Avoiding The "Tyranny" Of
Finding Your Optimal Dose of Thyroid Medicine
by Richard Shames, M.D. & Karilee Shames, Ph.D,
An art icle as it appears
on Mary Shomon's website
As a General Practice physician who
has been providing thyroid care for over 30 years, I am continually
surprised by my patients' stories of their experience with endocrinologists.
Many times patients tells me that they had just begun to feel
slightly better on thyroid medicine when their specialist said, "This
is it. We can not increase any further. Your tests tell me you're
presently at just the right dose." Evidently they had st
art ed working with this doctor right around the time of the
low thyroid diagnosis. They had begun a low dose of maybe 75mcg.
of Synthroid, and were beginning to feel better than rock bottom,
but not great. Now, some years later, they are still feeling
only p art ially back to their original full self.
They keep telling this to their specialist, who then keeps
responding, "we can't increase the dose any further. Your tests are fine
When confronted with what may be unfair tyranny of the test,
I generally tell my patients they have several options. Any one of their choices
might boost them up from their present p art ial
recovery to perhaps 90 or 100% of their prior full function.
These options include:
- Controlled trial of more thyroxine
- Switching brands of thyroxine.
- Adding some T-3 (Cytomel) to the thyroxine regime.
- Switching to Thyrolar (brand name mix of T-3/ T-4).
- Trying animal thyroid (Armour or Nature-throid).
- Boosting any medication with natural therapies.
This present discussion will focus
only on option #1.
First of all, 75 or 100 mcg. of thyroxine are a modest dosage
for most adults. A well-known professor of endocrinology is convinced that a
good "rule of thumb" eventual dose for most of his patients is one
microgram per pound of body weight. For instance, a woman who weighs 137 pounds
might do well with 137 mcg. of thyroxine (a few brands other than Synthroid are
available in pills at this exact dose). A man who weighs 175 pounds might do
well with the 175 mcg. pill. Before acquiescing to your doctor's test-result
edict of final dose, you might want to ask for a short clinical trial of the
medical center professor's protocol of "one mcg per pound of body weight".
Keep in mind that the rule of thumb dosage is only a general initial guide, and
that it might not apply well in cases of obesity.
If your doctor says "no, I realize you would like more
medicine, but I don't think that is wise considering your test results," then
you might want to look at your tests very carefully. Most likely your doctor
is talking about the level of TSH (thyroid stimulating hormone). Many physicians
are wrongly seeking to have their patients arrive at a TSH level that is in the
mid-normal range. In actuality, the mid-normal range is a great target goal for
most blood test results. However, it is not generally the most sensible goal
of therapy for thyroid patients taking thyroid pills. Instead, for most thyroid
sufferers, the goal of therapy should be to achieve a TSH near the low end of
the normal range. Let us explain why.
The "normal" range of the TSH test generally runs
from 0. 4 – 5.2. When I consult with people who call me from different
p art s of the country, I suggest to them a
therapeutic target range of 0.3 – 0.5. This is at the low end of the test's
normal range, not the mid-normal. The reason I do this is that most people who
are suffering from low thyroid are ill because of antibodies from the immune
system wrongly attacking the thyroid gland, and thereby compromising its function.
This immune attack is often lessened when the thyroid gland
is stimulated as little as possible by TSH. Recall that TSH means "thyroid
STIMULATING hormone". Rather, the person generally does better when her
body runs on thyroid hormone pills, allowing the gland to be in a mostly unstimulated,
resting state. The gland thereby receives a well-deserved vacation, in order
to heal and repair the immune system damage that caused the illness in the first
Sometimes, both patients and doctors are concerned about this
maneuver -- called "TSH suppression" -- where the TSH level is suppressed
to just at or just below the lower end of the normal range. They evidently feel
that giving the thyroid gland a healing vacation will cause harm or result in
the gland being irreversibly turned off. After working in this way for a great
many years, consulting for with numerous university specialists, and combing
the relevant medical literature, I am totally convinced that thyroid glands are
not at all injured by this maneuver.
If you haven't yet begun to feel as well as you would like,
then you get to look at this TSH issue very carefully. If the dose of thyroxine
you are currently taking (Synthroid, Levoxyl, Unithroid, Levothroid, L-thyroxine,
Levothyroxine) has not resulted in a TSH that is down to the lower end of the
normal range, then you may not be taking enough medicine. Neither I - nor any
other doctor - can promise you that simply taking an amount of thyroxine to reach
a TSH of 0.3, or 0.4, or 0.5 will give you full and lasting resolution of your
thyroid difficulties. But I can tell you this – it is the next thing to
try on your journey to full recovery. You may well be getting short-changed due
to an under-informed or overly cautious medical provider.
Just last week I provided phone advice follow up appointments
for four or five people from different parts
of the county with this exact TSH issue. It is evidently quite common. I had
advised them each, in earlier telephone consultations, to tell their practitioners
that medical center endocrinologists commonly aim for a TSH of 0.2 before saying "That's
enough thyroxine. More will not be a good idea". They know that insisting
on a TSH well within the normal range often condemns patients to less than full
recovery of function and enjoyment of life. All of the patients I spoke with
in follow-up were pleased to report an improvement. The additional increase in
their thyroxine dose resulted in a lower TSH level and also resulted in less
One patient, who lives in St. Louis ,
had previously said his general practitioner was concerned about the possible
adverse effect of thyroxine on the heart .
When I asked the patient if the doctor had now found anything about heart function
that was amiss, he said, "no, she did not." She had reported to the
patient that the pulse, blood pressure, he art sounds,
and cholesterol levels were actually all improved on the higher level of thyroxine
that resulted in the lowered level of TSH. Nevertheless, she was still concerned
about possible he art side effects. I was able
to put both the patient and his doctor at ease with a quick call to the doctor.
I reassured her that without any symptoms on the p art of
the patient or clinical signs able to be spotted by the doctor, the likelihood
of adverse cardiac problems due to a lowered TSH was negligible. Only those people
with a known history of he art arrhythmia,
mainly atrial fibrillation, need to be so concerned.
Another phone consult patient was from Chicago .
There, a doctor had told her that he did not want her TSH to go below 1.0 because
he was concerned about osteoporosis from too much thyroxine.
First of all, as we detailed in our book Thyroid Power, this
possible adverse effect of thyroxine is not really an issue unless the TSH is
suppressed to a level that is below 0.1. (The laboratory results of a TSH that
is clearly too low are often shown on lab reports as "less than 0.1",
or 0.06, or "less than 0.01"). There is a world of difference between
a TSH going below 1.0, which is quite okay to try, and going below 0.1, which
should be discouraged.
Secondly, this factor is more of an issue in people who have
osteoporosis in their family lineage, or who are already showing signs of osteoporosis
themselves. Keep in mind, however, that many people who are being treated for
low thyroid have early signs of osteoporosis BECAUSE OF UNTREATED OR LESS THAN
FULLY-TREATED HYPOTHYROISISM. These two conditions are known to cause osteoporosis,
worldwide they likely have in the past caused much more loss of bone density
than has over-treatment with thyroid hormone. Appropriate doses of thyroid medication
are not harmful to the bones of hypothyroid individuals.
The benefits of a full dose of thyroxine are enormous. A full
dose could possibly lead to a full recovery. Many people are being prescribed
less than a full dose, and are told to be satisfied with it. If you are going
to take thyroxine, and just thyroxine alone, at least take an optimal amount
of it. The actual proper amount of medicine varies tremendously from patient
to patient. Also, keep in mind that taking thyroxine alone is not always your
You deserve to live
the fullest life possible. Knowledge is power. We wish you full
recovery and empowerment on your thyroid journey! Next art icle
we will expand upon the topic of how to obtain additional benefit
in symptom relief by simply switching brands (such as replacing
Synthroid with Levoxyl).
NOTE: Also in the Thyroid Power book, we have a special section
that can help you enormously in getting the dose you need from
your health provider. It is called "Show This To Your Doctor".
In addition to this support, we have another powerful suggestion
for you. In asking your practitioner to aim for a low-normal
TSH, you might have better luck in if you write up your own
disclaimer ahead of time. A simple statement, inserted into your medical ch
art , could go as follows: "I understand that Dr. _________
has advised me that the amount of thyroxine on which I feel
most comfortable results in a TSH level that is considered
less than optimal by the doctor. I hereby release and hold
harmless the doctor for allowing me a clinical trial of this
dose. The pro and con have been explained to me."
Keep in mind that this high a dose of thyroxine, and this low a TSH
result may not be needed forever. Optimal thyroid dosing is an ongoing
process. The ideal level is always a moving target, depending upon
many factors. These may include age, constitution, illness, stress,
pregnancy, menopause, other life crises, and – in addition -
how long you have been on thyroid medicine.
An art icle as it
appears on Mary Shomon's