had some coincidental illness, and she wants me to start taking Synthroid again. I disagree with her. The relation is just too clear cut. I felt like crap after starting the drug, and after stopping it, I’m feeling better. Do you have any idea why I would react to the drug this way?

Dr. Lowe: First let me say that what you experienced is fairly common. Many patients react to low-dose T4-replacement as you did—badly—regardless of the brand of T4.

There are two potential sources I know of for people feeling awful when they are on T4-replacement. One source is the extremely low dosage that doctors typically prescribe nowadays. A low dose of T4 can effectively reduce TSH secretion. The lower TSH can in turn lower the thyroid gland’s output of thyroid hormone. At the same time, low-dose T4 may not compensate for the thyroid gland’s reduced output of thyroid hormone. The patient then has too little thyroid hormone to properly regulate the metabolism of most of her body’s tissues. She then ends up with abnormally low metabolism and troubling hypothyroid symptoms. I’ve written about this before on drlowe.com.

The second possible reason for your bad reaction to Synthroid is that T4-replacement simply won’t work for you. It doesn’t work for many hypothyroid patients. In a recent study in the United Kingdom, for example, T4-replacement left 50% of patient suffering from hypothyroid symptoms (Saravanan, P., Chau, W.F., Roberts, N., et al.: Psychological well-being in patients on ‘adequate doses of L-thyroxine: results of a large, controlled community-based questionnaire study. Clin. Endocrinol. (Oxf.), 57(5):577-585, 2002.) Unfortunately, through faulty reasoning, these researchers concluded that a much smaller percentage of patients suffered from symptoms despite being on T4-replacement. They are mistaken about the percentage. The evidence is overwhelming that T4-replacement is the lousiest approach to thyroid hormone therapy. I’ve documented the widespread failures of the approach in two critiques:

http://www.drlowe.com/frf/guttler/intro.htm

 http://www.drlowe.com/frf/t4replacement/intro.htm

Odds are, if you cooperate with your doctor and try T4-replacement again, you’ll waste time trying to get well. Moreover, you’ll most likely react badly again. T4-Replacement forsakes many patients. But most patients recover quickly with T4/T3 products such as Armour Thyroid, Westhroid, and Naturthroid, and with T3 alone—as long as the patients use high enough doses of the products. If your doctor will cooperate and treat you with one of these products and ignore your TSH level, you’re not likely to have another bad reaction to thyroid hormone therapy. Instead, other factors held constant, you can, I believe, expect a highly positive treatment outcome.

October 4, 2005
Question: I was recently at my parents visiting. During the visit, it became apparent to me that even after twenty years of dealing with this illness, hypothyroidism, they're even more clueless than many of the doctors I've seen. My questions are how do I get it through to my family that hypothyroidism is a big deal? How to a get them to understand that it can adversely affect a person's life and leave her feeling half dead? I'm quite frustrated with my family's response. I often don't bring it up because they behave as if it's something I should just "deal with," "get over," and shut up so we can talk about something that's actually important. It hurts and angers me to no end. What can I do to get them to understand?

Dr. Lowe: It’s unfortunate that your family doesn't understand the dreadful impact hypothyroidism can have on a patient. When untreated or under-treated—as with T4-replacement—hypothyroidism can not only ruin the quality of one's life. It can also shorten it.

You may never get your family to understand. Whether you do or don't, however, I suggest you arrange to get effective treatment. When you do, you'll no longer suffer from the symptoms you want them to understand. Their lack of understanding will then cease to be an issue. In addition, you'll also have a more enjoyable life that's likely to last a lot longer. Very best wishes.

August 2, 2005
Question: I just read your article on T4-replacement and how ineffective and dangerous it is. I am looking for a doctor in the Ellis, Oklahoma area who has your philosophy on thyroid treatment. My doctor just told me I’m perfectly fine since my TSH is 1.0. But I’m not fine. I’ve felt awful ever since I became hypothyroid five years ago, despite using T4-replacement. And I’ve gained twenty pounds I can’t lose no matter what I do. Over that five years, he’s switched me from Levoxyl to Synthroid and back again. I’ve complained that neither of them has worked, but he refuses to prescribe anything other than T4. Any suggestions for a doctor in this area?

Dr. Lowe: I am sorry to say that I don't know of a doctor in western Oklahoma I can refer you to. However, in my opinion, you’re smart to be looking for another doctor.

It is understandable that you’ve felt awful on T4-replacement. The published record now shows that in general, T4-replacement is not an effective approach to thyroid hormone therapy. I provide the evidence for this in my critique of recent  T4-replacement studies, and in my criticism of Dr. Richard Guttler’s false beliefs about hypothyroidism.

As in your case, T4-replacement leaves many patients suffering and burdened with excess weight they can’t lose. What’s more, it increases their risk of several potentially-fatal diseases and increases their use of drugs. Because of this, in my opinion, you should resolutely refuse to allow T4-replacement to keep you feeling poorly. No hypothyroid patient should settle for that.

Our research and clinical experience show that products containing combined T4 and T3 or T3 alone virtually always work better than T4-replacement. Because of that, I encourage you to insist on using one of these products.

It is always best for a patient to work with a cooperative doctor who is knowledgeable about thyroid hormone therapies other than T4-replacement. But if you can’t find such a doctor in your area, don’t get discouraged. You have other options that in general are better than T4-replacement. For example, you can switch to over-the-counter (OTC) desiccated thyroid. We’ve seen patients markedly improve or fully recover with these OTC products after remaining sick for years on T4-replacement. Changes are you’ll do much better on one of these products.

If you decide to take that option, I encourage you to use the by-the-numbers method for metabolic rehab that I describe in The Metabolic Treatment of Fibromyalgia. Using our method will help you safely get the most from your self treatment. If you take control of your thyroid hormone treatment in this way, you may soon join the expanding ranks of patients who’ve fully recovered their health after T4-replacement failed them. I sincerely hope so.

October 20, 2004
Question: Five years ago I was diagnosed with thyroid cancer and underwent the usual procedures. I have been on T4 ever since. I’ve felt steadily worse and I was recently diagnosed with chronic fatigue syndrome and fibromyalgia. I remain convinced that the root of the problem lies with my missing thyroid.

I am currently looking for an endocrinologist who’ll try using T3 as my primary replacement hormone, in the fashion with which you’ve had so much success. Does your office keep a list of regional doctors who are T3-friendly? I would be most grateful if you could recommend someone in the Midwest US. I'm in central Indiana. If not, then I guess I need to start making plans to come to Colorado.

Dr. Lowe: I am sincerely sorry you're suffering needlessly—as millions of other patients are—from the ineffectiveness of T4-replacement. As you may know, we know have substantial evidence of a truly tragic phenomenon: many—perhaps most—patients who undergo antithyroid therapy and then use T4-replacement have chronic, often debilitating, health problems. By starting T4-replacement five years ago, you unfortunately joined this multitude of patients living in doctor-induced misery.

From your own experience, you obviously know that fatigue and widespread pain are among the chronic hypothyroid symptoms that can plague these patients. It has become fashionable for doctors to diagnosis the pain and fatigue as "fibromyalgia" and "chronic fatigue syndrome." These are misdiagnoses, of course. An accurate diagnosis is the chronic hypothyroid symptoms of pain and fatigue caused by the ineffectiveness of T4-replacement.

Because you are hypothyroid, you most likely won’t have to find a doctor who’ll treat you with T3 alone. Most of our patients who became hypothyroid after antithyroid therapy don't use T3 alone; the majority fully recover their health using T4/T3 products. The particular product doesn’t matter; it may be Armour, Nature-Throid, Thyrolar, Westhroid, or over-the-counter desiccated thyroid. In our experience, all of these products are generally more effective than T4 alone.

What does matter is that your doctor not use the "replacement" practice of adjusting your dosage by your TSH, T4, and T3 levels. If he does, you’re not likely to fully recover your health. In contrast, if he adjusts your dosage by your symptoms and especially your resting metabolic rate, you stand the best possible chance of fully recovering.

June 11, 2004
Question: I had Graves’ disease and hyperthyroidism five years ago. I was treated twice with radioactive iodine. That made me hypothyroid, and I’m currently on 125 mcg of Synthroid. My main problem is considerable weight gain. I’ve gained the weight despite taking in only 1200-1500 calories each day and running for 40 minutes 3-4 times a week. I also have ongoing hair loss. My endocrinologist considers me healthy and "controlled" despite my symptoms. He asked me to follow up with my primary MD, which I did. He ran a TSH and T4 and said the results were "normal." When I asked about taking Armour or T3, he told me that no doctor at the local hospital, including him, will prescribe them—and to exercise harder. What do you think I should do?

Dr. Lowe: You are the classic example of a hypothyroid patient being harmed by her doctors restricting her to T4-replacement therapy. Because of this, I suggest you thoroughly read my critique of recent studies of thyroid hormone replacement therapies. The webpage address to the critique is http://www.drlowe.com/frf/t4replacement/intro.htm

Four studies I discuss in the critique showed that T4-replacement and T4/T3-replacement leave many hypothyroid patients suffering from hypothyroid symptoms. A fifth study I cite suggests that some patients on T4-replacement develop potentially fatal diseases. The patients also regularly used drugs to control their symptoms of hypothyroidism and the other associated diseases. Other studies I cite showed that patients taking higher-than-replacement doses of thyroid hormone have superior treatment results.

Most people who’ve read the critique find something a bit curious: Despite these recent studies documenting that thyroid hormone replacement therapies harm many patients, endocrinologists have advised that T4-replacement should remain the treatment of choice for hypothyroidism. This is especially curious in that one of the studies suggests that some patients on T4-replacement may die prematurely from diseases associated with hypothyroidism.

I recommend that you send a copy of the critique to the endocrinologist and the other doctor who've restricted you to T4-replacement. And I suggest you ask them: "In view of this critique of replacement studies, and in view of my continuing hypothyroid symptoms, can you, in good conscience, still restrict me to T4-replacement?"

If their answer is yes, your recourse is to find an alternative doctor who’ll cooperate in treating you with a more effective approach to thyroid hormone therapy. The number of such doctors is growing. So with a little persistence, you should find one who’ll help you fully recover your health.

March 24, 2004
 [The following email was sent to the Editorial Department of Dyn. Chir. The patient who sent the email had read my article on Synthroid that was published in Dyn. Chir. in October 2001. An editor forwarded the email to me, and I replied to the patient’s comments.]

Patient's Comments: Hello. I just wanted to let Dr. Lowe know that I've been taking Synthroid for almost ten years. It isn't doing much for me and hasn't ever, as far as I can tell. I feel no different taking Synthroid.

I did some research on the Internet and came across the FDA site where you can look up a drug to see if it's approved or pending approval. I was stunned when I read that Synthroid was awaiting approval or rather re-approval after so many complaints about its ineffectiveness. I copied some ten pages, took them to my internist, and asked for a different thyroid medicine. He looked me in the eye and told me that the drug was approved—when it was not. He told me he would never prescribe a medication that was not approved. He also told me there was nothing wrong with the drug, although the FDA site contradicts this. In so many words, he called me a liar. 

I sat there speechless, with all of my downloaded pages, my proof, in my hands. But I knew he would never change my thyroid medication from Synthroid. So I changed doctors. But even this doctor, whom I’ve known for a long time, wouldn’t change the Synthroid prescription to another medication. I’m still with this new doctor. I’m going to keep trying to get him to change his mind, even if I have to take an avalanche of information about Synthroid to him every chance I get.

A personal thought for Dr. Lowe: thank you for your article on Synthroid. We need more professionals to speak out against the use of Synthroid. Someday, perhaps, the doctors that prescribe Synthroid will start to listen, although at this point, I really wouldn't hold your breath. Thank you once again.

Dr. Lowe: It was kind of you to take the time to write and describe your experience with Synthroid and the doctors who’ve doggedly restricted you to it. Your experience—like that of tens of thousands of patients—confirms the opinion of Professor Linus Pauling: "Among all professionals, it’s physicians who do the least bit of thinking for themselves."

Conventional doctors do no thinking at all for themselves when it comes to thyroid hormone therapy. They’ve long left that chore up to two entities: the marketing departments of corporations (currently Abbot Laboratories) that have promoted sales of Synthroid, and the endocrinology specialty—whose endorsements of Synthroid boil down to parroting of marketing hype from the corporations' marketing departments.

Your attempts to educate your current doctor are most likely a waste of your time. Keep in mind an old aphorism: Exposing a closed mind to facts is like shining light on the iris of the eye—it just closes more tightly. In my experience, facts are useless in rescuing such a doctor from his state of non compos mentis. I’ve seen only one thing bring such a doctor around: His mother, his wife, or he himself becomes hypothyroid, and despite using Synthroid, they or he continues to suffer from hypothyroid symptoms. Whereas the suffering of his Synthroid-using patients didn’t change his mind, his personal anguish does.

Short of such a personal experience for your doctor, his mind will most likely remain putty in the hands of Abbott Labs and the endocrinology specialty. Because of that, you’d best cut your loses and find yourself an alternative thyroid doctor. Plenty of them are available nowadays, and your health and well-being most likely depends on you finding one in your area. By taking that course of action, thousands of patients have quickly recovered their health, and I hope you soon join their ranks. Very best of luck.

December 18, 2003
Question: I was diagnosed in 1999 with hypothyroidism and have been on Synthroid ever since. My doctor started me on 125 mcg, but he recently lowered me to 100 mcg because he said my blood work has improved. I honestly do not feel any better and find it very difficult to get out bed in the morning to the point where I cry for an hour in the bathroom.

I must admit that my weight is back to normal, but I feel terrible and always have bags under my eyes. I still feel like crap! Please help me. Can you recommend any good thyroid specialist in New York?

Dr. Lowe: If by "thyroid specialist," you’re referring to an endocrinologist, then no, I don’t know of one in your area I would refer you to. Over the years, I’ve spoken with many endocrinologists in Canada, France, and all across the United States. Based on those communications, I know of only of a few I could in good conscience refer you to. Unfortunately, none of those few are in your geographic area.

If you insist on being treated by an endocrinologist, I wish you luck; you’ll need it. I believe that a few—precious few—are cordial human beings and excellent clinicians who work collaboratively with their patients. In my experience, however, most are arrogant, rude, and dictatorial. Worse, I’m convinced that most are thoroughly ignorant of how to help hypothyroid patients overcome their symptoms and recover their health. You may eventually find one who’ll interact well with you and treat you properly. But to find that one, you may have to sort through many who’ll sustain your symptoms and insult you in the process.

The problem is that, for all practical purposes, the modern endocrinology specialty is a marketing wing of various corporations that lavish it with financial inducements. The inducements buy the specialty’s loyalty. As a result, what you as a patient can get from most members of the specialty is strictly what the corporations market and profit from—even if this leaves you ill and debilitated.

Consider, for example, the endocrinology specialty's obstinate endorsement of Abbott Laboratories products. Abbott markets Synthroid and TSH and thyroid hormone blood tests. Synthroid and the lab tests are a package of products that the endocrinology specialty dogmatically pronounces to be the be-all and end-all for diagnosing and treating hypothyroid patients.

No matter what the contrary evidence, high-profile members of the specialty, with no apparent shame, remain loyal to products marketed by Abbott (and in the past, its predecessor, Knoll). For example, the FDA has repeatedly recalled batches of Synthroid for subpotency. Subpotency, of course, means that the tablets contained less T4 than the label states. Despite the repeated FDA recalls, prominent endocrinologists vow that the product is highly reliable. To my amazement, they aren’t daunted by the public record showing their testimony to be false. In my mind, their conduct portrays the endocrinology specialty as bribable, corrupt, and of dubious scientific credibility.

Fortunately, patients such as you don’t have to be fodder for this cooperative financial venture between the endocrinology specialty and corporations. Alternative metabolic therapies are now widely available. When used properly, the alternative therapies are both safe and effective. A few endocrinologists provide these therapies, but finding one may be a challenge for you. It’s far easier to find physicians other than endocrinologists (chiropractic, naturopathic, and alternative medical and osteopathic) who provide these metabolic therapies. I encourage you to promptly seek one out and bring to an end the suffering that T4-replacement therapy with Synthroid has imposed on you.

 

Continued at top of right column . . .

 

 

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| Weight gain and the TSH (at Thyroid Science) |

 

Continued from bottom of right column . . .

December 22, 2002
Question: Great site! My problem is a little different. Over the past three years my TSH readings have ranged from 5.05 to 6.93. However, I have no hypothyroid symptoms whatsoever. My weight has remained constant for over 30 years (I'm a 55-year-old male) and I run five miles nearly every day. As a precaution to an even higher TSH reading, I went on 25 mcg of Levoxyl (T4). What a mistake! I’ve never felt right on thyroid medication (it makes me feel hyper) but even worse. My cholesterol, which normally is in the 170 to 180 range, shot up to 217, which, of course, is high. From what I’ve read on your site, it’s not uncommon for cholesterol to elevate on a low dose of T4. You don't have to convince me that T4 isn’t the way to go. My question is twofold: First, should I even concern myself with thyroid medication if I feel great with a TSH of 6? And Second, should I simply try a low dose of Armour? Thanks in advance.

Dr Lowe: Thanks for the compliment on our website. You didn't say whether the level of thyroid hormone in your blood is high-normal or high. If it is, you may have mild general resistance to thyroid hormone. In general resistance, most of the tissues of the body and brain, and perhaps all of them, are partially resistant to thyroid hormone. That is, the tissues don't respond as readily to thyroid hormone as do most other people's tissues. Because the patient's pituitary gland is partially resistant to thyroid hormone, it continues to secrete TSH until the blood level of thyroid hormone rises higher than normal. When the thyroid hormone level rises high enough, it begins to suppress the pituitary gland's production of TSH. As a result, the patient's TSH and thyroid hormone levels are either high-normal or high. Because the body tissues are also partially resistant, the high-normal blood level of thyroid hormone doesn't overstimulate them. So the person has normal metabolism and feels normal despite having fairly high TSH and thyroid hormone levels. I don’t know whether this is applies to you, but it is a possible mechanism.

The thyroid hormone preparation you took, T4 alone, is an extremely poor test to see whether you might benefit from thyroid hormone therapy. Nonetheless, taking thyroid hormone may be of no value to you. I say this for several reasons: You're apparently healthy, feel well, and have no evidence of deficient thyroid hormone regulation of your tissues, such as high cholesterol. It’s highly likely that your elevated cholesterol after starting to use Levoxyl resulted from the extremely small dose you were taking. That low a dose isn't likely to benefit anyone other than a very small pygmy. Moreover, you're correct—the small dose may impede metabolism and cause abnormalities such as your high cholesterol.

November 25, 2002
Question: May I first say what a blessing your site is. It's an oasis of sense in a desert of disillusion. Thank you.

After showing classic hypothyroid symptoms for over ten years, my general practitioner has finally decided that I’m borderline hypothyroid. Initially, she allowed me to take 50 mcg of thyroxine (T4) daily. Then, at my insistence, she allowed me to go up to 75 mcg. On 50 mcg, I still felt dreadful. On 75 mcg, I’m more alive but still not feeling really good. I was diagnosed at the end of July, so perhaps I'm expecting too much too soon.

My question is about my weight. Since starting T4 in August, my weight has increased by eight pounds! This has happened although my diet, exercise, and lifestyle have all remained constant. Have you any idea why I've gained the weight?

My general practitioner really doesn't want to discuss my thyroid problem any further. It seems that to her, now that I'm taking T4, that's the end of the problem. This attitude is very common here in the United Kingdom, and it's not possible to see an endocrinologist without a referral from your general practitioner. So once you've been diagnosed and prescribed T4, "Job’s done! No need to mention thyroid problems any more!" This is true even when you really feel you have problems that still need addressing.

Dr. Lowe: I regret that you're having problems getting effective thyroid hormone therapy, just as millions of other hypothyroid patients do. Weight gain after beginning low-dose T4, despite no change in lifestyle, is a common complaint; in fact, it’s one of the most common complaints we hear from hypothyroid patients under the care of conventional doctors.

You've most likely gained weight for one of two reasons. First is your use of T4 alone. T4 alone is effective for few hypothyroid patients. Due to this, most patients taking T4 alone continue to suffer from hypothyroid symptoms. To recover from their symptoms, the patients must use a high enough dose of a thyroid hormone preparation containing T3.

Second is your use of such a very small dose of T4. The TSH usually descends into its reference range (formerly "range of normal") in response to 75 mcg of T4. When that’s accomplished, the patient is well!—or so conventional endocrinologists hallucinate, as do general practitioners who foolishly take their advice about treating hypothyroid patients. Seldom is low-dose T4 effective in keeping metabolism normal in most body tissues. In fact, the low dose of T4 may actually slow metabolism further. This can happen when the T4 dose lowers the pituitary gland’s secretion of TSH, which in turn reduces the thyroid gland’s secretion of T4 and T3. If the patient’s T4 dose is too low to compensate for the thyroid gland’s reduced release of T4 and T3, metabolism slows further. To the patient's surprise, she develops more symptoms of hypothyroidism after beginning the use of T4 alone.

Fats breaks down in the body at an abnormally slow rate in most hypothyroid patients taking only 75 mcg of T4. As a result, the patients gain and retain excess body fat. Many also develop high cholesterol. They do so despite exercising and lowering their calorie intake. Hence, the excess body fat and high cholesterol of many hypothyroid patients is "iatrogenic"—that is, doctor caused.

My suggestion is that you find another doctor who'll treat you properly with thyroid hormone. But I have a comment on the type of doctor you seek out. You complained that hypothyroid patients’ have trouble getting general practitioners to refer them to endocrinologists. This is a "problem" I don’t recommend that patients try to rectify. A referral to an endocrinologist isn’t likely to lead to safe and effective thyroid hormone therapy. Remember, scientifically false beliefs of the endocrinology specialty have caused the very iatrogenic health problem you’re now suffering from: weight gain after beginning low-dose T4. After falling into the river, the shivering soaked person doesn't get warm and dry by moving closer to the fountainhead.

 

November 20, 2002
Question: I am a Brazilian hypothyroid patient and have been taking T4 My dosage is 50 mcg each day. I’m now experiencing some changes in my vision capabilities. My vision is a little fuzzy and blurred, and this started after a few months of taking T4. My question is: Can T4 reduce my capacity to see things clearly? Should I wear glasses? I’m very curious to know because it seems I’ll have to take the T4 for the rest of my life.

Dr. Lowe: Keep in mind that T4 alone is the least effective thyroid hormone preparation, and 50 mcg is an extremely small amount. I seriously doubt that 50 mcg is benefiting you in any way. It may, however, be harming you.

T4 is highly effective at one thing: suppressing TSH secretion by the pituitary gland. T4 can suppress pituitary TSH secretion while leaving the metabolism of other tissues so slow that the patient continues to suffer from hypothyroid symptoms. Consequently, the doctor concludes (from the lowered TSH) that the patient is well; in the mean time, the patient suffers from continuing hypothyroid symptoms. Even worse, if the T4 dose is too low, the patient’s symptoms may actually worsen.

It's possible that the paltry amount of T4 you’re taking, by lowering your TSH level, has reduced your thyroid gland’s release of T4 and T3. The T4 you're taking may be far too little to compensate for your thyroid gland’s reduced thyroid hormone output. As a result, the small dose of T4 you’re taking may actually be worsening some harmful effects of your hypothyroidism. The Physician’s Desk Reference contains an important statement largely ignored by conventional doctors: "Inadequate doses of Synthroid [and by extension, any other brand of T4] may produce or fail to resolved symptoms of hypothyroidism."[1,p.1500] (Italics mine.) Doctors currently restricting their hypothyroid patients to small doses of T4 would do well by their patients to read and seriously consider the implications of this quote.

Two possible mechanisms come to mind that could—at least theoretically—account for the visual problems that began after you began using T4. A possible harmful effect of a small T4 dose is myxedematous swelling behind the eyes that distorts the patient’s vision. (Myxedema is the swelling that occurs when too little thyroid hormone regulation of connective tissue cells causes an increase in water-binding molecules in connective tissues.) The swelling might cause you to feel pressure behind your eyes. And you may have other body areas that have become swollen or puffy since you began to use T4. If you have either of these symptoms, you should discuss this possibility with your doctor.

Another possibility is that you have autoimmune thyroid disease, and as part of the disease, you have anti-thyroglobulin antibodies. The suppression of your thyroid gland by too small a dose of thyroid hormone may have augmented the autoimmune process by increasing your anti-thyroglobulin antibodies. In some patients, serum containing anti-thyroglobulin antibodies was found to bind to human eye muscles.[2] Apparently, an antigen within the thyroglobulin molecule is the same or similar to one in an enzyme (acetylcholinesterase) at the nerve-muscle junction in the eye muscles.[3] The anti-thyroglobulin antibodies apparently cross-reacts with this muscle enzyme. Destruction of the enzyme could cause the eye muscles to stay contracted too long. This would distort the eye ball’s shape and produce the fuzzy, blurred vision you described.

The proper approach would be for your doctor to switch you to a more effective thyroid hormone preparation—one containing both T4 and T3, such as desiccated thyroid. Of course, if your doctor keeps your dosage as low as he has your T4 dose, you might not fair much better. So, if your present doctor won’t cooperate with your using a high enough dose of a more effective thyroid hormone preparation, prudence will lead you to another doctor who will.

References

[1] Physician’s Desk Reference, 53red edition. Montvale, Medical Economics Company, Inc., 1999.

[2] Mullins, B.R., et al.: Delayed hypersensitivity in Graves’disease and exophthalmos: identification of thyroglobulin in normal human eye muscle. Endocrinology, 100:351, 1977.

[3] McKenzie, J.M. and Zakarija, M.: Antibodies in autoimmune thyroid disease. In Werner and Ingbar’s The Thyroid: A Fundamental and Clinical Text, 6th edition. Edited by L.E. Braverman and R.D. Utiger, New York, J.B. Lippincott Co., 1991, pp.506-524.

August 15, 2002

Question: I am a chiropractic doctor. I sent your article on hypothyroidism and Synthroid to my patients. I received the response below from a patient who is a pharmaceutical rep. Will you please comment on her response?

Excerpts from my patient’s letter: "Dear Doctor: The report by Dr. Lowe was extremely biased. His "research paper" is designed to inflame and incite people—not educate them. His paper causes concern for those with hypothyroidism (which I have), and leaves them feeling as if they’re on inadequate medication. He left out some critical information that’s important when deciding which medication to use. Why leave out that Armour has a problem with dose variability? The T3 in Armour causes palpitations and tremors. Perhaps it doesn’t bolster Dr. Lowe’s case to mention these things. One might wonder if he’s being paid by Forest Pharmaceuticals, the maker of Armour. If Dr. Lowe has the patient’s best interest at heart, he should provide all the facts."

Dr. Lowe: In that your patient is both a pharmaceutical representative and a hypothyroid patient, I believe her questions are fair. At the same time, however, they’re misguided. Before answering them, let me comment on her characterizing my article on Synthroid as "biased." For her to do so is to miss the point of the article. The article’s intent wasn't to give the pros and cons of different thyroid hormone products. Instead, it was, in essence, to report on false claims made for Synthroid over the years.

Inadequate Medication. Your patient complained that I leave patients using Synthroid "feeling as if they’re on inadequate medication." Indeed, I believe this to be true of most of them.

Synthroid has long been touted as the virtually perfect thyroid hormone product—invariably reliable in potency and infallibly effective for every patient who uses it. This fantastical assessment of Synthroid turns out to be nothing more than advertising hype. I don’t know whether the corporations that have marketed Synthroid concocted the hype. But clearly, thyroid researchers and endocrinologists who've received lavish financial incentives from the corporations have vocalized the hype and lent their authority to its presumed veracity. Despite the hype, my article shows Synthroid not to be the height of medicinal perfection. In fact, it’s far from it.

One of my main professional activities during the last twelve years has been the objective evaluation of the effectiveness and safety of different thyroid hormone preparations. In that capacity, I've evaluated not only Synthroid and other brands of T4, but also other thyroid hormone preparations: desiccated thyroid (such as, but not limited to, Armour), synthetic T4/T3 combinations, and T3. The outcome of my evaluations is clear: T4 alone—whether Synthroid or other brands—is the least effective preparation. I emphasize that I've come to this conclusion completely independently of financial incentives from any company or other entity. I have no vested interest whatever in any thyroid hormone product.

Dose Variability With Armour. Your patient wrote that Armour has problems with dose variability. Her meaning, of course, is that compared to Synthroid, patients can’t be sure that Armour tablets contain the amount of thyroid hormone the label states. I'd challenge her, however, to show evidence that the amount of thyroid hormone in Armour (or any other brand of desiccated thyroid) is less reliable than in brands of T4. I don’t think she’ll be able to show such evidence. Instead, she’s like to come up only with ex cathedra pronouncements from thyroid researchers and endocrinologists who've fed lavishly off funding from T4-marketing corporations. All thyroid hormone products have dose stability problems from time to time, and, as my article shows, Synthroid is no exception.

Palpitations & Tremors with Armour. Your patient wrote that the T3 in Armour causes palpitations and tremors. I'm afraid this is nothing more than parroting of anti-competitive propaganda—a false proposition perpetrated and perpetuated to augment the commercial success of brands of T4. Patients whose tissues respond to T4 alone—just like patients using Armour—can have palpitations and tremors when their dose is too high for them. Over-stimulation is not a problem in properly-managed patients—no matter what thyroid hormone preparation they’re using.

As I stated at the outset, I believe your patient’s questions are fair but misguided. Nonetheless, I’ll be happy to discuss with her in greater detail my answers to each of her questions. Please give her my best regards.

 

January 25, 2002
Question: I had my thyroid burned out with radioactive iodine treatment 15 years ago. As a result I’ve been hypothyroid since. Before Sept. 2001, I was on 0.20 mg [200 mcg] of Levoxyl [a brand of T4]. I felt generally fine. Also, to my delight, I lost 35lbs over the past year and a half. But that changed in Oct. 2001. In Sept 2001, I went to my general physician. He did my annual TSH test. Because of the result, he lowered my dose to 0.15 mg [150 mcg] Levoxyl daily. About a month later, I started gaining weight despite watching and counting my calories every day, and exercising at least 30 minutes a day. I also became increasing sensitive to cold, which I never had a problem with before. I started taking my temperature at different times of the day for the past few weeks, and no matter when I take my temperature, it has been below or at 97 degrees. I have become more irritable, have no libido, have almost daily headaches, and am starting to experience a small amount of hair loss. I called my doctor and went in for another blood test three weeks ago. He tested my TSH again, and because of the result, he lowered my Levoxyl even lower, to 0.125 mg [125 mcg] per day.

I am going to an endocrinologist for the first time in 15 years on Friday to discuss my continuing symptoms of hypothyroid. My question comes here. I had my doctor's office fax my blood test result to me, and I’m very perplexed. The normal range for the TSH my doctor looks at is 0.49-to-4.67. My last two blood tests read less than 0.03. Now, I had my thyroid burned out, so why would my TSH reading be so low, indicating that my thyroid is producing enough hormone. I’m so confused and upset by this and really need some answers. I know I’m going to a specialist in a couple days, but I’d like to go to my appointment armed with as much knowledge as possible. Could it be that my pituitary gland is not functioning properly? I truly appreciate your input.

Dr Lowe: Your observations don’t suggest to me that your pituitary gland isn’t functioning properly. In fact, your observations are consistent with what science tells us about a patient's T4 dose, her TSH level, and her metabolic health or lack of it. If the goal of a doctor is metabolic health for his patient, he has no scientific basis for adjusting her thyroid hormone dose by her TSH level. If the doctor is going to make the imprudent choice of treating the patient with T4 (rather than T3 or a T3/T4 combination), he should be aware of the relevant physiology and treat her on the basis of it. Otherwise, he's likely to ruin her health, as your doctor appears to be doing to yours.

The TSH level is not well synchronized with the tissue metabolic rate. (Probably most doctors falsely assume that studies have shown that the TSH and metabolic rate are synchronized. But despite my diligently searching for years for such studies, I’ve yet to find them.) Adjusting the T4 dose by the TSH level is like adjusting the speed of your car by a speedometer that's out of synchrony with the actual speed of the car. Adjusting the speed of a car by an out-of-sync speedometer, of course, will get the driver into trouble—either with other drivers who'll object to the car traveling too slowly, or with a police officer who'll object to the car going too fast. And adjusting the thyroid hormone dose by the TSH level gets most patients in trouble—almost always because their tissue metabolism is so slow that they are sick.

The main enzyme complex that converts T4 to T3 in the pituitary gland is type II 5'-deiodinase. This enzyme complex is usually highly effective in generating T3. It’s generally more effective than the main enzyme complex (type I 5'-deiodinase) that converts T4 to T3 in other body tissues.[1,p134] As a result, the pituitary gland produces T3 more readily than other tissues do, and this pituitary T3 effectively suppresses the synthesis and secretion of TSH. Some researchers have reported that as little as 0.145 mg (145 mcg) of T4 suppresses TSH secretion.[2] It takes little cognizance in clinical practice to realize that this dose rarely is enough to keep a patient's metabolism normal. And rarely is this dose enough to free a patient from symptoms of abnormally slow metabolism. If  patients are going to have normal tissue metabolism and good metabolic health while using T4, most of them must take a dose that suppresses the TSH level. It’s this fact that mainstream doctors need to come to understand, if they’re going to stop keeping their hypothyroid patients ill.

When the typical patient’s T4 dose becomes just high enough to produce enough T3 in the pituitary to suppresses the TSH, T3 production in other tissues will be inadequate to keep their metabolism normal. As a result, the person's tissue metabolism will be slow, and she'll suffer from symptoms of too little thyroid hormone regulation. The net effect of all this is that the TSH is effectively suppressed by a T4 dose that is inadequate for keeping the metabolism of other tissues normal.[1,p.990]

I suspect, then, that the problem in your case is that you're being treated with T4—the poorest choice of thyroid hormone preparations. I can understand why most mainstream doctors don't understand this matter. It’s complex, and, because of that, they tend to simply accept the opinions of conventional endocrinologists. What utterly baffles me is why conventional endocrinologists don't understand it.

Reference

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

[2] 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

June 9, 2001
Question: My endocrinologist won’t let me try natural thyroid or T3. He insists that T4 is superior to these other types of thyroid hormone. Since I’m still sick with hypothyroidism, I don’t understand how it is superior. What are your thoughts on his claim?

Dr. Lowe: Most conventional endocrinologists do claim that the use of T4 alone is "superior" to the use of desiccated thyroid (such as Nutri-Meds and Armour) or T3 (such as Cytomel). I have carefully read the study reports they base this beliefs on, and it is clear to me what they mean. Precisely, they mean this: Taking desiccated thyroid or T3 causes the free T3 level in the blood to rise briefly, but T4 doesn’t cause the rise. Thus, the use of T4 is "superior."

That T4 doesn't cause the brief rise in the T3 level is a rather peculiar criterion for defining T4 as "superior." It is a peculiar criterion in that, for most patients, the brief rise in the T3 level is completely unimportant; almost without exception, the rise is important only for patients with fragile heart conditions. The criterion is also peculiar in that patients with thyroid hormone resistance may require surges in the free T3 level for relief of their symptoms and improvement of their health.

Relief of symptoms and improved health, of course, aren’t aims of most conventional endocrinologists treating hypothyroid patients. Some pay lip service to considering patients’ symptoms and overall health. But the fact is, most conventional endocrinologists strive only for an "ideal" blood level of the TSH. Then they explain away their patients’ continuing hypothyroid symptoms as mysterious "new diseases," such as fibromyalgia or chronic fatigue syndrome. This irrational, extremist technocratic orientation has ruined the health of millions of people and caused incalculable numbers of premature deaths. In short, it has caused a world-wide public health crisis.

I see no sane reason why a patient should let a doctor keep her ill because of his rigid choice of medication. According to what you say, you’re dissatisfied with the results of using T4 alone, and your endocrinologist won’t cooperate in trying alternatives. It seems that your best course of action is to find another endocrinologist who will cooperate. Bit by bit, more endocrinologists in the United States are coming to their senses, so hopefully you can find one who’ll treat you effectively. But if this proves too difficult, many family physicians and naturopathic doctors are perfectly willing to cooperate with you in getting well.

 

June 8, 2001
Question: When I was finally diagnosed with hypothyroidism, my doctor prescribed 75 mcg of Synthroid. Rather than getting better, I seem to have gotten worse. Is it possible that the Synthroid has made me worse?

Dr. Lowe: It is possible that the culprit is your low dose of Synthroid (a brand of T4). A dose of T4 (despite the brand) as low as 75 mcg slows some patients’ metabolism and worsens their symptoms. This confuses some patients and their doctors; it seems a paradox in that T4 is supposed to speed up rather than slow down metabolism. The reason metabolism slows and symptoms worsen in some patients with a low T4 dose is complicated, but I will explain it as plainly as I can.

Most body tissues are less responsive to T4 than is the pituitary gland. A dose as low as 75 mcg leaves the metabolism of most body tissues abnormally slow. In contrast, the pituitary gland may readily respond to the 75 mcg. If so, the pituitary decreases its release of TSH into the blood. TSH, of course, is the pituitary hormone that stimulates the thyroid gland to release thyroid hormones into the blood. So, when 75 mcg of T4 causes the pituitary to decrease its release of TSH, the thyroid gland in turn decreases its release of thyroid hormones. The decreased secretion of thyroid hormones (both T4 and T3) may then further slow the metabolism of most body tissues. The paltry 75 mcg dose of T4 won’t drive the metabolism of the tissues enough to compensate for the metabolic showdown caused indirectly by the 75 mcg dose.

May 26, 2001
Question: I am in a predicament. Twelve hours after my husband and I found out we were going to have our second baby, my endocrinologist called. He said that the biopsy of the cyst on my thyroid gland showed abnormal cells. He also said that I need to have my thyroid gland taken out and the cyst evaluated. He said this was pretty safe during my second trimester. However, I would like to know how necessary this surgery is during pregnancy. Is this your area, or can you recommend someone to me?

Dr. Lowe: This isn't my area of specialization. Hopefully your endocrinologist can resolve the problem competently. I will caution you, however, about something important to your future health—that is, doctor-induced illness that often follows anti-thyroid therapy. After you undergo anti-thyroid therapy, your thyroid gland is likely to produce too little thyroid hormone to maintain normal metabolism. To maintain your health, you’ll then need to use a thyroid hormone preparation. But whether you remain healthy will depend crucially on the thyroid hormone preparation you use and the daily dose you to take.

After putting a patient through anti-thyroid treatment, the typical endocrinologist prescribes T4 (thyroxine), almost always the brand Synthroid. Unfortunately for the usual patient, T4 is the least effective treatment option for most hypothyroid patients. But even if the T4 is effective for a particular patient, the endocrinologist usually restricts her to a dosage too low to maintain health. As a result, the she suffers from chronic hypothyroid symptoms despite her daily use of T4.

When the patient complains of being ill, the endocrinologist usually checks her TSH level. When the level is within the "reference range," the endocrinologist pronounces that the illness is caused by some other disorder. The patient then begins undergoing extensive and expensive diagnostic tests, all of which fail to reveal the cause of her symptoms. The cause remains enigmatic to her endocrinologist and other conventional doctors. Quite simply, though, the cause is too little thyroid hormone regulation of her tissues.

Her conventional endocrinologist or some other conventional doctor will diagnose her symptoms as a psychiatric disorder or one of the so-called "new disease"—fibromyalgia, chronic fatigue syndrome, or (if she lives in the United Kingdom) ME (myalgic encephalomyelitis). The source of these illusory new diseases, therefore, is the false beliefs of endocrinologists about how patients should be treated for hypothyroidism: that is, only with T4 according to the patient’s TSH levels.

When a patient, after anti-thyroid therapy, falls prey to this health-ruining process, she becomes burdened with more than chronic hypothyroid symptoms. She is also likely to suffer from adverse effects of drugs mainstream doctors prescribe to control her symptoms. If her predominant symptom is pain, she may also become addicted to narcotics the doctors prescribe. Hence, the beliefs of conventional endocrinologists about the treatment of hypothyroidism not only often sabotage the patient’s health; they also may enslave her to addicting drugs that can impair her ability to function as a productive member of society.

After you undergo anti-thyroid therapy, if you are to avoid chronic illness and debility from under-treated hypothyroidism, you must protect yourself from your conventional doctors’ false beliefs about proper treatment. To do so, I suggest you find an alternative doctor to treat you for hypothyroidism. Otherwise, it’s likely that your health will deteriorate. It is also likely that you’ll eventually join the growing list of improperly-medicated hypothyroid patients misdiagnosed as having one of the mysterious "new diseases."

September 6, 2001
Question: My wife has been diagnosed with hypothyroidism following a TSH test of 12.6. Her doctor prescribed 50 mcg of thyroxine, but she has had very adverse effects—severe nausea and dizziness. She experiences these an hour and a half after she takes even on a dose as small as 12.5 mcg. I know the drugs in America are different from those here in England, but I wonder if you've come across any reactions like this and can offer any advice. The doctors here don't even acknowledge such side effects exist!

Dr. Lowe: Your wife may be having an allergic reaction to some constituent of the thyroxine tablets she is taking. It is extremely unlikely that thyroxine molecules themselves are causing the reaction. Thyroxine is what we call an "orthomolecular" substance. This means that thyroxine is natural to the human body and necessary for health. Allergic reactions to orthomolecular substances are incompatible with health and extremely rare.

Your wife can test whether she's having an allergic reaction by taking an antihistamine, such as 50 mg of diphenhydramine HCL. She should take the antihistamine an hour or so before taking her next dose of thyroxine. If after taking the antihistamine, the thyroxine preparation doesn't cause the reaction, it’s safe to conclude that she’s having an allergic reaction to some constituent other than thyroxine in the tablets. In this case, her doctor should switch her to another brand of thyroid hormone.

In the last sentence above, I purposely didn't say "switch her to another brand of thyroxine." Thyroxine alone is relatively ineffective in relieving hypothyroid symptoms. Thyroxine alone will bring your wife’s TSH level down into the reference range. But she may continue to suffer from hypothyroid symptoms until she switches to a more effective thyroid hormone preparation—one containing both T4 and T3 or T3 alone. Over the years, we’ve found treatment results with thyroxine alone is distinctly inferior to these other preparations. Because of this, we can't in good conscious treat patients thyroxine alone anymore. So, when your wife switches to another brand of thyroid hormone, she might as well switch to one that’s likely to be more effective than thyroxine alone. Please give her my best wishes for a full and rapid recovery from her hypothyroid symptoms.